Treatment of diabetes mellitus

Insulin therapy is aimed at maximum compensation of diabetes mellitus and prevention of progression of its complications. Treatment with insulin can have both a permanent lifelong character for patients with type 1 diabetes, and temporary, caused by different situations for patients with type 2 diabetes.

Indications for insulin therapy

1. Type 1 diabetes.
2. Ketoacidosis, diabetic, hyperosmolar, hyperlacidemic coma.
3. Pregnancy and childbirth with diabetes.
4. Significant decompensation of type II diabetes mellitus, caused by various factors (stressful situations, infections, injuries, surgical interventions, exacerbation of somatic diseases).
5. Absence of effect from other methods of treatment of type II diabetes mellitus.
6. Significant weight loss in diabetes mellitus.
7. Diabetic nephropathy with impaired renal nitrogen function in type II diabetes mellitus.

Currently, there is a large range of insulin preparations that differ in the duration of action (short, medium and long), the degree of purification (monopic, monocomponent) and species specificity (human, pork, cattle - beef).

The Pharmaceutical Committee of the Ministry of Health of the Russian Federation recommends using only monocomponent preparations of human and porcine insulin for treatment of patients, as beef insulin causes allergic reactions, insulin resistance, lipodystrophy.

Insulin is released in vials of 40 U / ml and 100 U / ml for administration by subcutaneous injection with disposable syringes, specially designed for the use of insulins of the appropriate concentration of 40-100 U / ml.

In addition, insulin is released in the form of pencil-insoles with an insulin concentration of 100 U / ml for syringe pens. Penfill can contain insulins of different duration of action and combined (short + prolonged action), so-called microstards.

For the use of patients, various syringe pens are manufactured, allowing one to 36 units of insulin to be injected once. Novopen I, II, and III pen-syringes are produced by Novonordisk (1.5 and 3 ml liners), Optipin 1, 2 and 4 by Hoechst (liners 3 ml), Berlenpen 1 and 2 "- the company" Berlin-Chemie "(liners 1.5 ml)," Lilipen "and" B-D Pen "- the company" Eli Lilly "and" Becton-Dickenson "(liners 1.5 ml).

Domestic production is represented by syringes-handles "Kristall-3", "In-sulpen" and "Insulpen 2".

In addition to the traditional insulin, the insulin analogue "Humalog" (firm "Eli Lilly"), obtained by permuting the amino acids of lysine and proline in the insulin molecule, is used in the treatment of patients. This led to an acceleration of the manifestation of its hypoglycemic action and to a significant shortening of it (1-1.5 h). Therefore, the drug is administered immediately before meals.

For each patient, diabetes is individually selected one or another type of insulin in order to improve overall health, achieve a minimum glucosuria (no more than 5% of the sugar value of food) and allowable for this patient fluctuations in blood sugar levels during the day (not more than 180 mg% ). JS Skyler and M. L. Reeves believe that the criteria for its compensation should be more stringent in order to more reliably prevent or slow down the manifestations of diabetic microangiopathy and other late metabolic complications of diabetes mellitus. For patients prone to hypoglycemic conditions, the glucose level before meals can be 120-150 mg / 100 ml.

Criteria for the compensation of diabetes mellitus

Time of study	The level of glucose (mg / 100 ml)
	Ideal	Allowable
On an empty stomach before breakfast	70-90	70-110
Before meals during the day	70-105	70-130
1 hour after eating	100-160	100-180
2 hours after eating	80-120	80-150

When choosing insulin, you should take into account the severity of the disease, the previously used therapy and its effectiveness. In polyclinic conditions, the criteria for choosing insulin are fasting glycemia, glucose profile data or daily glucosuria. In the hospital there are great opportunities for a more correct appointment of insulin, as a detailed examination of carbohydrate metabolism is carried out: a glycemic profile (determination of sugar in the blood every 4 hours during the day: 8-12-16-20-24-4 hours), 5- one-time glucosuric profile (the first portion of urine is collected from breakfast to lunch, the second from lunch to dinner, the third from dinner to 22 hours, the fourth from 22 to 6 hours, and the fifth from 6 up to 9 hours). Insulin is prescribed depending on the level of glycemia and excessive glucosuria.

All insulins, depending on the method of their preparation, can be conditionally divided into 2 main groups: heterologous insulin from the pancreas of cattle and swine and homologous human insulin from the pig's pancreas (semisynthetic) or obtained by bacterial synthesis.

At present, mono-highly purified insulins (monopic and monocomponent) that are devoid of impurities are produced. These are predominantly preparations of porcine insulin with different duration of action. They are used mainly for allergic reactions to bovine insulin, insulin resistance, lipodystrophy. Certain hopes were placed on the use in human practice of human semisynthetic and genetically engineered insulin. However, the expected significant differences in the hypoglycemic effect or the effect on the formation of antibodies to insulin in comparison with monocomponent pig insulin have not been found.

Thus, at present, industrial production of various insulin guilds has been set up, the prolonged action of which depends on special treatment and addition of protein and zinc to them.

Patients with newly diagnosed diabetes mellitus and hyperglycemia and glucosuria that do not eliminate hyperglycemia and glucosuria within 2-3 days are required insulin therapy. If the body weight of the patient has deviations from the ideal not more than ± 20% and there are no acute stressful situations and intercurrent infections, the initial dose of insulin can be 0.5-1 ED / kg-day (based on ideal weight body) followed by correction for several days. Short-acting insulin can be used in the form of 3-4 single injections or a combination of a short insulin with an extended one. JS Skyler and M. L. Reeves [86] recommend even in the phase of remission to appoint patients with insulin dose 0.4 U / kg-day, and pregnant women (within the first 20 weeks) - 0.6 U / kg- day). The dose of insulin for patients with diabetes mellitus, already treated earlier, should not, as a rule, exceed, on average, 0,7 units / (kg-day) in terms of ideal body weight.

Presence in the practice of drugs of different duration of action led first to the tendency to create "cocktails" to provide a sugar reduction effect during the day with a single injection. However, this method did not allow good compensation in most cases, especially in the labile course of the disease. Therefore, in recent years, various regimes of insulin administration have been used to ensure maximum compensation of carbohydrate metabolism within the range of glycemia fluctuation during the day from 70 to 180 or 100-200 mg / 100 ml (depending on the criteria). The applied regimens of insulin therapy in patients with type I diabetes are largely due to factors such as the presence and severity of residual secretion of endogenous insulin, as well as the involvement of glucagon and other contrinsular hormones in eliminating significant fluctuations in blood sugar (hypoglycemia) and the degree of insulin response to the injected components of food, glycogen stores in the liver, etc. The most physiological is the regime of reusable (before each meal) insulin injections, which allows to stop postpr andial hyperglycaemia. However, it does not eliminate hyperglycaemia on an empty stomach (at night), since the duration of the action of simple insulin until the morning is not enough. In addition, the need for frequent injections of insulin creates a known inconvenience for the patient. Therefore, the regime of repeated introduction of insulin is most often used to quickly achieve the compensation of diabetes as a temporary measure (for the elimination of ketoacidosis, decompensation against intercurrent infections, as preparation for surgery, etc.). Under normal conditions, injections of simple insulin are usually combined with the administration of an extended-time drug in the evening hours, given the peak time of their action to prevent night hypoglycemia. Therefore, in a number of cases, "tape" and "long" drugs are administered after the second dinner before bedtime.

