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> Hyperglycemia And Diabetic Ketoacidosis

> Hyperglycemia And Diabetic Ketoacidosis

When blood glucose levels (also called blood sugar levels) are too high, it's called hyperglycemia. Glucose is a sugar that comes from foods, and is formed and stored inside the body. It's the main source of energy for the body's cells and is carried to each through the bloodstream. But even though we need glucose for energy, too much glucose in the blood can be unhealthy. Hyperglycemia is the hallmark of diabetes — it happens when the body either can't make insulin (type 1 diabetes) or can't respond to insulin properly (type 2 diabetes). The body needs insulin so glucose in the blood can enter the cells to be used for energy. In people who have developed diabetes, glucose builds up in the blood, resulting in hyperglycemia. If it's not treated, hyperglycemia can cause serious health problems. Too much sugar in the bloodstream for long periods of time can damage the vessels that supply blood to vital organs. And, too much sugar in the bloodstream can cause other types of damage to body tissues, which can increase the risk of heart disease and stroke, kidney disease, vision problems, and nerve problems in people with diabetes. These problems don't usually show up in kids or teens with diabetes who have had the disease for only a few years. However, they can happen in adulthood in some people, particularly if they haven't managed or controlled their diabetes properly. Blood sugar levels are considered high when they're above someone's target range. The diabetes health care team will let you know what your child's target blood sugar levels are, which will vary based on factors like your child's age. A major goal in controlling diabetes is to keep blood sugar levels as close to the desired range as possible. It's a three-way balancing act of: diabetes medicines (such as in Continue reading >>

Diagnosis And Treatment Of Diabetic Ketoacidosis

Diagnosis And Treatment Of Diabetic Ketoacidosis

85 Abstract Diabetic ketoacidosis (DKA) is the most frequent hyperglycaemic acute diabetic complication. Furthermore it carries a significant risk of death, which can be prevented by early and effective management. All physicians, irrespective of the discipline they are working in and whether in primary, secondary or tertiary care institutions, should be able to recognise DKA early and initiate management immediately. 86 Introduction Diabetic ketoacidosis (DKA) is a common complication of diabetes with an annual occurrence rate of 46 to 50 per 10 000 diabetic patients. The severity of this acute diabetic complication can be appreciated from the high death-to-case ratio of 5 to 10%.1 In Africa the mortality of DKA is unacceptably high with a reported death rate of 26 to 29% in studies from Kenya, Tanzania and Ghana.2 It is a complication of both type 1 and type 2 diabetes mellitus, although more commonly seen in type 1 diabetic patients. Of known diabetic patients presenting with DKA about one-quarter will be patients with type 2 diabetes. In patients presenting with a DKA as first manifestation of diabetes about 15% will be type 2.3 This correlates well with data from South Africa suggesting that one- quarter of patients with DKA will be type 2 with adequate C-peptide levels and the absence of anti-GAD antibodies.4 This review will focus on the principles of diagnosis, monitoring and treatment of DKA, with special mention of new developments and controversial issues. Clinical features DKA evolves over hours to days in both type 1 and type 2 diabetic patients, but the symptoms of poor control of blood glucose are usually present for several days before the onset or presentation of ketoacidosis.5 The clinical features of DKA are non-specific and patients may present with Continue reading >>

Diabetic Ketoacidosis

Diabetic Ketoacidosis

Type II Diabetes Mellitus with ketosis-prone diabetes (accounts for 20-50% of DKA cases) Compensatory response to lack of usable fuel sources (in the absence of Insulin ) Paradoxical exacerbation of Hyperglycemia Release of Glucagon , Catecholamine s, cortisol, and Growth Hormone Catabolism to Glucose of proteins and glycogen Results in osmotic diuresis, dehydration and hyperosmolar state Results in increased ketone production (acetone, acetoacetone, Beta hydroxybutyrate) May present as a vague Abdominal Pain with minimal tenderness on exam Consider Pancreatitis or Pyelonephritis (both are common in DKA) Beta hydroxybutyrate is converted to acetoacetate which is then detected on the Urine Dipstick as ketones Normal serum bicarbonate and Anion Gap suggests resolving DKA or false positive ketonuria Requires correction for Glucose ( Pseudohyponatremia secondary to Hyperglycemia ) Serum Sodium correction calculation: sNa + 0.016 * (Glu - 100) Serum Osmolality (calculate and measure if available) Serum Osmolality calculation: 2*(Na + K) + (glu/18) + (BUN/2.8) Other electrolytes (Phosphorus and Magnesium ) Venous Blood Gas is equivalent to monitoring Arterial Blood Gas for pH and bicarbonate Beta hydroxybutyrate (or Serum K etones if not available) Beta hydroxybutyrate is the most important ketone in Diabetic Ketoacidosis Leukocytosis is often present regardless of underling infection Bandemia ( Neutrophil band forms or Left Shift s) is highly predictive of infection Also indicated for ischemia evaluation over age 40 or over 10 years of Diabetes Mellitus Evaluation of Diabetes and Endocrine Status Frequently increased regardless of Pancreatitis Pancreatitis is present in 10-15% of DKA patients Troponin I is increased in absence of myocardial injury in more than 25% of DKA pa Continue reading >>

