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🔥+ reverses diabetes type 2 14 Jul 2020 Listed below are the ICD-10-CM codes commonly received by LabCorp. ... Type 2 diabetes mellitus with diabetic chronic kidney disease.

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Sign Up It''overview''clinical''workup''treatment''medication''s Standards of Medical Care in Diabetes for type 1 and 2 diabetes highlight recommendations most relevant to primary care. [79] (See Guidelines.)

The care of patients with type 1 diabetes mellitus is summarized below.

Tight glycemic control

The association between chronic hyperglycemia and increased risk of microvascular complications in patients with type 1 DM was demonstrated in the Diabetes Control and Complications Trial (DCCT). [80] In that trial, intensive therapy designed to maintain normal blood glucose levels greatly reduced the development and progression of retinopathy, microalbuminuria, proteinuria, and neuropathy, as assessed over 7 years.

The DCCT ended in 1993. However, the Epidemiology of Diabetes Interventions and Complications Study (EDIC), an observational study that continues to follow the patients previously enrolled in the DCCT, has demonstrated continued benefit from intensive treatment. [81, 82]

Benefits

Benefits of tight the 1 last update 14 Jul 2020 glycemic control include not only continued reductions in the rates of microvascular complications but also significant differences in cardiovascular events and overall mortality. These benefits occurred even though subjects in the intensively treated group and those in the standard treatment group maintained similar HbA1c levels (about 8%), starting 1 year after the DCCT ended. It is postulated that a “metabolic memory” exists and that better early glycemic control sets the stage for outcomes many years in the future.Benefits of tight glycemic control include not only continued reductions in the rates of microvascular complications but also significant differences in cardiovascular events and overall mortality. These benefits occurred even though subjects in the intensively treated group and those in the standard treatment group maintained similar HbA1c levels (about 8%), starting 1 year after the DCCT ended. It is postulated that a “metabolic memory” exists and that better early glycemic control sets the stage for outcomes many years in the future.

reverses diabetes type 2 olives (👍 onset symptoms) | reverses diabetes type 2 infohow to reverses diabetes type 2 for Increasing HbA1c levels correlated with increasing risk of developing heart failure in a study of 20,985 patients with type 1 DM. Thus, improved glycemic control should prevent heart failure as well. [83]

Risks

For many patients, the HbA1c target should be less than 7%, with a premeal blood glucose level of 80–130 mg/dL. However, targets should be individualized.

Individuals with recurrent episodes of severe hypoglycemia, cardiovascular disease, advanced complications, substance abuse, or untreated mental illness may require higher targets, such as an HbA1c of less than 8% and preprandial glucose levels of 100-150 mg/dL. The 2011 American Association of Clinical Endocrinologists (AACE) guidelines support the creation of individualized targets that consider these factors as part of a comprehensive treatment plan. [84]

Although tight glycemic control is beneficial, an increased risk of severe hypoglycemia accompanies lower blood glucose levels. The 2011 AACE guidelines for developing a comprehensive care plan emphasize that hypoglycemia should be avoided. [69]

In patients with type 1 DM, recurrent and chronic hypoglycemia has been linked to cognitive dysfunction. [85] This has important implications in the management of children with type 1 DM. [86]

An 18-year follow-up of the DCCT by Jacobson et al found that HbA1c levels and retinal and renal complications were independently linked to cognitive declines. No relation with macrovascular risk factors or severe hypoglycemic events was found. A smoking history was modestly associated with decrements in learning, memory, spatial information processing, and psychomotor efficiency. This information is useful in advising patients with type 1 DM interested in preserving cognitive function.

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Self-Monitoring of Glucose Levels

Optimal diabetic control requires frequent self-monitoring of blood glucose levels, which allows rational adjustments in insulin doses. All patients with type 1 DM should learn how to self-monitor and record their blood glucose levels with home analyzers and adjust their insulin doses accordingly.

Insulin-dependent patients ideally should test their plasma glucose daily before meals, in some cases 1-2 hours after meals, and at bedtime. In practice, however, patients often obtain 2-4 measurements each day, including fasting levels and levels checked at various other times (eg, preprandially and at bedtime).