The most convenient for students and working patients is a two-fold mode of insulin administration. In this morning and in the evening, short-acting insulin is administered in combination with medium or long-acting insulin. If at 3-4 o'clock in the morning there is a decrease in blood sugar below 100 mg / 100 ml, then the second injection is transferred to a later time, so that the sugar reduction is necessary in the morning, when you can examine the level of glycemia and take food. In this case, the patient should be transferred to a 3-time mode of insulin administration (in the morning - a combination of insulin, before dinner - simple insulin and before bedtime - prolonged). Calculation of the dose of insulin when transferring the patient to 2-time injections is as follows:% of the total daily dose is administered in the morning and 1/3 - in the evening; 1/3 of each calculated dose is insulin of short action, and 2/3 - of prolonged. With insufficient compensation for diabetes, increase or decrease the dose of insulin, depending on the blood sugar level at a specific time of day no more than 2-4 units a single.

Accordingly, the beginning and the maximum effect of each type of insulin and the number of injections distributed meals during the day. Approximate ratios of the daily diet are: breakfast - 25%, lunch - 15%, lunch - 30%, lunch - 10%, dinner - 20%.

The degree of compensation for diabetes on the background of ongoing therapy is assessed by the glycemic and glucosuric profile, the content of hemoglobin HbA _1c in the blood and the level of fructosamine in serum.

Methods of intensive insulin therapy

Along with the traditional methods of insulin therapy, since the early 1980s, the regime of reusable (3 or more) insulin injections during the day (basal-bolus) has been used. This method allows you to maximally reproduce the rhythm of insulin secretion by the pancreas of a healthy person. It is proved that the pancreas of a healthy person secrets 30-40 units of insulin per day. It is established that the secretion of insulin in healthy people occurs constantly, but at different rates. Thus, between meals, the secretion rate is 0.25-1.0 U / h, and during meals 0.5-2.5 U / h (depending on the nature of the food).

At the heart of the regime of intensive insulin therapy is the imitation of the constant secretion of the pancreas - the creation of a basal insulin level in the blood by introducing a long or intermediate action at a dose of 30-40% of the daily insulin before bedtime at 22 h. During the day before breakfast, lunch and dinner, sometimes before the 2 nd breakfast introduce short-acting insulin in the form of supplements - boluses depending on the need. Insulin therapy is carried out with the help of syringes-pens.

When using this method, the blood glucose level is maintained within 4-8 mmol / l, and the content of glycosylated hemoglobin is within its normal values.

The regime of intensive insulin therapy by means of multiple injections can be carried out only if there is motivation (desire of the patient), active learning it, the possibility to investigate the glucose level at least 4 times a day (test - strips or a glucometer) and constant contact of the patient with the doctor.

Indications for intensive care are newly diagnosed type I diabetes, childhood, pregnancy, absence or initial stages of microangiopathy (retino-, nephropathy).

Contraindications for the use of this method of insulin therapy are:

1. propensity to hypoglycemic conditions (if at bedtime glucose level <3 mmol / l, then night hypoglycemia occurs in 100% of cases, and if <6 mmol / l, then in 24%); 
2. presence of clinically pronounced microangiopathy (retino-, neuro-, nephropathy).

The side effects of intensive insulin therapy are a possible worsening of the manifestations of diabetic retinopathy and a 3-fold increase in the risk of hypoglycemic conditions (nocturnal and asymptomatic), weight gain.

Another method of intensive insulin therapy is the use of wearable insulin micropumps, which are dosing devices filled with short-acting insulin and injecting insulin under the skin in batches according to a predetermined program. Side effects are similar, plus possible pump failure and risk of ketoacidosis. The micropumps are not widely used.

The goal of intensive insulin therapy is an ideal compensation of carbohydrate metabolism to prevent the development of clinical forms of late complications of diabetes that do not undergo reverse development.

A number of countries have mastered the production of individual wearable devices based on the principle of diffusion pumps, by means of which insulin under pressure, with a speed that is regulated as required, enters through the needle under the patient's skin. The presence of several, regulating the intake of insulin regulators allows you to set the mode of its administration for each patient under the control of the level of glycemia individually. The inconvenience of use and disadvantages of these devices include the lack of a feedback system, the possibility of bedsores, despite the use of plastic needles, the need to change the area of insulin administration, as well as the difficulties associated with fixing the apparatus on the patient's body. The described diffusion pumps have found application in clinical practice, especially in the labile form of diabetes mellitus. In this case, the chamber of the diffusion pump can be filled with any kind of insulin of short action, including homologous.

Other methods of treatment with human insulin, associated with the transplantation of the pancreas or its fragments, have not yet been widely spread due to serious obstacles due to manifestations of tissue incompatibility. Failure to try and find methods for oral administration of insulin (on polymers, liposomes, bacteria).

Transplantation of pancreatic islet cell culture

Allo- and xenotransplantation is used as an auxiliary method for the treatment of type 1 diabetes mellitus. For allografts, microfragments of pancreas tissue of human fetuses (abortion material) are used, and for islet transplantation - islets or isolated beta cells of newborn piglets or rabbits. Insulin pig and rabbit differ in their structure from the human one amino acid. Typically, prior to transplantation, the donor material is cultured in vitro. When cultivated, the immunogenicity of islet cells is reduced. Allo- or xenogeneic islets and beta-cells are implanted into the spleen, liver or muscle. In most patients, the need for insulin decreases. The duration of this effect ranges from 8 to 14 months. The main result of transplantation is the inhibition of the development of chronic complications of type I diabetes mellitus. Some patients noted the reverse development of retinopathy and neuropathy. Apparently, islet tissue transplantation should begin at the stage of preclinical disorders characteristic of chronic complications of diabetes.

The main therapeutic effect can be caused not only by insulin, but also by the C-peptide. Since reports appeared that prolonged intramuscular administration of C-peptide to patients with type 1 diabetes mellitus for 3-4 months stabilizes the course of diabetes, improves kidney function and causes the reverse development of diabetic neuropathy. Mechanisms of this action of the C-peptide have not yet been elucidated, however, stimulation of Na ⁺ -K ⁺ -ATPase in the renal tubules has been observed . An assumption is made about the possibility of treatment with insulin in combination with a C-peptide.

