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netransmisibile (NCDs)?
1.Bolile cardiovasculare; Stroke
2. Diabetul zaharat
3. Cancerele
4. Bolile cronice respiratorii
WHO, 2011
Diabetul zaharat
Prima cauza de orbire
PREDATORR Study
~90% dintre persoanele
cu diabet zaharat de tip 2
sunt supraponderale sau
obeze
110
de varsta
100
90
80
70
60
1980 1982 1984 1986 1988 1990 1992 1994 1996
Anul
0
10,025 61 6629 279 631 24
(Patient Numbers)
Whitehall Paris Helsinki
Study Prospective Study Policemen Study
Balkau. Lancet 1997; 350: 1680.
Diabetul zaharat de tip 2 cauza majora
de mortalitate
Fifth leading cause of death after infections,
CVD, cancer, and accidents
10
9 8.6 8.8
attributable to diabetes (%)
Men
8 Women
Excess mortality
6.9
7 6.6
6.0 6.1
6 5.4
5.1
5 4.8
4 3.4
3 2.5
2.2
2
0
Africa Americas Eastern Europe Southeast Western
Mediterranean Asia Pacific
Diabetici
Non-diabetici
100 100
% supravieuitorilor
% supravieuitorilor
Brbai Femei
90 90
80 80
70 n=16 70 n=568
28
60 60
50 50
40 n=228 40 n=1
56
0 10 20 30 40 50 60 0 10 20 30 40 50 60
Luni Post-IM
Sprafka et al. Diabetes Care. 1991; 14: 537-543.
Riscul coronarian este echivalent
pentru diabetici i pentru nediabeticii
cu un IM in antecedente
P < 0.001
P < 0.001
P < 0.001
Fr Diabet Cu Diabet
800.000 1.500.000
1 2 % din masa
pancreatic total
Celule: A, B, G, D, PP
Insulinosecreia normal, bifazic
prima A doua
faz
faz
Declanarea
insulino-secreiei
INCHIDEREA CANALULUI KATP PRIN LEGAREA
UNEI MOLECULE DE ATP LA UNUL DIN CELE 4
SITUSURI DE PE SUR1
Insulinosecreia fiziologic profil 24 ore
Secreia insulinei
Pulsatorie
Bifazic
INSULIN SECRETION FOLLOWING
INTRADUODENAL OR INTRAVENOUS GLUCOSE
200
oral
intravenous
90
INSULIN (mU/L)
150
GLUCOSE (mg/100ml)
70
50
100
30
10 50
-10
-30 0
0 15 30 45 60 75 90 0 15 30 45 60 75 90
TIME (min) TIME (min)
Insulin Utilizarii
glucozo-dependenta glucozei in
tesuturile
(GLP-1 si GIP)
periferice
Eliberarea hormonilor -cells
-cells
incretinici -cells Concentratiei
GLP-1 si GIP glucozei pre- si
postprandial
X
DPP-4 Glucagon
DPP-4
enzyme Glucozo-dependenta
inhibitor
(GLP-1) Productiei
hepatice de
glucoza
Metabolit Metabolit
GLP-1 GIP
(non-insulinotrop)
Vezicule de Ca2+
PKC
PKA
Esteri Acetil CoA
GLP-1 cu lant lung Exocitoza
insulinei
Acizi grasi cu lant lung
(acid palmitic acid miristic)
PKA - Proteinkinaza A
PKC Proteinkinaza C
Intestin
Cand mancam glucoza
intestin in sange creste
Cresterea glicemiei
induce eliberarea de
pancreas
insulina insulina
Gligogenul se desface in
glucoza si se produce glucoza
Glucoza din proteine
Insulina
Glucagon
Glicogen
Insulina productie si actiune
Controlul hormonal al glicemiei
Insulina Hormoni de contrareglare
Efect net: scderea glicemiei Efect net: creterea glicemiei
NGT : Normal glucose tolerance IR: Insulin Resistance - IS : Insulin Sensitivity - CF : Cell function
Adapted from Kahn SE, Prigeon RL, McCulloch DK, Boyko EJ, Bergman RN, Schwartz MW, Neifing JL, Ward WK, Beard JC, Palmer JP et al. Quantification of the relationship
between insulin sensitivity and beta cell function in human subjects. Evidence for a hyperbolic function. Diabetes 1993, 42: 1663-72. Bergman RN, Ader M. Huecking K, Van Citters G.