Instruct patients with type 1 DM in the method of testing for urine ketones with commercially available reagent strips. Advise patients to test for urine ketones whenever they develop any of the following:

  • Symptoms of a cold, flu, or other intercurrent illness

  • Nausea, vomiting, or abdominal pain

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  • An unexpectedly high plasma glucose level on the 1 last update 14 Jul 2020 self-monitoringAn unexpectedly high plasma glucose level on self-monitoring

  • Persistent, rapid, and marked fluctuation in the degree of hyperglycemia

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Continuous Glucose Monitoring

Continuous glucose monitors (CGMs) contain subcutaneous sensors that measure interstitial glucose levels every 1-5 minutes, providing alarms when glucose levels are too high or too low or are rapidly rising or falling. CGMs transmit to a receiver, which either is a pagerlike device or is integral to an insulin pump. Looking at the continuous glucose graph and responding to the alarms can help patients avoid serious hyperglycemia or hypoglycemia.

CGMs have several drawbacks. First, there is a lag between glucose levels in the interstitial space and levels in capillary blood, so that the levels recorded by the CGM may differ from a fingerstick (capillary) glucose reading. For that reason, the trends (ie, whether the glucose levels are rising or falling) tend to be more helpful.

Second, patients may overtreat hyperglycemia (repeatedly giving insulin because the glucose levels do not fall rapidly enough—a phenomenon known as stacking), as well as overtreat low glucose levels (because the glucose levels rise slowly with ingestion of carbohydrate).

Use of CGMs may help to prevent significant glucose variability in patients receiving either multiple daily injection therapy or continuous insulin infusion therapy. [87] Additionally, continuous glucose monitoring is associated with reduced time spent in hypoglycemia. [88] Whether glucose variability is detrimental in the absence of hypoglycemia remains an unresolved question; in any event, variability leads to the expense of frequent testing.

reverses diabetes type 2 can drink alcohol (🔥 google scholar) | reverses diabetes type 2 danger zonehow to reverses diabetes type 2 for Guidelines from the Endocrine Society [89] recommend the use of real-time CGMs in adult patients with type 1 DM who have demonstrated that they are able to use these devices on a nearly daily basis. The guidelines suggest the intermittent use of CGM systems for short-term retrospective analysis in the following cases [89] :

  • Patients with suspected nocturnal hypoglycemia, dawn phenomenon, or postprandial hyperglycemia

  • Patients with hypoglycemic unawareness

  • Patients experimenting with important changes to their diabetes regimen (eg, instituting new insulin or switching from multiple daily injections to pump therapy)

The 2018 edition of the ADA’s Standards of Medical Care in Diabetes recommends that continuous glucose monitoring be used in all persons aged 18 years or older with type 1 DM (down from the previously recommended age of 25 years or above) in whom glycemic targets are unmet. [90]

A for 1 last update 14 Jul 2020 study comparing the performance of three CGM devices—Navigator (Abbott Diabetes Care), Seven Plus (Dexcom), and Guardian (Medtronic)—found the Navigator to be the most accurate. [6, 7] For commercial reasons, however, this device is no longer on the market in the United States, though it remains available in Europe, Israel, Australia, and other areas; the other two CGM devices are still available in the United States.A study comparing the performance of three CGM devices—Navigator (Abbott Diabetes Care), Seven Plus (Dexcom), and Guardian (Medtronic)—found the Navigator to be the most accurate. [6, 7] For commercial reasons, however, this device is no longer on the market in the United States, though it remains available in Europe, Israel, Australia, and other areas; the other two CGM devices are still available in the United States.

In September 2013, the US Food and Drug Administration (FDA) approved a sensor-augmented insulin pump system that includes an automated low-glucose suspend safety feature (Medtronic''s upper arm (via an office procedure), the device has a transmitter that is worn above the sensor, with the CGM employing a mobile app to show glucose values and trends. In addition, the app alerts the patient to high and low glucose values, with the transmitter also emitting on-body vibration alerts. The device is intended for adjunctive use, with fingerstick monitoring and twice-daily calibrations required. The implant lasts for up to 3 months before needing replacement. [96, 97]

Artificial pancreas

Closed-loop systems, also known as artificial pancreases, are in development for use in improving glycemic control in type 1 diabetes. These systems include a CGM that is in constant communication with an infusion pump, with a blood glucose device (eg, a glucose meter) utilized for CGM calibration. An external processor, such as a cell phone, runs control algorithm software, receiving data from the CGM. The data is used to perform a series of calculations, producing dosing instructions that are sent to the infusion pump. [98]

The artificial pancreases are being developed to administer either insulin or glucagon or a combination of the two agents. [99] A 1-month study in 20 patients indicated that, with regard to keeping blood glucose levels in the target range over a 24-hour period, round-the-clock use of closed-loop glucose control is more effective than use of a patient-controlled sensor-augmented pump. [100, 101]

In September 2016, the FDA approved the first artificial pancreas, Medtronic''s 2013 shift from a systolic target of 130 mm Hg to 140 mm Hg.)