Investigations of non-traditional ways of insulin administration are continuing: intra-rectally, in the form of inhalations, intranasally, as subcutaneous polymer granules undergoing biodegradation, as well as the creation of individual devices with a feedback system.

It is hoped that the serious research in this field will lead in the near future to a positive solution to the crucial task of radical improvement of insulin therapy in diabetic patients.

Physical activity

During physical exercises in working muscles, metabolic processes are intensified, aimed at replenishing the consumed energy. There is an increase in the utilization of energy substrates in the form of muscle glycogen, glucose and fatty acids, depending on the intensity and duration of exercise. Energy costs for intensive, but short-term physical activity, which lasts for several minutes, are replenished by muscle glycogen. A longer (40-60 min) and intense physical activity is accompanied by an increase of about 30-40 times the utilization of glucose. With an even longer muscular load, fatty acids become the main energy substrate, since glycogen stores in the liver decrease by 75% after 4 hours of operation.

The level of glycemia with intensive muscle work depends on two differently directed processes: the rate of utilization of glucose by muscles and the factors that ensure the entry of glucose into the blood. The main role in maintaining a normal level of glucose in the blood of healthy people is enhanced gluconeogenesis, glucogenolysis, activation of the sympathetic-adrenal system and contrinsular hormones. The secretion of insulin is somewhat reduced. In patients with diabetes mellitus, the body's response to physical stress may be different depending on the baseline level of glycemia, which reflects the degree of compensation for diabetes mellitus. If the sugar in the blood did not exceed 16.7 mmol / L (300 mg%), then physical exercises cause a decrease in glycemia, especially in those who are engaged regularly, and a decrease in insulin requirements by 30-40%. In one of the freestyle, a daily run of 25 km contributed to a decrease in the insulin's previously produced insulin (30 units), and later to its complete cancellation. However, it should be borne in mind that incomplete replenishment of energy costs, ie, inadequate and untimely intake of carbohydrates with food before physical exertion with a constant dose of insulin can cause a hypoglycemic state with subsequent hyperglycemia and ketoacidosis.

In patients with decompensated diabetes mellitus, if the baseline level of glycemia exceeds 19.4 mmol / L (350 mg%), physical activity causes activation of the contrinsular hormones and increased lipolysis, since the free energy fat is the main energy substrate for working muscles (in conditions of insulin deficiency) acid. Strengthening of lipolysis promotes and ketogenesis, because of what in insufficiently compensated patients with type I diabetes, with physical activity, ketoacidosis often occurs. The information available in the literature on the role of duration and intensity of physical activity during diabetes mellitus indicates an increase in glucose tolerance by increasing the sensitivity of insulin-dependent tissues to the action of exogenous or endogenous insulin, possibly due to the increase or activation of insulin receptors. However, the interdependence between the sugar reducing effect of physical activity, due to the increase in the energy expenditure of the organism, the necessary dose of insulin and the degree of adequate energy replenishment due to food carbohydrates, was not clearly quantified. This circumstance requires a cautious approach to the use of physical exertion in the treatment of diabetes mellitus, especially type I.

Energy consumption for various types of physical activity

Type of load	Energy costs, kcal / h	Type of load	Energy costs, kcal / h
State of rest: lying standing While eating Walk at a speed of 4 km / h Walk downhill Driving a car Playing volleyball Bowling Biking at a speed of 9 km / h	60 84 84 216 312 169 210 264 270	Swimming at a speed of 18 m / min Dancing Works in the garden Playing tennis Skiing Carpentry work Digging the Earth Two-stage trial of the Master Jogging	300 330 336 426 594 438 480 492 300

It must be remembered that the indications for an increase in physical activity depend not only on the degree of compensation for diabetes, but also on concomitant diseases and complications. So, diabetic retinopathy, especially proliferating, is a contraindication, since physical exercises, causing an increase in blood pressure, can contribute to its progression (hemorrhage, detachment of the retina). In patients with diabetic nephropathy, proteinuria increases, which also may adversely affect its course. In patients with type II diabetes, the presence of indications and contraindications to physical activity depends on the concomitant diseases of the cardiovascular system. In the absence of contraindications to the use of physical exercises as an additional therapeutic measure, you need to increase the intake of carbohydrates or reduce the dose of insulin before exercise. It should be remembered that the subcutaneous injection of the drug over the area of working muscles is accompanied by a significant acceleration of its absorption.

Phytotherapy for diabetes mellitus

In the treatment of diabetes mellitus, and used herbal products, which are decoctions, for example from the leaves of blueberries, and tinctures of various herbs: zamanichi, ginseng, eleutterococcus. A good effect is also provided by official plant kits - arfazetine and myphasine, produced in our country and used as a decoction.

The composition of arfazetine includes: blueberry (shoots) - 0.2 g, beans (leaves) - 0.2 g, zamaniha high (roots) - 0.15 g, horsetail field (grass) - 0.1 g, chamomile flowers) - 0.1 g.

Phytotherapy can be used only as an additional method against the background of the main type of treatment for diabetes mellitus.

Treatment of patients with diabetes mellitus during surgery

At present, this disease is not a contraindication for any operations. The number of patients with diabetes mellitus in surgical clinics is 1.5-6.4% of the total number of people requiring surgical intervention. Before the planned operations, it is necessary to compensate for diabetes, the criteria of which are the elimination of ketoacidosis, hypoglycemic conditions, the increase in glycemia during the day to no more than 180-200 mg% (10-11.1 mmol / l), the absence of glucosuria or its decrease to 1%. In addition, violations of water-electrolyte metabolism (dehydration or fluid retention and changes in potassium content in the blood serum), acid-base balance (the presence of metabolic acidosis) are regulated. Particular attention in preparing for surgery should be turned to the elimination of cardiac, pulmonary and renal failure. Heart failure and myocardial infarction are the most frequent complications during surgery and during the postoperative period and are 9% and 0.7%, respectively. Preoperative preparation includes the use of cardiac glycosides, diuretics, hypotensive and vasodilating agents. Correction of renal failure includes antibiotic therapy in the presence of urinary tract infection, the use of antihypertensive drugs, diet therapy. A significant role in the preparation for the operation is played by the state of coagulating and anti-coagulating blood systems. Hypercoagulable syndrome is often observed in patients with myocardial infarction, cholecystitis and with diabetic gangrene, which leads to the need for the use of direct and indirect anticoagulants. Compensation of diabetes mellitus in the preoperative period can be achieved by diet, sulfanilamide preparations or insulin of short or prolonged action. Indications for surgical intervention, choice of anesthesia and treatment tactics for patients are determined by a consultation of specialists, including surgeon, anesthesiologist, therapist and endocrinologist.