Accurate assessment of beta-cell function: the hyperbolic correction. Diabetes 2002, 51 Suppl. 1: S212-20. Bergman RN. Pathogenesis and prediction of diabetes mellitus: lessons
from integrative physiology. Mt Sinai J Med. 2002, 69: 280-90.
IS x CF defines a functional area
that determines glucose
homeostasis
NGT : Normal glucose tolerance IR: no Insulin Resistance (i.e. normal insulin sensitivity) - CF : Cell
function
Adapted from Kahn SE, Prigeon RL, McCulloch DK, Boyko EJ, Bergman RN, Schwartz MW, Neifing JL, Ward WK, Beard JC, Palmer JP et al. Quantification of the relationship
between insulin sensitivity and beta cell function in human subjects. Evidence for a hyperbolic function. Diabetes 1993, 42: 1663-72. Bergman RN, Ader M. Huecking K, Van Citters G.
Accurate assessment of beta-cell function: the hyperbolic correction. Diabetes 2002, 51 Suppl. 1: S212-20. Bergman RN. Pathogenesis and prediction of diabetes mellitus: lessons
from integrative physiology. Mt Sinai J Med. 2002, 69: 280-90.
Hyperbolic relation between IS x
CF in NGT and T2DM subjects
Adapted from Kahn SE, Prigeon RL, McCulloch DK, Boyko EJ, Bergman RN, Schwartz MW, Neifing JL, Ward WK, Beard JC, Palmer JP et al. Quantification of the relationship between
insulin sensitivity and beta cell function in human subjects. Evidence for a hyperbolic function. Diabetes 1993, 42: 1663-72. Bergman RN, Ader M. Huecking K, Van Citters G. Accurate
assessment of beta-cell function: the hyperbolic correction. Diabetes 2002, 51 Suppl. 1: S212-20. Bergman RN. Pathogenesis and prediction of diabetes mellitus: lessons from integrative
physiology. Mt Sinai J Med. 2002, 69: 280-90.
Hyperbolic relation between IS x CF
NGT : Normal glucose tolerance IFG/IGT: Impaired Fasting Glucose/Impaired Glucose Tolerance T2M:
Type 2 Diabetes Mellitus
Adapted from Kahn SE, Prigeon RL, McCulloch DK, Boyko EJ, Bergman RN, Schwartz MW, Neifing JL, Ward WK, Beard JC, Palmer JP et al. Quantification of the relationship
between insulin sensitivity and beta cell function in human subjects. Evidence for a hyperbolic function. Diabetes 1993, 42: 1663-72. Bergman RN, Ader M. Huecking K, Van Citters G.
Accurate assessment of beta-cell function: the hyperbolic correction. Diabetes 2002, 51 Suppl. 1: S212-20. Bergman RN. Pathogenesis and prediction of diabetes mellitus: lessons
from integrative physiology. Mt Sinai J Med. 2002, 69: 280-90.
Type 2 Diabetes: Major Metabolic Defects
IS : Insulin sensitive
Hafner SM et al. Diabetes Care 1999;22:562-
568
The Metabolic Syndrome: Historical
Perspective
1988: Syndrome X
Insulin
Insulin
Resistance
Resistance
Glucose
Glucose Hyperinsulinemia TG Hypertension
Intolerance
Intolerance
Hyperinsulinemia TG HDL-C
HDL-C Hypertension
Coronary
Coronary Heart
Heart Disease
Disease
Insulin
Insulin Resistance
Resistance
+
Hyperinsulinemia
Hyperinsulinemia
Glucose
Glucose Uric
Uric Acid
Acid Dyslipidemia Hemodynamic Novel
Novel Risk
Risk
Metabolism Dyslipidemia Hemodynamic
Metabolism Metabolism
Metabolism Factors
Factors
Glucose Uric acid TG SNS activity CRP
intolerance Urinary PP lipemia Na retention PAI-1
uric acid HDL-C Hypertension Fibrinogen
clearance PHLA
Small, dense LDL
Coronary
Coronary Heart
Heart Disease
Disease
Adapted from Reaven G. Drugs 1999;58(suppl):19-20 with permission from WolthersKluwer Health.
