During the 1990s, diabetes mellitus emerged as an international health crisis. Much of the attention has focused on type 2 diabetes, reflecting the skyrocketing incidence of obesity and associated illness around the world. Many oral therapies are available for type 2 diabetes, and practicing physicians are generally knowledgeable about their use. However, given the progressive nature of type 2 diabetes, more than one oral antidiabetic agent is often required, and combination oral therapy is now considered the standard of care for most patients. Continued progression of the disease causes oral therapy to eventually fail in many patients, requiring exogenous insulin either as monotherapy or in combination with oral agents. Thus, when glycemic control is not achievable in the type 2 diabetic patient as determined by failure to achieve the target HbA,c level with traditional oral therapies, it is appropriate to consider insulin.
Insulin therapy has undergone major changes over the last few years. Insulin analogs (often referred to as designer insulins) are now available that closely approximate the delivery of insulin from a healthy pancreas. Injection equipment is easy to use, and for most patients injections are painless. Further, in a few years we will likely have inhaled insulin or some other noninvasive approach for insulin delivery. However, these advances have not been easily integrated into clinical practice. Insulin therapy of both type 1 and type 2 diabetes remains a difficult, frustrating experience for physicians and patients, reflecting most patients' wish to avoid self-injection therapy, plus the concerns of many physicians
ft about hypoglycemia, weight gain, or worsening cardiovascular risk. Contributing to this is a dearth of educational material regarding insulin therapy; many caregivers do not feel knowledgeable about how to use insulin optimally.
The current volume is intended to be a comprehensive, up-to-date, clinically based resource for practicing providers and those in training regarding insulin therapy. Contributors were charged to use a "how to" format, but also to include physiological and pharmacological concepts to make understandable the design and troubleshooting of inpatient and outpatient insuJin programs.
The book is divided into three sections. Part I (Chapters 1-6) provides a general background: a rationale for optimal glycemia control in diabetes and standards of care, injection and glucose-monitoring equipment, dietary practices, physiology of insulin secretion and blood glucose regulation, and pharmacokinetics of the available insulin preparations. Part II (Chapters 7-12) applies these principles to specific patient populations: those with type 1 and type 2 diabetes, children, inpatients, pregnant women, and patients experiencing hyperglycemic emergencies. Part 111 (Chapters 13-15) addresses prevention and therapy of hypoglycemia, insulin pumps, and noninvasive approaches for insulin delivery.
There is one style issue. The term "analog" is used throughout the text: prior medical literature mostly used "analogue," but this alternative spelling is now increasingly used.
We would like to thank the many contributors to this volume. Without their diligence, patience, and humor, this project would have remained simply a fantasy of the editors.
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