Name
GOUT
DESCRIPTION
DETAIL
CAUSES : 1. PRERECEPTOR CAUSES - ABNORMAL INSULIN - ANTI-INSULIN ANTIBODIES 2. RECEPTOR - DECREASED NUMBER OF RECEPTORS - REDUCED BINDING OF INSULIN - INSULIN RECEPTOR MUTATIONS - INSULIN RECEPTOR BLOCKING ANTIBODIES 3. POST RECEPTOR - DEFECTIVE SIGNAL TRANSDUCTION - MUTATIONS OF GLLUT4 ( RARE ) 4. COMBINATION OF DEFECTS : LIKE - OBESITY, ASSOCIATED WITH POSTRECEPTOR ABNORMALITY & DECREASED NUMBER OF INSULIN RECEPTORS - TYPE A SYNDROME - TYPE B SYNDROME - LEPECHAUNISM - LIPODYSTROPHIC STATES - ATAXIA-TELANGIECTASIA - WERMER SYNDROME - RABSON-MENDENHALL SYNDROME - PINEAL HYPERTROPHIC SYNDROME 5. AGING 6. INCREASED PRODUCTION OF INSULIN ANTAGONISTS : - CUSHING SYNDROME - ACROMEGALY - STRESS STATES LIKE TRAUMA, BURN, SURGERY, KETOACIDOSIS, SEVERE INFECTIONS, UREMIA, LIVER CIRRHOSIS 7. MEDICATIONS ASSOCIATED WITH INSULIN RESISTANCE SYNDROME : - GLUCOCORTICOIDS - CYCLOSPORINE - NIACIN - PROTEASE INHIBITORS 8. HIV : PROTEASE-ASSOCIATED LIPODYSTROPHY IS RECOGNISED ENTITY 9. INSULIN TREATMENT - LOW TITER IGG ANTI-INSULIN ANTIBODIES ARE PRESENT - ENHANCED DESTRUCTION OF INSULIN AT THE SITE OF INJECTION 10. SYNDROME X OR METABOLIC OR DYSMETABOLIC SYNDROME* FASTING INSULIN LEVELS - * PLASMINOGEN ACTIVATOR INHIBITOR 1 - ELEVATED LEVELS ARE ASSOCIATED WITH INSULIN RESISTANCE * FIBRINOGEN LEVELS - INCREASED
TYPENOTES
PER DAY INSULIN REQUIREMENT OF > 200 UNITS SUGGESTS INSULIN RESISTANCE Medical Care Evaluate patients for comorbid conditions; this is generally feasible on an outpatient basis. Admission for laboratory studies may be warranted for patients whose conditions require urgent or emergent intervention. Syndrome X requires aggressive control of cardiovascular and metabolic risk factors. Tailor therapy for optimal benefits. Surgical Care " In severe cardiovascular disease, procedures such as coronary artery bypass graft and peripheral vascular surgery may be necessary. " " Wedge resection largely has been abandoned, but it once was thought to be beneficial in PCOD. " " Cosmetic and palliative treatments may be indicated in the treatment of many patients with IRS depending on the type and severity of physical anomalies (eg, epilation and electrolysis for hirsutism in patients with PCOD). Consultations " Consultation with an endocrinologist is indicated. " Consultation with a cardiologist is indicated. " Other specialists, such as a dermatologist, gynecologist, cardiothoracic surgeon, and ophthalmologist, may need to be consulted based on the nature of disease and the prevailing pathology. Diet " Weight reduction improves insulin sensitivity in patients who are obese and in patients with most of the obesity-related insulin-resistant states. " Restriction of caloric intake is indicated. Activity " Exercise improves insulin sensitivity via the following: " o Increased oxidative enzymes o Increased glucose transporters (GLUT-4) o Increased capillarity o Reduction of central adiposity The goals of pharmacotherapy are to reduce morbidity and to prevent complications. Medications that reduce insulin resistance include biguanides and thiazolidinediones, which have insulin-sensitizing and antihyperglycemic effects. Large quantities of insulin are also used in overcoming insulin resistance. Response to usual dosage of insulin is observed in instances in which the resistance is due to enhanced destruction at the subcutaneous injection site. The treatment of type 2 diabetes and impaired glucose tolerance (IGT), of which both are strongly associated with insulin resistance and significant cardiovascular morbidity and mortality, should aim at restoring the normal relationship between insulin sensitivity and secretion. For diabetes, this involves pharmacotherapy, which includes stimulation of insulin secretion (sulfonylureas, meglitinides, incretin mimetics) and insulin sensitivity (metformin, thiazolidinediones), as well as treatment intended to support the signals that mediate the islet adaptation (incretin mimetics). Pramlintide (an amylin analogue) acts as an amylinomimetic agent by modulating gastric emptying, preventing postprandial increases in plasma glucagon, and promoting satiety, leading to decreased caloric intake and potential weight loss. Antiobesity drugs such as orlistat and sibutramine may reduce insulin resistance and related cardiovascular risk factors through weight reduction and other mechanisms. Administration of insulin is also crucial in the treatment of diabetes in most patients. DRUG TREATMENT : 1. BIGUANIDES : - METFORMIN 2. THIAZOLIDINEDIONES : - PIOGLITAZONE - ROSIGLITAZONE 3. GLUCOCORTICOIDS : ARE IMMUNOSUPPRESSANTS USED FOR TREATMENT OF IMMUNE INSULIN RESISTANCE DUE TO ANTIINSULIN ANTIBODIES. - PREDNISONE 4. ANTIDIABETIC AGENTS, INSULIN - HUMAN INSULIN 5. LIPASE INHIBITORS : INHIBIT NUTRIENT ABSORPTION - ORLISTAT 6. ANOREXIANTS : REDUCE APPETITE & MAY INCREASE METABOLISM - SIBUTRAMINE
RELATED DISEASE
Not Available Disease
Disease
Remarks
INSULIN RESISTANCE
ASSOCIATION OF THIS MAY LEAD TO INCREASED CHNACES OF CORONARY ARTRY DISEASE WHICH ALREADY IS MORE COMMON IN GOUT, SO IT SHOULD BE WELL TREATED
DISEASE
INVESTIGATION
BLOOD SUGAR ( FASTING ), GLYCOSYLATED HAEMOGLOBIN (HBA1C), SERUM CREATININE, SERUM URIC ACID, URINE FOR MICROALBUMIN, BLOOD SUGAR ( AFTER MEALS ), BUN, SERUM INSULIN ( FREE ), LIPIDS PROFILE, HOMOCYSTEINE