Defining the metabolic syndrome
WHOa EGIRb NCEPc IDFd
Insulin Insulin resistance FPG Central
resistance (hyperinsulinaemia obesity
&/or FPG
Plus 2 or more of
Central Central obesity Central FPGe
obesity obesity
BP BP BP BPe,f
TG, HDL-C TG, HDL- TG TGf
Cf
Microalbumin HDL-C HDL-Cf
uria aWorld Health Organisation; bEuropean Group for the study of Insulin
resistance;
cNational Cholesterol Education Program; dInternational Diabetes
Federation
eor diagnosis of diabetes or hypertension as applicable; fand/or
Definiia sindromului metabolic (IDF, 2009)
High Metabolic
LDL-C Syndrome
Type 2
Diabetes
Poliurie
Polidipsie
Polifagie
Scdere ponderal
Astenie
CRITERIILE PENTRU DIAGNOSTICUL
DIABETULUI ZAHARAT
simptome clasice de diabet + glicemie plasmatic
ntmpltoare 200mg/dl (11,1 mmol/l)
- simptomele clasice de diabet includ poliuria, polidipsia, polifagia i
scderea inexplicabil n greutate;
- glicemia ntmpltoare se refer la recoltare fr relaie cu ultimul prnz.
Sau
Normal
- bazal < 110 mg/dl (7 mmol/l)
- la 2 h dup glucoz < 140 mg/dl (7,8 mmol/l)
VALORI DIAGNOSTICE PENTRU DIABET ZAHARAT I
ALTE CATEGORII DE HIPERGLICEMIE
Snge integral
venos capilar Plasma
venoas
mg/dl (mmol/l) mg/dl (mmol/l)
Diabet zaharat
Pe nemncate sau 110 (6,1) 110 (6,1) 126 (7,0)
La 2 ore dup glucoz 180 (10,9) 200 (11,1) 200 (11,1)
Scderea toleranei la glucoz
Pe nemncate i < 110 (<6,1) i < 110 (<6,1) i < 126 (<7,0) i
La 2 ore dup glucoz 120 (6,7) 140 (7,8) 140 (7,8)
Glicemie bazal modificat
Pe nemncate 100 (5,6) i 100 (5,6) i 110 ( 6,1) i
< 110 (<6,1) < 110 (<6,1) < 126 (<7,0)
Glicozilarea neenzimatic a proteinelor
Proporional cu - conc. glucozei din sg.
- durata meninerii ei
ADA. Tests of glycemia in diabetes. Diabetes Care 2003; 26 (Suppl 1): S106-S108.
Risc pentru
ochi, rinichi,
Diabet nervi
STG Risc
CV
Limita glicemiei
normale
Gerstein H. 2003
CLASIFICAREA DIABETULUI ZAHARAT
Diabetul gestaional
Diagnosis and types
Curriculum Module II-1
Slide 15 of 48
Trigger
Immunological
Genetic abnormalities
Beta-cell
mass Clinical
diabetes
Pre-diabetes Honeymoon
Chronic
phase
Time (months - years)
Ateroscleroza
Retinopatie Orbire
Susceptibilitate genetic
Diagnostic Nefropatie Boal renal n
Factori de mediu Neuropatie stadiul final Deces
Amputare
Boal coronarian
Tip 2
Intoleran la glucoz Diabet - Hiperglicemie
Insulino-rezisten Ateroscleroza
Hiperinsulinemie
HDL-C
Trigliceride
Hipertensiune
Factorii de risc implicai n patologia
diabetului zaharat tip 2
vrst (ani)
20
Normal
30
Gene Insulino-rezisten Ambient
40
Deficienta de secretie
Diabetogene 50
a insulinei Obezitate
primare
secundare Diet
Gene legate de diabet Activitate fizic 60
Diabet tip II
Insulin resistant;
low insulin secretion (54%)
83%
Insulin sensitive;
good insulin
secretion (1%)
Insulin resistant;
good insulin secretion
(29%)
Non-Diabetic State
Diabetic State
S
L L MAS
-C E
N C TION
&F U
N
L I N SULI
A
R I P HER
PE TANC
E
SI S
RE
Chris Rhodes Ph.D.
PNRI, Seattle, WA.
DZ tip 2 deficitul insulinosecreiei
postprandiale
800
Persoane nediabetice
insulinosecretie (pmol/min)
DZ tip 2
600
400
200
0
6 am 10 am 2 pm 6 pm 10 pm 2 am 6 am
timp
100
75
-Cell 50
function
(%)
IGT Postprandial Type 2 Type 2 Diabetes
25 Hyperglycemia Diabetes Phase III
Phase I Type 2
Diabetes
Phase II
0
-12 -10 -6 -2 0 2 6 10 14
Diagnosis
Years from diagnosis
Dashed line shows extrapolation forward and backward from years 0 to 6 based on HOMA data from UKPDS.