  • With regard to physical activity, the document now advises limiting the time spent sitting to no longer than 90 min.

  • The ADA does not support e-cigarettes as alternatives to smoking or to facilitate smoking cessation.

  • Immunization against pneumococcal disease is recommended.

  • A new HbA 1c target of less than 7.5% for children is now recommended.

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    Glycemic Control During Serious Medical Illness and Surgery

    Serious medical illness and surgery produce a state of increased insulin resistance and relative insulin deficiency. Hyperglycemia can occur even in patients without diabetes as a consequence of stress-induced insulin resistance coupled with the use of dextrose-containing IV fluids. Increases in glucagon, catecholamines, cortisol, and growth hormone levels antagonize the effects of insulin, and the alpha-adrenergic effect of increased catecholamine levels inhibits insulin secretion. Counterregulatory hormones also directly increase hepatic gluconeogenesis.

    Much less is known about optimal blood glucose levels in hospitalized patients with preexisting diabetes whose hyperglycemia reflects both their diabetes and a stress response to illness. Nonetheless, it is clear that management of hospitalized patients with preexisting diabetes requires modification of treatment regimens to compensate for both the decreased caloric intake and the increased physiologic stress. Near-normal blood glucose levels should be maintained in medical and surgical patients with diabetes, for the following reasons:

    • To prevent the development of ketosis

    • To prevent electrolyte abnormalities and volume depletion secondary to osmotic diuresis

    • To prevent the impairment of leukocyte function that occurs when blood glucose levels are elevated

    • To prevent the impairment of wound healing that occurs when glucose levels are elevated

    Patients with type 1 DM must take in insulin and carbohydrate at all times to prevent ketosis. It is strongly recommended that continuous IV infusions of dextrose and insulin be used in patients who are undergoing general anesthesia or who are critically ill.

    Blood glucose levels must be measured with a glucose meter every hour, and the rates of insulin and dextrose infusion must be adjusted accordingly to prevent hypoglycemia or persistent hyperglycemia. [145] Algorithms are available for insulin infusions, and the use of a preprinted order facilitates administration and reduces dosing errors.

    For patients who are less seriously ill or are undergoing minor surgery, frequent blood glucose for 1 last update 14 Jul 2020 monitoring is not always possible. These patients may do as well with subcutaneously injected insulin. A basal bolus insulin regimen, rather than a sliding-scale regular insulin regimen, should be used in these patients.For patients who are less seriously ill or are undergoing minor surgery, frequent blood glucose monitoring is not always possible. These patients may do as well with subcutaneously injected insulin. A basal bolus insulin regimen, rather than a sliding-scale regular insulin regimen, should be used in these patients.

    The same principles of providing a constant source of insulin and carbohydrate apply to patients with type 1 DM who must also take nothing by mouth for medical reasons. Patients should receive a basal insulin (eg, glargine or detemir insulin) with additional correction doses of regular insulin or a rapid-acting insulin. In many localities, regular insulin has been replaced by rapid-acting insulin (eg, lispro, aspart, or glulisine)

    To prevent hypoglycemia, regular insulin should not be given more the 1 last update 14 Jul 2020 often than every 3-4 hours, because a dose is effective for up to 6 hours. Rapid-acting insulins may be given every 3 hours. Once the patient is eating, a preprandial insulin dose can be added.To prevent hypoglycemia, regular insulin should not be given more often than every 3-4 hours, because a dose is effective for up to 6 hours. Rapid-acting insulins may be given every 3 hours. Once the patient is eating, a preprandial insulin dose can be added.

    Cardiovascular disease or renal dysfunction increases surgical morbidity and mortality, and diabetic autonomic neuropathy increases the risk of cardiovascular instability. The emergency physician caring for patients with diabetes who require emergency surgery must notify the surgeon and the anesthesiologist of the patient’s condition, consult medical specialists when appropriate, and promptly initiate a thorough medical evaluation.

    Recent guidelines have trended away from stressing intensive glucose control in ill patients with diabetes. The ADA recommends that in critically ill patients, insulin therapy should be initiated if the glucose level exceeds 180 mg/dL (10 mmol/L), with a target range of 140-180 mg/dL (7.8-10 mmol/L) for the majority of critically ill patients. [5] More stringent goals, such as 110-140 mg/dL (6.1-7.8 mmol/L), may be appropriate for selected patients, provided that significant hypoglycemia can be avoided.

