By R. Armon. Maranatha Baptist Bible College.
Hypoglycemia treat- use and carbohydrate intake and exer- with type 1 diabetes generic apcalis sx 20mg on line, found no associa- ment requires ingestionofglucose-orcar- cise are necessary buy 20mg apcalis sx with amex, but these strategies tion between frequency of severe hypo- bohydrate-containing foods. Pure glucose awareness (or hypoglycemia-associated Severe hypoglycemia was associated is the preferred treatment, but any form of autonomic failure) can severely compro- withmortalityinparticipantsinboththe carbohydrate that contains glucose will mise stringent diabetes control and qual- standard and the intensive glycemia arms raise blood glucose. Ongoing insulin activity or insulin release, especially in older adults, and a treatment intensity were not straightfor- secretagogues may lead to recurrent hypo- diminished autonomic response, which ward. An association of severe hypoglyce- glycemia unless further food is ingested af- both are risk factors for, and caused by, mia with mortality was also found in the ter recovery. An association be- normal, the individual should be counseled cycle” is that several weeks of avoidance tween self-reported severe hypoglycemia to eat a meal or snack to prevent recurrent of hypoglycemia has been demonstrated and 5-year mortality has also been report- hypoglycemia. Hence, patients with one or more The use of glucagon is indicated for the and the elderly are noted as particularly episodes of clinically signiﬁcant hypogly- treatment of hypoglycemia in people un- vulnerable to clinically signiﬁcant hypo- cemia may beneﬁt from at least short- able or unwilling to consume carbohy- glycemia because of their reduced ability term relaxation of glycemic targets. Those in close contact to recognize hypoglycemicsymptoms and with, or having custodial care of, people effectively communicate their needs. Impact reduces severe hypoglycemia in hypoglycemia- panied by ketosis, vomiting, or alteration in of self monitoring of blood glucose in the man- unaware patients with type 1 diabetes. Diabetes agement of patients with non-insulin treated Care 2013;36:4160–4162 the level of consciousness, marked hyper- diabetes: open parallel group randomised trial. Adequate ﬂuid and 1174–1177 insulin-pump interruption for reduction of hy- caloric intake must be ensured. N Engl J Med 2013;369:224–232 dehydration is more likely to necessitate Farmer A; Diabetes Glycaemic Education and 26. Cost effectiveness of Safety of a hybrid closed-loop insulin delivery self monitoring of blood glucose in patients system in patients with type 1 diabetes. A ofbloodglucose inpatientswithtype 2diabetes clinical trial of continuous subcutaneous insulin and the hyperglycemic nonketotic hyper- mellitus who are not using insulin. Juvenile Diabetes Research Foundation Con- 28:1568–1573 in Adult Patients With Diabetes” (69). Continuous glu- Diabetes Control and Complications Trial/ cose monitoring and intensive treatment of type 1 Epidemiology of Diabetes Interventions and References diabetes. As- strong association between frequency of self- guided pump therapy in type 1 diabetes: a rand- sociation of glycaemia with macrovascular and monitoring of blood glucose and hemoglobin omised controlled trial. Frequent monitoring of A1C during niﬁcantly reduces A1C levels in poorly con- T1D Exchange clinic registry. Diabetes Care 2008;31:1473–1478 test strips in veterans with type 2 diabetes mel- 2014;51:845–851 33. Diabe- tients who self-monitor blood glucose and their glucose monitoring on hypoglycemia in type 1 tes Care 2016;39:1462–1467 unused testing results. Choosing wisely [Internet], Continuous Glucose Monitoring Study Group, glucose concentrations in children with type 1 2013. Accessed 18 ousglucose monitoringinwell-controlledtype 1 cose determinations by sensors. Sustained beneﬁtof betes screening with hemoglobin A1c versus fast- detemir with insulin glargine when adminis- continuous glucose monitoring on A1C, glucose ing plasma glucose in a multiethnic middle-school tered as add-on to glucose-lowering drugs in proﬁles, and hypoglycemia in adults with type 1 cohort. Treat-to-target trials: uses, inter- parative effectiveness and safety of methods cose in children with type 1 diabetes. Diabetes of insulin delivery and glucose monitoring for Care 2010;33:1025–1027 Obes Metab 2014;16:193–205 diabetes mellitus: a systematic review and 37. Acta Diabetol 2016;53:57–62 time continuous glucose monitoring signiﬁcantly gression of diabetic retinopathy in patients with S56 Glycemic Targets Diabetes Care Volume 40, Supplement 1, January 2017 type 1 diabetes: 18 years of follow-up in the cardiovascular disease in patients with type 1 58. Diabetes Control and Complications Trial/ tes, 2015: a patient-centered approach: update Trial/Epidemiology of Diabetes Interventions Epidemiology of Diabetes Interventions and to a position statement of the American Diabe- and Complications Research Group. Diabetes Care 2001;24: sive insulin therapy prevents the progression of ventions and Complications and Pittsburgh 775–778 diabetic microvascular complications in Japa- Epidemiology of Diabetes Complications Expe- 60. Effect of intensive blood-glucose control tion between 7 years of intensive treatment of Glucose concentrations of less than 3. Lan- 2015;313:45–53 joint position statement of the American Diabe- cet 1998;352:854–865 51. Lan- Association and a scientiﬁc statement of the group of the American Diabetes Association cet 1998;352:837–853 American College of Cardiology Foundation and the Endocrine Society.