Insulin Hyperinsulinemia,
secretion then -cell failure
Post-
Abnormal
prandial
glucose tolerance
glucose
Fasting Hyperglycemia
glucose
*IGT = impaired glucose tolerance
Adapted from Type 2 Diabetes BASICS. International Diabetes Center (IDC), Minneapolis, 2000.
Numeroi factori contribuie la declinul progresiv
al funciei celulei pancreatice
Hiperglicemie
(toxicitatea glucozei)
Insulinorezisten
Glicarea Lipotoxicitate
proteinelor Celula (creterea AGL, Tg)
Development of Type 2 Diabetes
Role of obesity in insulin resistance
Caloric
intake
Free Oxidative
Visceral Sedentary fatty acids stress Insulin
Obesity lifestyle Glucose resistance
Inflammation
Genetic Lipids
factors
Deteriorarea
Lipoliz crescut
secreiei insulin
Celule
Secreie crescut
Vas sangvin
glucagon
Reabsorbie
Celule Hiper- crescut a
glicemie glucozei
Hiperproductie
hepatica de glucoza
Utilizare sczut a
glucozei
Disfuncia neurotransmitorilor
hypertrofie atrofie
Capacitatea Insulino-
insulino- rezistenta
secretorie
0 100
Etiopatogenia DZ 2
Factori genetici transmitere poligenic
Rezisten crescut la aciunea insulinei
Hiperinsulinism funcional
Deficien n secreia insulinic hiperglicemie persistent
Tulburri insulinosecretorii
- caracterului pulsator al insulinei
- dispariia fazei precoce a rspunsului insulinic
- ntrzierea secreiei de insulin
Scderea absolut a secreiei insulinice
DZ 2 insulinonecesitant
INSULINOREZISTENTA SI
INSULINODEFICIENTA IN DZ 2
Insulin
Resistance
Euglycaemia
Normal IGT obesity Diagnosis of Progression of
type 2 diabetes type 2 diabetes
FPG PPG
Postprandial
Fasting Glucose Variabilitatea glucose
glicemica
HbA1c
Perioada postprandial predomin
Legend:
perioada postprandial;
perioada postabsorbtiv;
jeun
hyperglycaemia
contributes HbA1c ~1%
200 Post-prandial
hyperglycaemia
Fasting
hyperglycaemia
100
Normal
HbA1c ~5%
0
6 B 12 L 18 D 24 6
Time of day (h)
B=breakfast; L=lunch; D=dinner.
Adapted from Riddle MC. Diabetes Care. 1990;13:676-686.
OBIECTIVE BIOMEDICALE PENTRU CONTROLUL
DIABETULUI ZAHARAT
20
16
Progression rate
12
8%
8
4 7%
0
1 2 3 4 5 6 7 8 9
Intensive group:
0.45
Mean HbA1c 7.1%
0.40
Mean blood glucose 8.6 mmol/l
0.35
Density estimate
Conventional group:
0.30
Mean HbA1c 9.0%
0.25
Mean blood glucose 12.8 mmol/l
0.20
0.15
0.10
0.05
0.00
5 6 7 8 9 10 11 12 13 14
Glycosylated haemoglobin (%)
DCCT Group. Diabetes 1995;44:96883.
Glycaemic control throughout EDIC
Conventional group
12
Intensive group
10
HbA1c %
DCCT 1 2 3 4 5 6 7 8
Closeout
EDIC year
EDIC Group. Diabetes Care 1999;22:99111.
Sustained risk reduction from improved
control
0.5 Conventional group
Intensive group
0.4
Cumulative incidence
0.3
0.2
0.1
0
0 1 2 3 4 5 6 7
Tratamentul dietetic
Exerciiul fizic
Modul
EducatiMonitorizar
e e,
Stil de viata
Evaluare
Metformin
Terapia orala plus
insulina
Terapia orala
combinata
Monoterapia orala
N.Hancu, 2008
ALIMENTAIA SNTOAS 5 CRITERII
Adecvat alimentele consumate s aduc nutrieni eseniali, fibre i
energie n cantiti suficiente pentru meninerea sntii i a greutii
corpului.
Echilibrat nu trebuie s prevaleze un nutriment sau aliment n
defavoarea altuia (respectarea proporiilor).
Controlat caloric se refer la aportul energetic care trebuie s
corespund nevoilor metabolice; astfel se asigur controlul greutii
corporale.
Moderat atenie la posibile excese alimentare precum sarea, grsimile,
zahrul sau alt component peste anumite limite.
moderaie, nu abstinen!
