The bile acid-binding resins cholestyramine and colestipol were the mainstay of therapy. Their usefulness is limited by side effects such as constipation, bloating, nausea, and heartburn, and by their tendency to interfere with the absorption of other drugs. Nicotinic acid (500 mg three times daily) decreases triglycerides, LDL, and lipoprotein (a ) and increases HDL more than any other drug. Flushing, pruritus, gastrointestinal distress, and, rarely, hepatotoxicity are a few of the adverse effects of nicotinic acid. Starting at a low dose and pretreating with aspirin 325 mg or ibuprofen 200 mg can minimize the facial ﬂushing. Fibric acid derivatives like clofibrate and gemfibrozil are used to lower triglycerides and increase HDL but may increase LDL in some patients. The HMG-CoA (3-hydroxy-3methyl-glutaryl-coenzyme A) reductase inhibitors (statins) include atorvastatin, ﬂuvastatin, lovastatin, pravastatin, and simvastatin. These medicines inhibit HMG-CoA reductase, the enzyme that catalyzes the rate-limiting step in cholesterol synthesis. Several clinical trials showed that pravastatin, simvastatin, and lovastatin have a beneficial effect in cardiovascular disease. Statins are better tolerated than other lipid-lowering drugs, but reported side effects include severe myalgias, muscle weakness with increases in creatine phosphokinase, and, rarely, rhabdomyolysis, leading to renal failure.
Diabetes mellitus (DM) is a chronic disorder of altered carbohydrate, protein, and fat metabolism resulting from a deficiency in the secretion or function of insulin. The disease is defined by the presence of either fasting hyperglycemia or elevated plasma glucose levels based on an oral glucose tolerance testing (OGTT). The major complications of DM are primarily vascular and metabolic. The prevalence of DM is higher in women and certain ethnic groups, although a background rate in the general population is 6.29%, which has increased threefold in 15 years (34). Risk factors for DM are: 1.
2.
3.
A family history of diabetes 4.
5.
6.
HDL cholesterol less than or equal to 35 mg/dL and/or a triglyceride level greater than or equal to 250 mg/dL 7.
History of gestational diabetes or delivery of a baby weighing more than 9 pounds
Major complications of DM include blindness, renal disease, gangrene of an extremity, heart disease, and stroke. Diabetes is one of the four major risk factors for cardiovascular disease.
Classification In January 1999, the Expert Committee on the Diagnosis and Classification of Diabetes Mellitus published a report revising the system that was in use since 1979 (35,36). The goal of the revision was to provide guidelines for nomenclature and testing that might reduce diagnostic confusion and improve patient well-being (Table 9.9). The terms insulin dependent diabetes mellitus (IDDM) and noninsulin dependent diabetes mellitus (NIDDM) were replaced by the terms type 1 and type 2 diabetes mellitus.
Type 1 Diabetes Mellitus With type 1 diabetes, the major metabolic disturbance is the absence of insulin from the destruction of beta cells in the pancreas. Insulin is necessary for glucose metabolism and cellular respiration. When insulin is absent, ketosis results. The cause of type 1 diabetes is unknown; data suggest an autoimmune association from either a viral infection or toxic components in the environment. Studies in the past decade showed a correlation between many autoimmune diseases and the human leukocyte antigens (HLA).