If surgical intervention does not interfere with the intake of food and medicines or the restrictions are short-term, the planned surgery may be performed against the background of the diet (if the glycemia does not exceed 11.1 mmol / L - 200 mg% - and there is no ketoacidosis within 24 hours) or hypoglycemic drugs, when the compensation of diabetes is achieved by medium doses of sulfonamide drugs. If higher allowable doses are required to compensate, and fasting blood sugar exceeds 150 mg% (8.3 mmol / l), the patient should be transferred to insulin or added to oral therapy.

Malotraumatic surgeries are performed against a background of diet therapy or treatment with sulfonamide drugs (SP). The patients are operated on in the morning on an empty stomach. Sulfanilamidnye drugs patients take after surgery in normal doses together with a meal. In preparation for surgery and in the postoperative period, biguanides are excluded. Significant differences in the course of the postoperative period and the glycemic profile in patients operated on the background of diet therapy or the use of sulfanilamide preparations, insulin, was not.

All patients with type I diabetes, as well as type II diabetes mellitus (for abdominal operations and contraindications to food intake in the postoperative period), it is necessary to translate into operation short-acting insulin before the operation. In routine operations, the basal level of glycemia should be 6.5-8.4 mmol / l, and the highest glucose level in capillary blood is not more than 11.1 mmol / l. Compensation of carbohydrate metabolism during and after surgery is achieved by intravenous drip injection of insulin with glucose and potassium chloride.

The total amount of glucose per day should be 120-150 g. The concentration of glucose in the administered solution is determined by the volume of liquid recommended in each specific case.

Calculation example: the amount of glucose that is supposed to be administered during the day (for example, 120 g), and the daily dose of insulin (48 units) is divided by 24 hours and the amount of glucose and insulin is obtained, which must be administered intravenously every hour, i.e. For of the selected example, 5 g / h glucose and 2 U / h insulin.

Since the operation induces a patient's stress response, involving adrenaline, cortisol, STH, glucagon, which increase glycemia due to suppression of glucose utilization by insulin-dependent tissues, increase in gluconeogenesis and glycogenolysis in the liver, the amount of glucose administered (120-150 g) is sufficient to prevent excessive hypoglycemic the action of the usual daily dose of insulin. Control of the level of glycemia is carried out every 3 hours and if necessary change the amount of insulin or glucose injected intravenously. Intravenous introduction of insulin and glucose during surgery is not accompanied by large fluctuations of glycemia during the day and does not cause insulin resistance, which is an advantage of this method. The described method of treatment is used and in the postoperative period, until the patient is not allowed oral intake of food. After this, it is transferred to the mode of subcutaneous administration of simple or prolonged insulin.

In the presence of purulent processes, it is not always possible to achieve full compensation for diabetes mellitus due to expressed insulin resistance and intoxication. In this case, surgical intervention can be performed at a level of glycemia exceeding 13.9 mmol / L (250 mg%), and even in the presence of ketoacidosis. The mode of insulin administration should be intravenous. As a rule, after an operation that facilitates the removal of a foci of pyogenic infection from the body and the use of antibiotics, the daily need for insulin decreases and ketoacidosis disappears. Given the danger of hypoglycemia, it is necessary to continue the study of blood sugar every 2-3 hours for 3-5 postoperative days.

In recent years, in the foreign surgical practice, a standard glucose-potassium-insulin (GCR) mixture, proposed by Albert and Thomas for patients with type I and type II diabetes, is used for intravenous drip insulin injection. It consists of: 500 ml of a 10% solution of glucose, 15 units of short-acting insulin and 10 ml of a 10 ml solution of potassium chloride. The ratio of insulin / glucose is 0.3 U / g.

Infusion of this solution begins immediately before the operation and is continued for 5 hours. The rate of injection of glucocorticoids is 100 ml / h. The basal level of glucose should be 6.5-11.1 mmol / l. With the introduction of this variant of the mixture, the patient receives 3 units of insulin and 10 g of glucose per hour. If the basal level of glucose exceeds 11.1 mmol / l, the amount of insulin added to the mixture increases to 20 units, and with a decrease in basal glycemia <6.5 mmol / l - decreases to 10 units. With these options, the amount of insulin injected intravenously is 10 g of glucose 4 and 2 units per hour, respectively. If you need a long infusion of glucocorticosteroids, you can change the dose of added insulin or the concentration of glucose.

In addition to the initial level of glycemia, the insulin requirement during surgery can be affected by insulin resistance, which is observed in certain conditions and diseases. If in uncomplicated diabetes mellitus the insulin requirement for insulin / glucose is 0.3 U / g, then with concomitant liver diseases and significant obesity, it increases to 0.4 U / g. The greatest increase in insulin requirements is observed with severe infection, septic states and against steroid therapy and is 0.5-0.8 U / g. Therefore, the dose of insulin added to SCI with 15 units may, in the presence of various insulin-resistant conditions, be increased to I 40 ED.

Urgent surgical interventions associated with a strict time limit for preoperative preparation always cause great difficulties in compensating for diabetes mellitus. Before the operation, it is necessary to examine sugar in the blood, the content of acetone in the urine and, if the patient is conscious, find out the dose of insulin administered. In the presence of ketoacidosis it is important to establish the degree of dehydration (hematocrit number), to determine the level of potassium and sodium in the blood (the possibility of hyperosmolarity), to investigate the indicators of hemostasis. The tactics of medical measures in this condition during preparation for an urgent operation and the operation itself are the same as during acidosis and diabetic coma. In the absence of ketoacidosis and normal arterial pressure, insulin can be injected intramuscularly (just 20 units), and then every 6 hours intravenously every 6-8 units for 4-5 hours under the control of the level of glycemia. Glucose is administered intravenously at doses of 5-7.5 g / h in the form of 5-10-20% solutions, depending on the daily volume of fluid required for administration. Controlling the level of glycemia is produced every 2-3 hours. The dose of insulin with a decrease in blood sugar to 11.1 mmol / l (200 mg%) and less reduces to 1.5-3 U / h. Since insulin is partially adsorbed on the polyvinylchloride and glass surfaces of the system used for its intravenous administration (25-50%), 7 ml of a 10% albumin solution is added to every 500 ml of the solution to prevent adsorption, or the insulin dose is increased by 50%. For the prevention of hypokalemia within 3-4 hours, intravenously potassium chloride is introduced at 0.5 g / h. In the postoperative period (with indications) the patient is transferred to oral nutrition and subcutaneous administration of insulin of short and prolonged action.

