Diabetes mellitus☆: A hypercoagulable state

Marcus E Carr
,

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Departments of Internal Medicine and Pathology, Medical College of Virginia, Virginia Commonwealth University, Box 980230, Richmond, VA 23298-0230, USA McGuire V.A. Medical Center, Richmond, VA, USA
Received 3 March 2000; Accepted 30 August 2000. Available online 14 March 2001.

Abstract
Eighty percent of patients with diabetes mellitus die a thrombotic death. Seventy-five percent of these deaths is due to cardiovascular complications, and the remainder is due to cerebrovascular events and peripheral vascular complications. Vascular endothelium, the primary defense against thrombosis, is abnormal in diabetes. Endothelial abnormalities undoubtedly play a role in the enhanced activation of platelets and clotting factors seen in diabetes. Coagulation activation markers, such as prothrombin activation fragment 1+2 and thrombin–anti-thrombin complexes, are elevated in diabetes. The plasma levels of many clotting factors including fibrinogen, factor VII, factor VIII, factor XI, factor XII, kallikrein, and von Willebrand factor are elevated in diabetes. Conversely, the level of the anticoagulant protein C (PC) is decreased. The fibrinolytic system, the primary means of removing clots, is relatively inhibited in diabetes due to abnormal clot structures that are more resistant to degradation and an increase in plasminogen activator inhibitor type 1 (PAI-1). Increased circulating platelet aggregates, increased platelet aggregation in response to platelet agonists, increased platelet contractile force (PCF), and the presence of higher plasma levels of platelet release products, such as βthromboglobulin, platelet factor 4, and thromboxane B2, demonstrate platelet hyperactivity in diabetes. This constellation of findings supports the clinical observation

that diabetes is a hypercoagulable state. . This article briefly reviews the published evidence for this conclusion and the putative roles played by hyperglycemia and hyperinsulinemia in its development.

The burden of the disease. damage the body's vital organs and contribute to heart disease. is the most common type. life-long disorder that is.D iabetes About 16 million people in the United States have diabetes mellitus. Asian Americans and Pacific Islanders. There are two main types of diabetes: non-insulin dependent (type-2) and insulin dependent (type-1). . incurable. American Indians.95 percent of those who have the disease. Each year. it most often appears in childhood or during the teen years. Insulin-dependent diabetes affects the remaining proportion of those with the disease. a serious. a hormone secreted by the pancreas. Individuals with diabetes are at increased risk for heart disease. in time.000 people are diagnosed with diabetes. In Illinois. About one-third of these people do not know they have diabetes and are not under medical care. Although this type of diabetes can occur at any age. blindness. is heavier among the elderly and certain racial and ethnic populations. Insulin. approximately 500. Hispanics/Latinos. affecting 90 percent . approximately 600. glucose and lipids (fats) remain in the bloodstream and. as yet.000 persons 18 years of age and older have diagnosed diabetes. kidney failure and lower extremity amputations not related to injuries. Non-insulin dependent diabetes. allows glucose (sugar) to enter body cells and be converted to energy. What is diabetes? The term diabetes refers either to a deficiency of insulin or to the body's decreased ability to use insulin. which usually appears after the age of 40. including African Americans. In uncontrolled diabetes. It also is needed to synthesize protein and to store fats. however. Diabetes and its complications occur among Americans of all ages and racial and ethnic groups.

Members of certain racial or ethnic groups. Those who are 45 years of age and older. A number of studies have confirmed that regular exercise. of kidney disease by 50 percent. especially for those who are at high risk.What are the signs of diabetes? The signs of diabetes are frequent thirst. Who is most at risk for developing diabetes? The following have a greater risk of developing non-insulin dependent diabetes: • • • • • • • Those with a family history of diabetes (parents or siblings with diabetes). Individuals with hypertension or who have excessive levels of fat in their blood (hyperlipidemia). rapid loss of weight. The study concluded that lowering blood sugar levels reduces the risk of eye disease by 76 percent. and obvious weakness and fatigue. Can diabetes be prevented? Non-insulin dependent diabetes often can be prevented through a healthy diet and physical activity. . unusual hunger. Women who have a history of gestational diabetes during pregnancy or who have delivered babies weighing more than 9 pounds.6 times) and Cuban Americans (1. Those who are more likely to develop diabetes are Mexican and Puerto Rican Americans (twice as likely). Can the complications of diabetes be prevented? A clinical study conducted by the National Institute of Diabetes and Digestive and Kidney Disease showed that keeping blood sugar levels as close to normal as possible slows the onset and progression of eye. can prevent this type of diabetes. of nerve disease by 60 percent and of cardiovascular disease by 35 percent. kidney and nerve diseases caused by diabetes.5 times). African Americans (1. Individuals previously identified as having impaired glucose tolerance. Individuals who are obese (20 percent or more over ideal body weight). constant urination.