What Is Diabetic Ketoacidosis (dka)?

What Is Diabetic Ketoacidosis (dka)?

Susan B. Sloane, BS, RPh, CDE, has been a registered pharmacist for more than 20 years and a Certified Diabetes Educator for more than 15 years. Her two sons were diagnosed with diabetes, and since then, she has been dedicated to promoting wellness and optimal outcomes as a patient advocate, information expert, educator, and corporate partner. Diabetic ketoacidosis, or DKA, is a term most people with diabetes hear at some point in their journey with the disease. Sometimes it happens when you are diagnosed, and other times it happens when you start to lose control of your blood sugars. If you heed some good practices and keep track of blood sugars, you can potentially avoid DKA, but sometimes even with the best efforts to keep it at bay, it happens. What causes DKA? DKA occurs when blood glucose starts to get very high and STAYS high for an extended period of time; this can happen over several hours or several days depending on many factors. The body’s response to prolonged periods of high blood sugars is to frantically try to get back to normal by secreting what are known as counter-regulatory hormones like glucagon, epinephrine, and cortical, just to name a few. These hormones cause more glucose in the blood and enhance the breakdown of fat for fuel because the cells can’t absorb the glucose due to lack of insulin. Insulin serves as the key to get energy into the cells. What happens next With the release of fat stores for energy and no ability to store fat, weight loss occurs rapidly. Fats are also broken down in the body to free fatty acids that create an acidic environment in the blood. This imbalance signals the kidneys to excrete the ketones that result from fat breakdown and the excess glucose. The kidneys work frantically to correct this, taking precious wate Continue reading >>

Diabetic Ketoacidosis

Diabetic Ketoacidosis

Practice Essentials Diabetic ketoacidosis (DKA) is an acute, major, life-threatening complication of diabetes that mainly occurs in patients with type 1 diabetes, but it is not uncommon in some patients with type 2 diabetes. This condition is a complex disordered metabolic state characterized by hyperglycemia, ketoacidosis, and ketonuria. Signs and symptoms The most common early symptoms of DKA are the insidious increase in polydipsia and polyuria. The following are other signs and symptoms of DKA: Nausea and vomiting; may be associated with diffuse abdominal pain, decreased appetite, and anorexia History of failure to comply with insulin therapy or missed insulin injections due to vomiting or psychological reasons or history of mechanical failure of insulin infusion pump Altered consciousness (eg, mild disorientation, confusion); frank coma is uncommon but may occur when the condition is neglected or with severe dehydration/acidosis Signs and symptoms of DKA associated with possible intercurrent infection are as follows: See Clinical Presentation for more detail. Diagnosis On examination, general findings of DKA may include the following: Characteristic acetone (ketotic) breath odor In addition, evaluate patients for signs of possible intercurrent illnesses such as MI, UTI, pneumonia, and perinephric abscess. Search for signs of infection is mandatory in all cases. Testing Initial and repeat laboratory studies for patients with DKA include the following: Serum electrolyte levels (eg, potassium, sodium, chloride, magnesium, calcium, phosphorus) Note that high serum glucose levels may lead to dilutional hyponatremia; high triglyceride levels may lead to factitious low glucose levels; and high levels of ketone bodies may lead to factitious elevation of creatinine levels. Continue reading >>

Diabetic Ketoacidosis (dka)

Diabetic Ketoacidosis (dka)

