Editorial

Dear Reader

We are happy to place before you the latest issue of Capsule. This issue portrays a clinical case review and other regular features: but, the highlight is a lucid article on Management of diabetes mellitus in acute coronary syndrome by Prof.Dr.H.S.Devaraj. The article delineates the pathophysiological aspects in ACS and the benefits bestowed by good glycemic control achieved by insulin therapy. The article places a clear management protocol before the reader which would be very handy in day to day practice. The message on the wall is clear - Insulin is the only option in clinical situations like ACS and other critically ill patients. However, the target of glycemic control, ensuing effect on the length of ICU stay, morbidity and mortality have been creating storms in the cup ever since the publication of first Leuven study, in 2001 by Van den Berghe et al. The study highlighted on Intensive Insulin Therapy (ITI) targeting blood glucose of 80 to 110 mg/dL. The subsequent NICE-SUGAR (Normoglycemia in Intensive Care Evaluation Survival Using Glucose Algorithm Regulation), VISEP (Volume Substitution and Insulin Therapy in Severe Sepsis ) - Glucontrol trials and also Leuven medical trial all of them land on the common recommendation of a less stringent glycemic control in mixed medical and surgical ICU patients -a more permissive blood glucose range of 140 to 180 mg/dL.

On the other hand, patients in the ambulant setting exhibit great resistance for initiation of Insulin. However, the reasons for insulinophobia are worth giving a proper consideration along with the less discussed but, more pondering issues which would make a big difference on the long run. These include progressive weight gain and its associated complications. Increased risk of neoplasms noted in long term insulin users has not received much attention amongst researchers! These considerations would tempt any conscientious clinician to explore the possibility of residual Beta cell activity in a diabetic elegantly demonstrated by the PioSwitch Study. The switch from insulin therapy resulting in a moderate HbA1c level, to oral treatment with pioglitazone was successful in a majority of patients with sufficient residual beta-cell function. It allows a simple and less expensive therapy with a better cardiovascular risk marker profile. These points would leave our elite reader with the practical issues of diabetes management on every occasion when the oft quoted phrase 'Insulin is the final option in progressive Type 2 Diabetics' is heard!

Hope you will have a great reading.

Dr. Sudharshana Murthy K.A.

Professor & Head, Dept of Medicine

JSSMC & Hospital, Mysore