    In the absence of clear evidence for specific blood glucose goals in non–critically ill patients, the ADA suggests that reasonable targets are premeal blood glucose levels lower than 140 mg/dL (7.8 mmol/L) with random blood glucose levels below 180 mg/dL (10.0 mmol/L), provided that these targets can be safely achieved. [5] It may be appropriate to use more stringent targets in stable patients with previous tight glycemic control and less stringent targets in patients with severe comorbidities.

    The guidelines on glycemic control in hospitalized patients formulated by the American College of Physicians (ACP) recommend a target blood glucose level of 140-200 mg/dL if insulin therapy is used to manage patients with diabetes in nonsurgical (medical) intensive care units (ICUs). [146] These guidelines were based on a review of 21 trials in intensive care, perioperative care, myocardial infarction, stroke, or brain injury settings. [147]

    The ACP found no convincing evidence that intensive insulin therapy reduced short-term or long-term mortality, infection rates, length of hospital stay, or the need for renal replacement therapy. In recommending 200 mg/dL as the upper target, the ACP guidelines depart from the 2009 AACE/ADA consensus statement on inpatient glycemic control, which recommended a target range of 140-180 mg/dL in critically ill patients. [148]

    Nevertheless, in certain circumstances, such as after cardiovascular surgery and during treatment in a surgical ICU, it is very important to maintain near-normal blood glucose levels in patients with acute hyperglycemia of illness. These patients should receive sufficient insulin to maintain glucose levels around 100 mg/dL. [149]

    Perioperative blood glucose management

    Surgical procedures—including the preoperative emotional stress and the effects of general anesthesia as well as the trauma of the procedure itself—can markedly increase plasma glucose levels and induce DKA in patients with type 1 DM. (See Perioperative Management of the Diabetic Patient.) In patients going to surgery who have not received a dose of intermediate-acting insulin that day, injection of one third to one half of the total daily dose as NPH insulin or 80% of the dose as glargine or detemir insulin before surgery is often effective.

    At the same time, an IV infusion containing 5% glucose in either 0.9% saline solution or water should be started at a rate of 1 L (50 g glucose) over 6-8 hours (or 125-150 mL/h). Blood glucose levels should be checked every 2 hours during the surgical procedure, and small doses of regular or rapid-acting insulin (eg, lispro, aspart, or glulisine) should be given if values exceed 140 mg/dL.

    After the operation, check plasma glucose levels and assess for a reaction to ketones. Unless a change in dosage is indicated, repeat the preoperative dose of insulin when the patient recovers from the anesthesia, and continue the glucose infusion.

    Monitor plasma glucose and ketones at 2- to 4-hour intervals, and administer regular insulin every 4-6 hours for 1 last update 14 Jul 2020 as needed to maintain the plasma glucose level in the range of 100-250 mg/dL (ie, 5.55-13.88 mmol/L). Continue until the patient can be switched to oral feedings and a 2- or 3-dose insulin schedule.Monitor plasma glucose and ketones at 2- to 4-hour intervals, and administer regular insulin every 4-6 hours as needed to maintain the plasma glucose level in the range of 100-250 mg/dL (ie, 5.55-13.88 mmol/L). Continue until the patient can be switched to oral feedings and a 2- or 3-dose insulin schedule.

    Some physicians prefer to withhold subcutaneous insulin on the day of the operation and to add 6-10 units of regular insulin to 1 L of 5% glucose in normal saline or water infused at 150 mL/h on the morning of the operation, depending on the plasma glucose level. The infusion is continued through recovery, with insulin adjustments depending on the plasma glucose levels obtained in the recovery room and at 2- to 4-hour intervals thereafter.

    Postoperative IV insulin infusion after major surgical procedures is currently considered the standard of care in most hospitals.

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    Glycemic Control During Pregnancy

    Because pregnant patients with type 1 DM are at risk for multiple poor maternal and fetal outcomes, it is essential to provide these patients with prepregnancy counseling, good glycemic control before and during pregnancy, and a complete medical evaluation. (See Diabetes Mellitus and Pregnancy.) High-risk possibilities include exacerbation of existing hypertension, renal insufficiency, retinopathy, and more frequent congenital anomalies. These patients should be referred to obstetricians specializing in high-risk pregnancies.

    Despite advanced age, multiparity, obesity, and social disadvantage, patients with type 2 DM were found to have better glycemic control, fewer large-for-gestational-age infants, fewer preterm deliveries, and fewer neonatal care admissions than patients with type 1 DM. [150] This finding suggests that better tools are needed to improve glycemic control in patients with type 1 DM.

