Type 2 diabetes mellitus and insulin resistance: Stroke prevention and management |
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Authors: | Walter N Kernan Silvio E Inzucchi |
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Institution: | (1) Department of Medicine, Yale University School of Medicine, P.O. Box 208025, 06520 New Haven, CT, USA |
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Abstract: | Opinion statement Clinically recognized disorders of glucose metabolism include impaired fasting glucose, impaired glucose tolerance (both termed
prediabetes), and diabetes mellitus. Type 2 diabetes mellitus affects 6% to 13% of adults in the United States. Among patients
with recent stroke, 70% will have known diabetes, occult diabetes (detectable on an oral glucose tolerance test), or prediabetes.
Type 2 diabetes mellitus is associated with a two- to six-fold increased risk for first or recurrent ischemic stroke. The
mechanisms for the association are myriad and include the effects of hyperglycemia on vascular tissues and coagulation, and
aberrations in blood pressure regulation, lipid metabolism, endothelial function, vascular inflammation, lipid metabolism,
smooth muscle cell proliferation, and fibrinolysis. The most effective strategies to prevent stroke among people with diabetes
include blood pressure control, antiplatelet therapy, and statin therapy. Tight glycemic control is recommended to prevent
microvascular disease, but the effect on macrovascular disease, including stroke, has not been proven. Target blood pressure
should be less than 130/80. Antiplatelet therapy may be accomplished with 81 to 325 mg of aspirin daily or 75 mg of clopidogrel
daily. Statins should be given in dosages effective to reduce lowdensity lipoprotein cholesterol to less than 100 mg/dL. For
glycemic control, first line therapy for most patients is metformin, starting at 500 mg daily. With time, most patients will
need two or three oral medications from different classes and many eventually will require insulin therapy. Prevention of
diabetes may be best accomplished by identifying those at risk and modifying diet, weight, and exercise habits. Screening
for prediabetes and diabetes is appropriate for men and women older than 45 years and all individuals with vascular disease.
Insulin resistance and impaired insulin secretion is the major underlying defect in type 2 diabetes mellitus. It also affects
50% of nondiabetic subjects with a recent ischemic stroke. Emerging evidence has linked insulin resistance to the pathophysiologic
derangements in type 2 diabetes mellitus that accelerate atherosclerosis. Treatment of insulin resistance with weight loss,
exercise, or medication can correct these derangements, and represents a promising approach to stroke prevention. |
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