ask your physician when to take the pills. these pills do not lower blood sugar all by themselves. playing baseball and bowling are all examples of good ways to exercise. at least three times a week for about 30 to 40 minutes each time. swimming. Your physician or diabetes educator will show you how and where to give yourself a shot. Blood sugar should be less than 200 about two hours after your last meal. or four to five hours after a meal. Try to exercise regularly. riding a bicycle. how much and when to give yourself a shot. and grains. Exercise regularly. dancing. Try to eat foods that are low in fat. Always use your own needles and never share them with anyone else. such as beans. If you do not use insulin or take diabetes pills. be sure to check with your physician. you need a small needle called a lancet. Ask your physician what the best blood sugar range is for you. This is before a meal. People with diabetes do not need special foods. follow your physician's advice about eating and getting enough exercise. A good blood sugar range for one person may not be the best for someone else. salt and sugar and high in fiber. eat at about the same time. If you take insulin. You will still have to follow your diet and exercise to lower your blood sugar. fruits and vegetables. your physician will tell you what kind of insulin to use. and do not skip meals. Test your blood sugar. If you take diabetes pills. be sure to take it before you eat. Ask your physician how often and when you should test your blood sugar. such as breakfast. Insulin and diabetes pills are the two kinds of medicines used to lower blood sugar. Foods on your diabetes meal plan are good for everyone in the family. If you have not exercised in a while. Take your diabetes medicine.What is a good blood sugar level? Everyone has some sugar in his or her blood. Exercise is good for your diabetes. What is the best way to maintain a good blood sugar level? There are some things you can do every day to maintain a good blood sugar level and to stay healthy: • • • • Eat healthy food. special blood testing strips and a glucose monitor (a . To test your blood. If you use insulin. Walking. begin slowly and gradually increase intensity and duration. Remember. everyone is different. A good blood sugar range for most people with diabetes is from about 70 to 150. Before beginning any exercise program. Remember.

il.idph. This test will tell you if you have ketones in your urine.• special electronic device used to test for blood sugar). Ask your physician for this test every six months. ***http://www.state. Two other tests can help you keep track of your blood sugar.us/public/hb/hbdiabet. Your physician or a nurse can show you how to test your blood and give you information on glucose monitors.htm . You may need aurine test when you are ill or if your blood sugar is above 240 before eating. they can make you very sick. The hemogloboin A1c test shows what your average blood sugar was for the past three months. Call your physician immediately if you find ketones in your urine. Ketones are present when there is not enough insulin in your blood.

Diabetes Treatment Self-Care at Home If you or someone you know has diabetes. Activity can also reduce the risk of developing complications of diabetes such as heart disease. they would be wise to make healthful lifestyle choices in diet. • A consistent diet that includes roughly the same number of calories at about the same times of day helps the healthcare provider prescribe the correct dose of medication or insulin. • If the patient has complications of diabetes (eye. Consult with your health care provider before starting any exercise program. As little as 20 minutes of walking three times a week has a proven beneficial effect. low in saturated fat. which can be dangerous and even life-threatening. • . exercise. they may be limited both in type of exercise and amount of exercise they can safely do without worsening their condition. and other health habits. Any exercise is beneficial. and leg ulcers. and low in concentrated sweets. talk to a healthcare provider. kidney. • Eat a consistent. can help reduce the risk of developing diabetes. stroke. • Exercise: Regular exercise. blindness. in any form. He or she can recommend a dietitian or a weight modification program to help the patient reach a goal. well-balanced diet that is high in fiber. kidney failure. or nerve problems). Diet: A healthy diet is key to controlling blood sugar levels and preventing diabetes complications. These will help to improve glycemic (blood sugar) control and prevent or minimize complications of diabetes. no matter how light or how long. • It will also help to keep blood sugar at a relatively even level and avoid excessively low or high blood sugar levels. some exercise is better than no exercise. If the patient is obese and has had difficulty losing weight on their own.

com/diabetes/page6_em. Excessive alcohol use is a known risk factor for type 2 diabetes. Try to have no more than seven alcoholic drinks in a week and never more than two or three in an evening. • Medicare now pays for diabetic testing supplies. talk to a healthcare provider. or 12 ounces of beer. Self-monitored blood glucose: Check blood sugar levels frequently. at least before meals and at bedtime. and record the results in a logbook. when and what the patient ate. Alcohol consumption can cause low or high blood sugar levels. and poor circulation in the limbs. as do many private insurers and Medicaid. which is a type of fat in our blood. A daily blood sugar diary is invaluable to the healthcare provider in seeing how the patient is responding to medications. stroke. and increase in triglycerides.Alcohol use: Moderate or eliminate consumption of alcohol. Smoking damages blood vessels and contributes to heart disease.emedicinehealth. This log should also include insulin or oral medication doses and times. when and for how long they exercised. • Better equipment now available makes testing blood sugar levels less painful and less complicated than ever. Smoking: If the patient has diabetes.5 ounces of liquor. If someone needs help quitting. • ***http://www.htm#Self-Care at Home . and any significant events of the day such as high or low blood sugar levels and how they treated the problem. and exercise in the treatment of diabetes. One drink is considered 1. they are raising the risks markedly for nearly all of the complications of diabetes. and you smoke cigarettes or use any other form of tobacco. nerve pain called neuritis. 6 ounces of wine. diet.

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