Complications caused by the introduction of insulin

Complications caused by the introduction of insulin include: hypoglycemia, allergic reactions, insulin resistance, postinjection insulin lipodystrophy.

Hypoglycaemia is a condition that develops in patients with diabetes mellitus when the level of glycemia falls below 50 mg% (2.78 mmol / l) or when it decreases very quickly at normal or even elevated rates. Clinical observations indicate that such relative hypoglycemia is possible when patients with a high level of glycemia are feeling well. Reducing its level to normal leads to a worsening of the condition: headache, dizziness, weakness. It is known that in patients with a labile course of diabetes mellitus, with frequent hypoglycemic conditions, adaptation to low sugar content in the blood develops. The possibility of hypoglycemia in normal glycemia is confirmed by the rapid elimination of symptoms after the introduction of glucose. Various factors can lead to hypoglycemia: violation of diet and diet, exercise, the development of fatty liver, deterioration of the functional state of the kidneys, an overdose of insulin. Especially dangerous hypoglycemia in patients with coronary heart disease and brain. They can cause the development of myocardial infarction or cerebrovascular accident. In addition, these conditions contribute to the progression of microangiopathies, the emergence of fresh retinal hemorrhages, fatty liver infiltration. Frequent hypoglycemia sometimes leads to organic damage to the central nervous system. Therefore, the prevention of hypoglycemia is of great importance for the life of a patient with diabetes mellitus. For their prevention in patients with atherosclerosis of coronary and cerebral vessels, the criteria for compensation of diabetes should be less stringent: fasting glycemia not lower than 100 mg% (5.55 mmol / l), fluctuations during the day - 100-200 mg% (5.55- 11.1 mmol / L). Light hypoglycemia is eliminated by the intake of easily assimilated carbohydrates (sugar, honey, jam). In severe cases, intravenous infusions of up to 50 ml of a 40% solution of glucose, sometimes repeated, intramuscular injection of 1 mg of glucagon or adrenaline (0.1% solution - 1 ml) are necessary.

Post-hypoglycemic hyperglycemia (Somogy phenomenon). In patients with type 1 diabetes, especially when treated with high doses of insulin, acetonuria and high fasting blood sugar are observed. Attempts to increase the dose of insulin administered do not eliminate hyperglycemia. Despite decompensation of diabetes mellitus, in patients the body weight gradually increases. The study of daily and portioned glucosuria indicates the absence of sugar in the urine in some night portions and the presence of acetone and sugar in the urine - in others. These signs allow us to diagnose postglycemic hyperglycemia, which develops as a result of an overdose of insulin. Hypoglycemia, which develops more often at night, causes a compensatory release of catecholamines, glucagon, cortisol, dramatically enhancing lipolysis and promoting ketogenesis and increased blood sugar. When Somogy is suspected, it is necessary to reduce the dose of injected insulin (usually evening) by 10-20%, and if necessary, more.

Somogy's effect is differentiated from the phenomenon of "dawn", which is observed not only in diabetic patients, but also in healthy individuals and is expressed in morning hyperglycemia. Its origin is due to the hypersecretion of growth hormone in the night and pre-hours (from 2 to 8 hours). In contrast to Somogy's phenomenon, morning hyperglycemia is not preceded by hypoglycemia. The phenomenon of "morning dawn" can be observed both in patients with I and II type of diabetes (against the background of diet therapy or treatment with sugar-reducing drugs).

Allergic reactions with insulin administration are local and common. The first are the appearance of insulin hyperemia at the site of injection, which can persist for several hours to several months. The general reaction is manifested in the form of urticaria generalized rash, weakness, itching, edema, gastrointestinal disturbances, increase in body temperature. If there is an allergy, you should prescribe antihistamine therapy, change the type of insulin, and appoint monopic, mono-component preparations of pig or human insulin. Prescription of prednisolone 30-60 mg every other day (in severe cases) for 2-3 weeks with a gradual cancellation is possible.

Postinjection insulin lipodystrophy occurs in 10-60% of patients receiving the drug, and develops predominantly in women. They arise in the treatment of all types of insulin, regardless of the dosage of the drug, compensation or decompensation of diabetes, more often after several months or years of insulin therapy. However, cases that occurred after a few weeks of insulin treatment are described. Lipodystrophy occurs in the form of a hypertrophic form (increased fat in the subcutaneous adipose tissue at the injection site), but more often as fat atrophy (atrophic form).

Lipoatrophy is not only a cosmetic defect. It leads to a violation of suction of insulin, the appearance of pains that increase when the barometric pressure changes. There are several theories of the appearance of lipodystrophy, considering them as a consequence of one or a number of factors: an inflammatory reaction, a response to mechanical destruction of cells, insulin insulin quality (impurity of pancreatic lipase, phenol, antigenic properties, low pH), low temperature of the injected drug, alcohol into the subcutaneous cellulose. Some researchers adhere to the neurogenodystrophic concept of violation of local regulation of lipogenesis and lipolysis, the other main role is assigned to immune mechanisms. A good effect is provided by highly purified (monocomponent) porcine insulin and, especially, human. The duration of therapy depends on the magnitude, prevalence of lipodystrophy and the effect of treatment. In the prevention of lipodystrophy, the change in insulin injection sites is of great importance (some authors suggest the use of special films with perforations), the reduction of mechanical, thermal and chemical stimuli when it is introduced (the introduction of insulin warmed to body temperature, the inadmissibility of alcohol with it, the depth and speed of administration preparation).

Insulin resistance, as a complication of insulin therapy, was due to the use of beef poorly purified insulin preparations, when the daily requirement sometimes reached several thousand units per day. This forced to create industrial insulin preparations with a content of 500 U / ml. The high demand for insulin was due to a high titer of antibodies to beef insulin and other components of the pancreas. At present, using monocomponent human and porcine insulin, insulin resistance is more often caused by the action of contrinulsory hormones and is of a temporary nature in patients with type I diabetes. This type of insulin resistance is observed in stressful situations (surgical intervention, trauma, acute infectious diseases, myocardial infarction, ketoacidosis, diabetic coma), as well as during pregnancy.

Immunological resistance to insulin can occur with rare conditions and diseases even when injected with human insulin. It can be caused by defects on the pre-receptor (antibodies to the insulin molecule), receptor (antibodies to insulin receptors) levels. Insulin resistance, caused by the formation of antibodies to insulin, occurs in 0.01% of patients with type 1 diabetes mellitus, long-term insulin-treated, but can develop several months after the onset of insulin therapy.

In some cases, with high titers of antibodies to insulin, increasing hyperglycemia can be eliminated only by the introduction of 200 to 500 units of insulin per day. In this situation it is recommended to use insulin-sulfate, to which insulin receptors have a greater affinity in comparison with insulin antibodies. Sometimes insulin resistance takes on a wavy character, i.e., hyperglycemia is replaced by severe hypoglycemic reactions for several days (as a result of the breakdown of the connection of insulin with antibodies).