Effects on impulsive aggression (67) and anger (44) were independent of effects on affective symptoms generic 20 mg apcalis sx otc, including depressed mood (44 apcalis sx 20mg on line, 67) and anxiety (67). Side effects reported in these studies are consistent with routine clinical usage. One investigator used very high doses of sertraline (200–600 mg/day) for nonresponders, with some improved effi- cacy (45). The duration of treatment is therefore a clinical judgment that depends on the patient’s clinical status and medication tolerance at any point in time. Tricyclic and heterocyclic antidepressants a) Goals In borderline personality disorder, antidepressants are used for affective dysregulation, mani- fested most commonly by depressed mood, irritability, and mood lability. Evaluation of anti- depressant trials in the treatment of borderline personality disorder must take into account the presence of comorbid axis I mood disorders, which are common in patients with borderline personality disorder. Studies in which there is a preponderance of comorbid axis I depression would be expected to demonstrate a favorable response to antidepressant treatments but may not reflect the pharmacological responsiveness of borderline personality disorder. Mianserin, a tetracyclic antidepressant not available in the United States, has been used in an outpatient setting. Most of these studies were parallel comparisons with anoth- er medication and placebo. A 5-week inpatient study of patients with borderline personality disorder that compared amitriptyline (mean dose=149 mg/day) with haloperidol and placebo found that amitriptyline decreased depressive symptoms and indirect hostility and enhanced attitudes about self-control compared with placebo (51). It is interesting to note that amitrip- tyline was not effective for the “core” depressive features of the Hamilton Depression Rating Scale but rather was effective for the seven “associated” symptoms of diurnal variation, deper- sonalization, paranoid symptoms, obsessive-compulsive symptoms, helplessness, hopelessness, and worthlessness. Treatment of Patients With Borderline Personality Disorder 57 Copyright 2010, American Psychiatric Association. A small open-label study that assessed the use of amoxapine (an antidepressant with neuro- leptic properties) in patients with borderline personality disorder with or without schizotypal personality disorder found that it was not effective for patients with only borderline personality disorder (174). However, it was effective for patients with borderline personality disorder and comorbid schizotypal personality disorder, who had more severe symptoms. This latter group had improvement in cognitive-perceptual, depressive, and global symptoms (174). In outpatients with a primary diagnosis of atypical depression (which required a current di- agnosis of major, minor, or intermittent depression plus associated atypical features) and bor- derline personality disorder as a secondary diagnosis, imipramine (200 mg/day) produced global improvement in 35% of patients with comorbid borderline personality disorder. The presence of borderline personality disorder symptoms predicted a negative global response to imipramine but a posi- tive global response to phenelzine. One longer-term study was conducted in patients hospitalized for a suicide attempt who were diagnosed with borderline personality disorder or histrionic personality disorder but not axis I depression (175). In this 6-month, double-blind, placebo-controlled study of a low dose of mianserin (30 mg/day), no antidepressant or prophylactic efficacy was found for mianserin compared with placebo for mood symptoms or recurrence of suicidal acts. The toxicity of tricyclic antidepressants in overdose, including death, indicates that they should be used with caution in patients at risk for suicide. Patients with cardiac con- duction abnormalities may experience a fatal arrhythmia with tricyclic antidepressant treat- ment. For some inpatients with borderline personality disorder, treatment with amitriptyline has paradoxically been associated with behavioral toxicity, consisting of increased suicide threats, paranoid ideation, demanding and assaultive behaviors, and an apparent disinhibition of impulsive behavior (50, 177). If tricyclic antidepressants are used, the patient should be care- fully monitored for signs of toxicity and paradoxical worsening. Doses used in published stud- ies were in the range of 150–250 mg/day of amitriptyline, imipramine, or desipramine. Blood levels may be a useful guide to whether the dose is adequate or toxicity is present. In an outpatient study of phenelzine versus imipra- mine that selected patients with atypical depression (with borderline personality disorder as a secondary comorbid condition), global improvement occurred in 92% of patients given 60 mg/ day of phenelzine compared with 35% of patients given 200 mg/day of imipramine (57). In a study of tranylcypromine, trifluoperazine, alprazolam, and carbamazepine in which borderline personality disorder was a primary diagnosis but comorbid with hysteroid dysphoria (55), tranylcypromine (40 mg/day) improved a broad spectrum of mood symptoms, including de- pression, anger, rejection sensitivity, and capacity for pleasure. When borderline personality disorder is the primary diagnosis, with no selection for atypical depression or hysteroid dysphoria, results are clearly less favorable. Soloff and colleagues (56) studied borderline personality disorder inpatients with comorbid major depression (53%), hysteroid dysphoria (44%), and atypical depression (46%); the patient group was not selected for presence of a depressive disorder. Phenelzine was effective for self-rated anger and hostility but had no specific efficacy, compared with placebo or haloperidol, for atypical depression or hysteroid dysphoria.
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