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    Prevention

    reverses diabetes type 2 kidney pain (🔥 weight loss) | reverses diabetes type 2 natural remedyhow to reverses diabetes type 2 for Significant improvements in the prediction of type 1 the 1 last update 14 Jul 2020 DM have led to several trials of prevention. These include the Diabetes Prevention Trial–Type 1 (DPT-1) in the United States and the European Nicotinamide Diabetes Intervention Trial (ENDIT) in Europe and North America. Both trials have reported disappointing results.Significant improvements in the prediction of type 1 DM have led to several trials of prevention. These include the Diabetes Prevention Trial–Type 1 (DPT-1) in the United States and the European Nicotinamide Diabetes Intervention Trial (ENDIT) in Europe and North America. Both trials have reported disappointing results.

    In DPT-1, parenteral insulin failed to delay or prevent type 1 DM in subjects at elevated risk (as indicated by family history and the presence of islet cell antibodies). These subjects received low-dose subcutaneous Ultralente insulin twice daily, plus annual 4-day continuous IV infusions of insulin. [151] DPT-1 subjects who received oral insulin experienced considerable delays in the onset of diabetes, but once therapy was stopped, their rate of developing diabetes increased to a rate similar to that seen in the placebo group. [152]

    In the ENDIT study, nicotinamide (which prevents autoimmune diabetes in animal models) did not prevent or delay the clinical onset of diabetes in people with a first-degree family history of type 1 DM. Subjects in the treatment arm received oral modified-release nicotinamide in a dose of 1.2 g/m2. [153]

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    In animal models of autoimmunity, treatment with a target antigen can modulate aggressive autoimmunity. However, a trial of antigen-based immunotherapy with 2 or 3 doses of glutamic acid decarboxylase formulated with aluminum hydroxide (GAD-alum) vaccine for 4-12 weeks in patients with newly diagnosed type 1 DM did not alter the course of loss of insulin secretion during the first year. [154]

    A phase 3 trial using an anti-CD3 the 1 last update 14 Jul 2020 monoclonal antibody, teplizumab, found an encouraging trend toward preservation of beta-cell function with reduction in daily insulin requirements in patients with recently diagnosed type 1 DM. However, rash was almost 3 times more common in treated patients than in those receiving placebo. [155] A phase 3 trial using an anti-CD3 monoclonal antibody, teplizumab, found an encouraging trend toward preservation of beta-cell function with reduction in daily insulin requirements in patients with recently diagnosed type 1 DM. However, rash was almost 3 times more common in treated patients than in those receiving placebo. [155]

    A study by Orban et al found that costimulation modulation of activated T cells with abatacept slowed reduction in beta-cell function over a 2-year period of administration. However, this effect was reduced after 6 months of treatment, suggesting that T-cell activation lessens over time. Further studies are needed. [156]

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    Consultations

    Patients with type 1 DM should be referred to an endocrinologist for multidisciplinary management. They should also undergo a complete retinal examination by an ophthalmologist at least once a year. Those patients with significant proteinuria or a reduced creatinine clearance should be referred to a nephrologist. Patients with significant foot involvement should see a podiatrist.

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    117. Suissa S, Azoulay L, Dell''Vulnerable Subgroup''IMAGE''VIDEO''s Association, Medical Society of the State of New York, and Society of Teachers of Family Medicine

      Disclosure: Nothing to disclose.

      Anne L Peters, MD, CDE Director of Clinical Diabetes Programs, Professor, Department of Medicine, University of Southern California, Keck School of Medicine, Los Angeles, California, Los Angeles County/University of Southern California Medical Center

      Anne L Peters, MD, CDE is a member of the following medical societies: American College of Physicians and American Diabetes Association

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      reverses diabetes type 2 treatment options (☑ graph) | reverses diabetes type 2 oliveshow to reverses diabetes type 2 for Frederick H Ziel, MD Associate Professor of Medicine, University of California, Los Angeles, David Geffen School of Medicine; Physician-In-Charge, Endocrinology/Diabetes Center, Director of Medical Education, Kaiser Permanente Woodland Hills; Chair of Endocrinology, Co-Chair of Diabetes Complete Care Program, Southern California Permanente Medical Group

      Frederick H Ziel, MD is a member of the following medical societies: American Association of Clinical Endocrinologists, American College of Endocrinology, American College of Physicians, American College of Physicians-American Society of Internal Medicine, American Diabetes Association, American Federation for Medical Research, American Medical Association, American Society for Bone and Mineral Research, California Medical Association, Endocrine Society, andInternational Society for Clinical Densitometry

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