Variat evitarea consumului unui anumit aliment, chiar nalt nutritiv, zi
dup zi, pentru perioade lungi de timp.
Dietoterapia n diabetul zaharat
http://www.ms.ro/?pag=185
Tratamentul dietetic n diabetul zaharat tip 2
Schimb
stilul de via Restrnge caloriile
Monitorizeaz
glicemia i pentru normalizarea
medicaie greutii
Controlul glicemic
Modific cant.
Respect orarul
de grsimi
meselor
ingerat
inte terapeutice recomandate ADA
PARAMETRU INT
Glicemie preprandial (capilar) 70-130 mg/dl (3,9-7,2 mmol/l)
Glicemie postprandial (capilar) < 180 mg/dl (10,0 mmol/l)
HbA1c < 7,0%
LDL-colesterol < 100 mg/dl
Trigliceride < 150 mg/dl
HDL-colesterol > 40 mg/dl (B), > 50 mg/dl (F)
TA < 140/80 mmHg
Diabetes Care
2014;37(suppl.1):120-143.
inte terapeutice recomandate ADA
Necesarul nutriional individual n funcie de:
ndulcitori i suplimente
Aportul de buturi alcoolice
Aportul de sare
Pattern-uri alimentare
-
IEIRI
+ Ceea ce
INTRRI arzi
Ceea ce
mnnci
Creterea ponderal
Echilibrul alimentar
-
INTRRI
Ceea ce
mnnci
IEIRI +
Ceea ce
arzi
Pierdere n greutate
Terapia nutriional n diabet
Balana energetic
- G beneficii importante
- Cantitate individualizat
- Legume i
vegetale
- Fructe
- Cereale
integrale Diabetes Care 2014;37(suppl.1):120-
Terapia nutriional n diabet
Macronutrieni - glucide
- Index glicemic
- ncrctura
glicemic
Fibre alimentare
14 g/1000 kcal
- Cereale
integrale?
Indicele glicemic
Reprezintbazafiziologicaierarhizriialimentelor,n
funciedeefectullorasupraglicemieipostprandiale,
cuimplicaiiimportanteasuprasntiipublice.
Indexulglicemic(glicemicindexGI)estedefinit
prinariaincrementalacurbeiderspunsglicemic,
indusdeocantitatede50gdeglucidedisponibile,
proveninddintrunalimenttestat,exprimatn
procentealerspunsuluiprodusfatadeocantitatede
glucideegalafurnizatdeunalimentdereferin/
control(glucozaGI=100),consumatdeacelai
subiect
Definitia Indexului glicemic
Glicemia
(mmol/l)
4
0 0.5 1 1.5 2 2.5 Timp (h)
Indicele glicemic
-In functie de digestia si absorbtia glucidelor (proprietile fizice i chimice)
-concentraia n glucide a alimentelor
- coninutul de proteine i lipide al alimentelor, indexul glicemic fiind cu
att mai redus cu ct concentraia acestora este mai mare;
- coninutul n fibre alimentare, indexul glicemic fiind cu att mai redus
cu ct cantitatea acestora este mai mare;
- prezena de amidon greu digerabil;
- mrimea particulelor de amidon;
- forma fizic a hranei;
- coninutul hidric al alimentelor;
- temperatura alimentelor;
- prezena inhibitorilor enzimatici naturali i a unor substane cum sunt
fitaii i taninele;
- gradul de prelucrare mecanic prin masticaie. raportul dintre amilose /
amylopectin:
Indexul Glicemic
GI (Glucoza) = 100%
Sczut 0 to 10
Intermediar 11 to 19
Inalt 20
GI = 60 GL = 48 GI = 42 GL = 31
Pictures of Low/High GI Meals & Snacks
GI = 80 GL = 32 GI = 61 GL = 12
Terapia nutriional n diabet
- Risc de hipoglicemie!!!
- Agravarea afectrii
pancreatice i hepatice
Etapele alctuirii unei diete
Transformarea n alimente
Individualizarea dietei!
REGULI N ALCTUIREA UNEI DIETE
DENSITATE ENERGETIC
- procentajul de kcal pe gramul de aliment
- este invers proporional cu volumul alimentelor
- cu ct un aliment este mai srac n lipide densitatea sa energetic
este mai
mic
alimente cu densitate energetica foarte mica < 0,6 calorii/gram
alimente cu densitate energetica mica 0,6-1,5 calorii/gram
alimente cu densitate energetica medie 1,5-4 calorii/gram
alimente cu densitate energetica inalta > 4 cal/gram
DENSITATE NUTRIIONAL
- coninutul n nutrimente nonenergetice (sau de proteine) pentru 100 kcal de
aliment
- un aliment avnd o densitate nutriional optim pentru un nutriment dat
va conine o mare cantitate din acel nutriment i un slab aport de lipide.