True insulin resistance can be observed with acantosis nigricans. Generalized and partial lipodystrophy, when the cause is the formation of antibodies to insulin receptors. Attraction of immunological insulin resistance using glucocorticoids in doses of 60-100 mg of prednisolone per day. The effect of treatment is manifested no earlier than 48 hours after the initiation of therapy.

Another cause of insulin resistance is degradation or impaired absorption of insulin. At higher protease activity, subcutaneous administration of large doses of insulin does not have a hypoglycemic effect due to insulin degradation. At the same time, intravenous insulin administration has an effect in normal doses. Malabsorption of insulin can be caused by infiltrates, a violation of blood supply in the zones of insulin injections and the presence of lipodystrophy. As a prophylaxis of malabsorption of insulin, frequent changes in the areas of subcutaneous administration are recommended.

With insulin resistance, associated with excessive formation of somatotropic hormone, glycocorticoids and other contrinulsory hormones, it is necessary to treat the underlying disease.

Insulinic edema. Patients with type I diabetes mellitus at the onset of insulin-n therapy or against the background of the administration of large doses of the drug observed fluid retention, which is caused by a significant decrease in glucosuria and, consequently, fluid loss, as well as the direct effect of insulin on the reabsorption of sodium in the renal tubules. When the dose is reduced, the puffiness usually disappears.

Visual impairment. Insulin therapy sometimes causes a change in refraction caused by a deformation of the curvature of the lens. With decompensated diabetes and high hyperglycemia, the accumulation of sorbitol in the lens with subsequent fluid retention promotes the development of myopia or weakens hyperopia. After the decrease in glycemia under the influence of insulin, the swelling of the lens decreases, and after a while the refraction is restored to its former values.

[1], [2], [3], [4], [5], [6], [7], [8], [9],

Treatment of complications of diabetes mellitus

Prophylaxis and treatment of complications of diabetes mellitus is first of all a maximum compensation of diabetes with a decrease in the level of glycemia during the day to 10-11.1 mmol / l (180-200 mg%) by repeated injections of insulin short-acting or 2-3-single administration prolonged insulins in combination with short-acting in type I diabetes, or by diet therapy, whose goal is to normalize body weight, or a combination of dietary therapy with its low efficacy with oral sugar-lowering drugs. The tendency of insulin administration in patients with type II diabetes is unreasonable in order to treat diabetic retinopathy and neuropathy, as these clinical syndromes develop in non-insulin-dependent tissues, and the introduction of insulin promotes obesity, hypoglycemic conditions (provoking hemorrhage in retinopathy) and insulin resistance.

Treatment of diabetic neuropathy

In severe pain, analgesics, sedatives are prescribed. In some cases it is necessary to resort to promedol and pantopon. A good effect is the use of vitamin B12, ascorbic acid, diphenine, a metabolic drug dipromonium in injections or tablets. Clinical trials of sorbinil and its domestic analogue - isodibutum, used in tablets of 0.5 g to 3 times a day, allow to hope for successful action of pathogenetic therapy. At the same time, physiotherapy procedures are recommended.

In the presence of clinical syndromes, characteristic for autonomic (autonomic) neuropathy, additional therapeutic measures are used. In the treatment of orthostatic hypotension, mineralocorticoid drugs are used: DOXA in injections, fluorhydrocortisone in doses of 0.0001-0,0004 g per day. A good effect is the bandaging of the legs with an elastic bandage to reduce the venous volume of the blood.

With gastropathy, cholinomimetics, cholinesterase inhibitors, metoclopramide, toning and motor activity of the smooth muscles of the stomach are applied and have an antiemetic effect. In severe cases, the stomach is resected.

Atony of the bladder is often combined with an ascending infection of the urinary tract, so treatment should include antibiotics according to the sensitivity of the bacterial flora. Catheterization of the urinary bladder should be avoided. In therapy, use anticholinesterase drugs, and if necessary resort to partial resection of the bladder.

With neuroarthropathy, the main medicines are the prevention and removal of calluses, the treatment of neurotrophic ulcers, and the use of orthopedic footwear.

New in the treatment of patients with type II diabetes is the use of the interval hypoxic training method. Treatment is carried out using a kipoksikatora (the device that supplies at certain intervals for inhalation (air with a reduced oxygen content) .Thus, the number of cycles per session increases from 3 to 10. The procedure is carried out daily, 15-20 sessions are recommended for treatment.

The conducted studies showed that the use of interval hypoxic training significantly improves the clinical course of diabetes mellitus, reduces the manifestation of diabetic neuropathy, has a positive effect on metabolic rate, tissue diffusion, parameters of central, intracardiac hemodynamics, oxygen-transport function of blood and increases resistance to hypoxia.

Treatment of retinopathy

Treatment of retinopathy, except for the compensation of diabetes, includes the elimination of hemorheological disorders, the use of antihypertensive drugs, hypolipidemic drugs and vitamin therapy.

To eliminate hemorheological disorders laser therapy is used.

In nonproliferative stage, focal laser therapy is recommended to eliminate macular edema. In the pre-proliferative stage, pancreatic photocoagulation is performed, and during the proliferative phase, panretinal photocoagulation and, if necessary, vitrectomy, are performed. At the last stage, pregnancy is interrupted.

To prevent the progression of the process, antihypertensive therapy is used (ACE blockers, calcium, selective beta-blockers in combination with diuretics), lipid-lowering drugs depending on the nature of hyperlipidemia, as well as B vitamins, ascorbic acid, ascorutin.

With proliferating retinopathy, the main method of treatment is laser photocoagulation, which contributes to the elimination of neovascularization, hemorrhages in the retina and the prevention of its detachment. When a hemorrhage occurs in the vitreous body, the vitrectomy operation is applied, i.e., its removal with replacement with saline solution. Operation of a hypophysectomy or introduction of radioactive yttrium in a cavity of a Turkish saddle for treatment of a retinopathy practically is not applied. Treatment of the disease is carried out in conjunction with an ophthalmologist, who watches the patient every six months.

Treatment and prevention of diabetic nephropathy

Treatment of the clinical form of diabetic nephropathy (DN) in the stages of severe diabetic nephropathy (proteinuria) and chronic renal failure (uremia) is aimed at eliminating arterial hypertension, electrolyte disorders, hyperlipidemia, urinary tract infection and improving renal nitrogen excretion.

