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A Journal on Internal Medicine
Indexed/Abstracted in: Current Contents/Clinical Medicine, EMBASE, PubMed/MEDLINE, Science Citation Index Expanded (SciSearch), Scopus
Impact Factor 1,236
Minerva Medica 2003 December;94(6):387-400
Antidiabetic therapy in diabetic patients with coronary heart disease
The role of metabolic control following acute myocardial infarction, (AMI) is still subject of study to date. The only study performed in diabetic patients with an AMI is the DIGAMI which demonstrated that endovenous insulin therapy in the acute phase, followed by multiple subcutaneous administrations of insulin therapy in the follow-up, was able to obtain not only a better metabolic control in both the acute phase and in the follow-up, but also a better survival only in the follow-up. Even if this latter fact is disappointing, endovenous insulin infusion seems to be the best approach to effectively contrast the metabolic events secondary to hyperglycemia which accompany AMI. From the DIGAMI study derives the indication of multiple insulin injections in diabetic patients having survived an AMI, even if doubt still exists as to whether it is the insulin therapy in itself or rather the metabolic compensation obtained that is responsible for a better survival rate. There is no controversy regarding the use of multiple (3 but above all 4/day) subcutaneous rapid insulin administrations at meal time and retard insulin administrations at bed time. Over the last few years ultrarapid insulin has become available as well the newcomer glargine, a retard insulin, which presents a homogenous 24 hour release pattern. These insulin forms, obtained by genetic engineering, allow for a 4 daily dose administration, ultrarapid at meal times and glargine once daily, which mimic a more physiological insulin secretion and as such probably render them more efficacious.
When oral drugs are opted for, it is imperative to have acquaintance with their half-lives, bonding properties with K+ATP channels, the antioxidant and antithromobophylic properties. It is necessary to modulate their use considering the glycemic daily rhythm in diabetics (glycemia tending to be high in the early morning and low in the evening). In order to obtain an optimal metabolic control it is essential to have the patient perform a glycemia level self-assessment by means of portable measuring instruments which employ instantaneous reactive strips. Self-assessment is imperative for the prevention of hypoglycemic episodes considered particularly dangerous in diabetic patients with coronary heart disease, even if studies which have demonstrated and documented this danger do not exist.