Fructe / Legume (amidon) Carne
slab
Grsimi solide
Vegetale
Cte porii din fiecare etaj al piramidei
ar trebui s consumai zilnic?
1 porie 1 uncie
Farfuria
sntoas
Terapia nutriional n diabet
Echilibrul alimentar se
defineste simplu prin aporturi si
consumuri
(1888-1971)
Clasificarea insulinelor
Dup provenien - animale
- de tip uman
Convenional
Intensificat
Insulinoterapia intensificat
Insuline prandiale
Insuline bazale
Insulinemia plasmatic la persoane cu
diabet zaharat tip 1 i subieci sntoi
N=8 Subieci sntoi N=24 DZ1
480 Regular Human Insulin
Humalog
400
320
pmol/L240
160
80
0
07:00 12:00 18:00 24:00 06:00 h
Momentul
zilei Ciofetta M et al. Diabetes Care 1999;22(5):795-800.
Efectele insulinei in cadrul regimurilor de tratament
conventionale
Lebovitz HE, Therapy for Diabetes Mellitus and Related Disorders, 2004
Efectele insulinei in cadrul regimurilor de
tratament cu multi-injectii
Lebovitz HE, Therapy for Diabetes Mellitus and Related Disorders, 2004
Efectele insulinei in cadrul regimurilor de
tratament cu multi-injectii
Lebovitz HE, Therapy for Diabetes Mellitus and Related Disorders, 2004
Analogii de insulin cu aciune rapid
Insuline prandiale
Mai eficiente dect insulina regular n reducerea
hiperglicemiei postprandiale
Prin hiperglicemiei postprandiale efect mai bun
dect insulina regular asupra reducerii complicaiilor
DZ
Efect redus asupra ameliorrii HbA1c comparativ cu
insulina regular
Risc redus de hipoglicemie
Caracteristicile analogilor de
insulin cu aciune rapid
Disociaz rapid n monomeri n esutul s.c.
Variabilitate mai mic a absorbiei de la locul de injectare
Variabilitate mai mic inter- i intraindividual
Profil imunogenic similar cu al insulinei umane
Comparativ cu doze echivalente de insulin regular:
- determin o concentraie maxim dubl
- timpul n care se atinge conc. max. e de 2 X mai mic
Tratamentul bazal-bolus cu analogi de
insulin
Insulinemia plasmatic (U/mL)
75
mic dejun prnzul cina
25 Glargine
sau
Detemir
Subinsulinizarea
Fenomenul Somogyi
Cile de administrare
Dispozitivele de administrare
Pompa de insulin
Indicaiile insulinoterapiei
MiniMed 670G System
INDICATIILE INSULINOTERAPIEI in DZ2
Insulinoterapie definitiva
DZ tip 1 (LADA)
DZ tip 2 la care medicatia orala in asociere si la doze
suficiente nu induce controlul glicemic propus
Complicatii cronice evolutive
Insuficientele severe de organ
Insulinoterapie temporara
Afectiuni acute: IMA, infectii cu diferite localizari
Interventii chirurgicale (pre-, intra- si postoperator)
Sarcina
Coma hiperglicemica hiperosmolara
Scopurile insulinoterapiei temporare
Anihilarea glucotoxicitii
Insulinoterapia este:
- terapia indicat pacienilor cu DZ tip 2 dac se
are n vedere:
- glucotoxicitatea i lipotoxicitatea
- insuficienta producere a insulinei endogene
- contraindicaii la ADO
Levy P, 2004
Polonsky KS et al. N Engl J Med. 1988;318:1231-1239
Polonsky KS et al. N Engl J Med. 1988;318:1231-1239
Polonsky KS et al. N Engl J Med. 1988;318:1231-1239
Strategie terapeutic propus
Hipoglicemia
Creterea n greutate
Lipodistrofia
Abcesele la locul injeciei
Alergia la insulin
Producia de anticorpi la preparatele insulinice
Neuropatia dureroas (temporar)
Scderea acuitii vizuale (temporar)
Lineage relationships
during pancreatic Glucagon Insulin
development
Duodenum Endocrine precursors
?
Endodermal precursor
Pancreatic precursor Ductal
Time