The stage of pronounced diabetic nephropathy is characterized by the appearance of proteinuria more than 0.5 g / day, microalbuminuria more than 300 mg / day, arterial hypertension, hyperlipidemia and a combination with diabetic retinopathy, neuropathy, IHD. Treatment at this stage of diabetic nephropathy is aimed at preventing chronic renal failure.

Compensation of carbohydrate metabolism

The maximum compensation of carbohydrate metabolism in patients with type I diabetes is achieved through intensive insulin therapy (reusable short-acting insulin injections) or a combination of long-acting insulins with a short one. Patients with type II diabetes are transferred to glufenorm or dibotin, and in the absence of a sufficient effect on insulin or a combination with the above drugs to eliminate the nephrotoxic effect of other sulfanilamide preparations and their metabolites.

Hypotensive therapy inhibits the reduction of GFR and reduces proteinuria. Arterial pressure is maintained at a level not exceeding 120/80 mm Hg. Art. For this purpose, ACE blockers (captopril, enalapril, ramipril, etc.), cardioselective beta-blockers, calcium antagonists (nifeditin, veropamil, rhyodipine, etc.), alpha-blockers (prazosin, doxazosin) are used. The most effective) consider the combination of captopril or enalapril with hypothiazide.

Arterial hypertension in patients is largely due to hypervolemia due to the delay of sodium, in connection with which complex therapy uses a restriction of table salt to 3-5 g per day, diuretics, mainly potassium-sparing, as often patients have hyper-lipemia.

Hypolipidemic therapy helps to reduce proteinuria and the progression of the pathological process in the kidneys.

Since various variants of hyperlipidemia (hypercholesterolemia, hypertriglyceridemia and mixed form) are observed in 70-80% of patients, the use of a hypocholesterolemic diet, as well as tar, nicotinic acid, statins, fibrates or a combination thereof, is used.

A low-protein diet provides protein restriction to 0.8 g / kg of body weight. In the presence of obesity - hypocaloric and moderate physical load (with the exclusion of IHD).

Elimination of urinary tract infection. Given the high incidence of cystitis, atypical pyelonephritis, asymptomatic bacteriuria, it is advisable to periodically perform an overall urinalysis, and if necessary, Nechiporenko. According to the data of urine culture, antibiotic therapy is routinely performed. Concomitant pyelonephritis worsens the functional; the state of the kidneys and can cause interstitial nephritis.

[10], [11], [12], [13], [14], [15], [16], [17], [18], [19]

Treatment at the stage of chronic renal failure (uremia)

Progression of the proteinuria stage (severe diabetic nephropathy) leads to chronic renal failure. An increase in the level of creatinine in the blood from 120 to 500 μmol / l corresponds to the stage of the process, at which conservative therapy is possible.

Compensation of carbohydrate metabolism is complicated by the fact that patients may experience hypoglycemia due to a decrease in the need for insulin, a reduction in insulin degradation by the renal enzyme insulinase, and an increase in the duration, circulation of insulin administered. Patients with type I diabetes mellitus are shown intensive insulin therapy with frequent control of glycemia for the timely reduction of the necessary dose of insulin.

• Low protein diet. Patients are recommended to reduce the protein to 0.6-0.8 g / kg body weight and increase the dietary content of carbohydrates.
• Hypotensive therapy. All drugs used to treat the stage of severe diabetic nephropathy. ACE inhibitors are used at a creatinine level not exceeding 300 μmol / L.
• Correction of hyperkalemia. From the diet exclude foods rich in potassium. With high hyperkalemia, an antagonist is administered, a 10% solution of calcium gluconate, and ion exchange resins are used. If hyperkalaemia is caused by hyponeinemic hypoaldosteronism (with reduced blood pressure), then fluorhydrocortisone (cortinef, florinef) is used in small doses.
• Treatment of nephrotic syndrome. This condition is characterized by proteinuria> 3.5 g / day, hypoalbuminemia, edema and hyperlipidemia. Treatment measures include: infusion of albumin solutions, furosemide 0.6-1 g / day, hypolipidemic drugs.
• Correction of phosphorus-calcium metabolism. Hypocalcemia (the result of decreasing the synthesis of vitamin D ₃ in the kidneys) is the cause of secondary hyperparathyroidism and renal osteodystrophy. In the treatment, a diet with phosphorus restriction is used, calcium preparations and vitamin D ₃ are added .
• Enterosorption in the form of activated carbon, ion exchange resins, minisorb and others is used to remove toxic products from the intestine.
• Treatment of chronic renal failure at terminal stage. Hemodialysis or peritoneal dialysis is prescribed with a decrease in GFR to 15 ml / min and an increase in creatinine> 600 μmol / l.
• Kidney transplantation is indicated with GFR <10 ml / min and a creatinine level in the blood> 500 μmol / l.

Prevention of diabetic nephropathy

Since traditional methods of treatment of diabetes mellitus do not prevent the progression of diabetic nephropathy at its clinical stages, it becomes necessary to prevent diabetic nephropathy at preclinical stages.

According to the classification, the first 3 stages of diabetic nephropathy are preclinical. Prophylactic measures, in addition to the ideal compensation of carbohydrate metabolism, include normalization of intrarenal hemodynamics (elimination of intra-cerebral hypertension) by the administration of ACE inhibitors in small doses, and at stage III - elimination of hyperlipidemia and the appointment of a diet with a protein content of not more than 1 g / kg body weight.

Recently, the search for factors hindering the development of diabetic nephropathy in patients with type II diabetes has continued. It is known that mortality from uremia among patients with type II diabetes is an order of magnitude smaller than in type I diabetes mellitus. Great attention should be paid to the message of L. Wahreh et al. (1996) that intravenous infusion of C-peptide in physiological doses for 1-3 hours normalizes the glomerular filtration rate in patients with type I diabetes, and daily intramuscular injections of L-peptide stabilize the course of Type I diabetes for 3-4 months and improve kidney function. It was found that the C-peptide stimulates the N ⁺ -K ⁺ -ATPase in the renal tubules. It is possible that the C-peptide possesses a protective property for diabetic nephropathy, considering that the main pathophysiological difference between diabetes mellitus I and type II diabetes mellitus is the practical absence of the C-peptide.

Treatment of lipoid necrobiosis

The best results were obtained by subcutaneous administration of glucocorticoid preparations to the border zone with the affected area or by electrophoresis and phonophoresis with hydrocortisone succinate. Also effective is the combination of dipyridamole in 0.0025 g 3-4 times a day with aspirin, which contributes to inhibition of platelet aggregation and the formation of microthrombi. Locally used lotions with 70% solution of dimexin and insulin. When an ulcer is infected, antibiotics are used.

Prevention and treatment of heart disease

First of all, the prevention of heart disease is to maximize the compensation of diabetes mellitus with a decrease in glycemia to a level not exceeding 11.1 mmol / L (200 mg%) s during the day, by repeated injections of small doses of insulin or 2-time administration of prolonged insulins in diabetes I type.

The literature data show that good compensation of diabetes mellitus improves the functional capacity of the myocardium by normalizing metabolic processes in the cardiac muscle. It is necessary to avoid a chronic overdose of insulin, which causes hyperinsulinemia. In the prevention and prevention of coronary atherosclerosis, elimination of such risk factors as hypertension and hyperglycemia plays a role. Both are more pronounced in patients with obesity, and therefore limiting the daily caloric intake of food plays a large role in eliminating these additional risk factors for atherosclerosis.

Increased blood pressure in patients with diabetes mellitus is due to a combination with hypertensive disease or diabetic nephropathy, in connection with which therapeutic tactics has some features. Patients often experience sodium retention in the body and hypervolemia caused by activation of the renin-angiotensin system, hyperosmolarity of the plasma or the administration of insulin (in patients with type I diabetes).

As is known, under the influence of an increase in plasma renin activity, the formation of angiotensin I, as well as angiotensin II, with the participation of the angiotensin converting enzyme (ACE) is enhanced. Angiotensin II has a dual effect - both vasoconstrictor and stimulating the secretion of aldosterone. Therefore, when combined with diabetes mellitus with hypertensive disease, drugs that block ACE (captopril, enalapril, lisinopril, ramipril, pyrindapril, etc.) were widely used. In addition to ACE antagonists, angiotensin II receptor blockers (losartan, aprovel) are also used.

In the presence of tachycardia or heart rhythm disturbances in hypertensive disease, selective adrenoblata-blockers (atenolol, metoprolol, cordanum, bisoprolol, etc.) are used. It is not recommended that these drugs be administered to diabetic patients with a tendency to hypoglycemia, as they inhibit the sympathetic adrenal response to hypoglycemia, which is the main clinical manifestation of hypoglycemia.

The hypotensive effect of calcium antagonists is due to a relaxing effect on myofibrils of arterioles and a decrease in the resistance of peripheral vessels. In addition, these drugs improve coronary blood flow, that is, have an antianginal effect in the presence of IHD.

In the treatment of patients, selective calcium blockers of verapamil (isoptin), nifedipine (corinfar) and diltiazem (norvask) are used, which do not significantly affect carbohydrate metabolism.

In the absence of sufficient hypotensive effect from ACE blockers, a combination with adrenobate blockers or calcium antagonists is possible. It should be noted that ACE and calcium blockers have a nephroprotective effect and are used in small doses at the initial stages of arterial hypertension.

All the antihypertensive drugs in the treatment of patients are combined with a restriction in the diet of table salt to 5.5-6 grams, as well as with diuretics. Potassium-sparing drugs are not indicated for patients with diabetic nephropathy, accompanied by hyperkalemia (giporeninemic hypoaldosteronism).

The use of thiazine diuretics often causes a violation of glucose tolerance by suppressing the release of insulin. However, the severity of the increase in glycemia may be different, which in general does not prevent their use.

If orthostatic hypotension is present, methyldopa, prazosin and reserpine should be used with caution, as they can aggravate the manifestations of orthostatic hypotension.

Potassium-sparing diuretics (aldactone, triampeter, veroshpiron) are used together with ACE blockers, which helps eliminate sodium retention and a tendency to hypokalemia as a result of blocking the action of aldosterone in the renal tubules.

Treatment of hypertension in diabetes should begin as early as possible, and blood pressure should preferably be maintained at levels not exceeding 130/80 mm Hg. Art.

In the prevention and prevention of the progression of atherosclerosis, an important role is played by the correction of hyperlipidemia, which is one of the additional causes that aggravate its course. For this it is necessary to eliminate obesity, hypothyroidism and kidney disease, to give up alcohol. Hyperlipidemia IV, V and occasionally I types can be treated with a restriction in the diet of fats (in the presence of chylose serum VLDLP - very low density lipoproteins). When the LDL level (low-density lipoprotein), consisting of 75% of cholesterol, is increased, a diet with a restriction of products containing it (not more than 300 mg / day), addition of rancid foods with high content of unsaturated fats and soy protein is recommended. Cholestyramine, polisponin, tribusponin inhibit the absorption of cholesterol in the intestine. Mischerlon and citamiphene delay the synthesis of cholesterol and lower the level of triglycerides. To drugs that accelerate the metabolism of lipids and their excretion from the body include bile acid resins, linethol, arachidene, heparinoids, guar and some vitamins (nicotinic acid, pyridoxine), as well as lipotropic substances (methionines, choline chloride).

In the presence of patients with coronary heart disease, the use of nitrates of rapid (nitroglycerin) and prolonged action (nitron, sutac, trinitrolong, erynitol, nitrosorbide) is recommended, the effect of which is associated with relaxation of the smooth muscle of venous vessels, a decrease in venous inflow to the heart, discharge of the myocardium and restoration of blood flow in the myocardium, as well as with the increased synthesis of prostacyclin in the vascular wall. In the treatment of IHD, adrenoblockers (tracicore, cordarone, cordanum) are also used.

Treatment of acute myocardial infarction is carried out by conventional means. To reduce the risk of often occurring in a patient with diabetes mellitus, ventricular fibrillation is recommended intravenous administration of lidocaine. Since in most cases during an acute myocardial infarction in hypertensive patients with hyperglycemia, it is advisable (if necessary) to administer small doses of simple insulin in 3-4 injections against the background of the main therapy with oral sulfanilamide preparations. It is not necessary to transfer patients with type II diabetes from oral medications to insulin, as this is often accompanied by severe insulin resistance. The combination of oral (sulfanilamide) drugs with insulin prevents this complication of insulin therapy and more gently affects the level of glycemia, preventing hypoglycemic reactions. Daily glycemia should be maintained in the range of 8.33-11.1 mmol / l (150-200 mg%).

The most effective method of treating diabetic myocardiopathy and autonomic cardiac neuropathy is maximum compensation of diabetes mellitus, metabolic abnormalities peculiar to it and prevention of progression of diabetic microangiopathy. In order to improve microcirculation, trental, clomatin, curantyl, prodectin, carmidine are used, periodically with courses of 2-3 months. In complex therapy, inosine-F, riboxin, cocarboxylase, vitamins B and C are used. In the presence of signs of vegetative neuropathy, a diet rich in myo-inositol, anticholesterase drugs, adenyl-50, dipromonium in the form of course treatment for 2-3 months per year is recommended. Since the accumulation of sorbitol in the nervous tissue plays a significant role in the pathogenesis of diabetic neuropathy, the hope is placed on the use of aldose reductase inhibitors (sorbinyl, isodibut) that undergo clinical trials.