Diabetic ketoacidosis, also called DKA, is a life-threatening complication occurring with undiagnosed and/or untreated Type 1 diabetes in adults and children. DKA symptoms often remain undiagnosed because they can look like (mimic) influenza, a stomach bug, strep infections, and other common illnesses and conditions. However, someone may actually have a common illness and DKA at the same time, causing the common illness symptoms to hide (mask) the underlying DKA symptoms. Either way, untreated Type 1 diabetes and DKA are 100% fatal. ​IMPORTANT: Diabetic ketoacidosis is LIFE-THREATENING and can progress quickly–often within 24 hours! If you or a loved one have any of the following symptoms with VOMITING AND LETHARGY COMBINED WITH LABORED BREATHING, do not consume sugar and seek emergency medical care immediately. Insist medical personnel Test One Drop of blood or urine for glucose (sugar) levels. DKA can be fatal! ​ SYMPTOMS OF DKA: excessive thirst frequent urination or bedwetting increased appetite or sugar cravings abdominal pain irritability, grouchiness, or mood changes headaches and/or vision changes itchy skin/genitals (yeast or thrush) sudden weight loss flushed, hot, dry skin nausea and vomiting* fruity/acetone scented breath* lethargy, drowsiness, or fatigue* labored, rapid, and/or deep breathing* confusion, stupor, or unconsciousness* *A combination of any of these symptoms can be life-threatening. Seek EMERGENCY CARE. When new onset Type 1 diabetes remains undiagnosed and untreated the shortage of insulin causes blood glucose (sugar) levels to climb above the normal range. Without adequate insulin to regulate levels of glucose in the blood, high levels of acids called ketones build up in the body causing diabetic ketoacidosis. Ketones are toxic and if l Continue reading >>

Diabetic Ketoacidosis

Diabetic Ketoacidosis

The Facts Diabetic ketoacidosis (DKA) is a condition that may occur in people who have diabetes, most often in those who have type 1 (insulin-dependent) diabetes. It involves the buildup of toxic substances called ketones that make the blood too acidic. High ketone levels can be readily managed, but if they aren't detected and treated in time, a person can eventually slip into a fatal coma. DKA can occur in people who are newly diagnosed with type 1 diabetes and have had ketones building up in their blood prior to the start of treatment. It can also occur in people already diagnosed with type 1 diabetes that have missed an insulin dose, have an infection, or have suffered a traumatic event or injury. Although much less common, DKA can occasionally occur in people with type 2 diabetes under extreme physiologic stress. Causes With type 1 diabetes, the pancreas is unable to make the hormone insulin, which the body's cells need in order to take in glucose from the blood. In the case of type 2 diabetes, the pancreas is unable to make sufficient amounts of insulin in order to take in glucose from the blood. Glucose, a simple sugar we get from the foods we eat, is necessary for making the energy our cells need to function. People with diabetes can't get glucose into their cells, so their bodies look for alternative energy sources. Meanwhile, glucose builds up in the bloodstream, and by the time DKA occurs, blood glucose levels are often greater than 22 mmol/L (400 mg/dL) while insulin levels are very low. Since glucose isn't available for cells to use, fat from fat cells is broken down for energy instead, releasing ketones. Ketones accumulate in the blood, causing it to become more acidic. As a result, many of the enzymes that control the body's metabolic processes aren't able Continue reading >>

Ketoacidosis During A Low-carbohydrate Diet

Ketoacidosis During A Low-carbohydrate Diet

To the Editor: It is believed that low-carbohydrate diets work best in reducing weight when producing ketosis.1 We report on a 51-year-old white woman who does not have diabetes but had ketoacidosis while consuming a “no-carbohydrate” diet. There was no family history of diabetes, and she was not currently taking any medications. While adhering to a regimen of carbohydrate restriction, she reached a stable weight of 59.1 kg, a decrease from 72.7 kg. After several months of stable weight, she was admitted to the hospital four times with vomiting but without abdominal pain. On each occasion, she reported no alcohol use. Her body-mass index (the weight in kilograms divided by the square of the height in meters) was 26.7 before the weight loss and 21.7 afterward. Laboratory evaluation showed anion-gap acidosis, ketonuria, and elevated plasma glucose concentrations on three of the four occasions (Table 1). She had normal concentrations of plasma lactate and glycosylated hemoglobin. Screening for drugs, including ethyl alcohol and ethylene glycol, was negative. Abdominal ultrasonography showed hepatic steatosis. On each occasion, the patient recovered after administration of intravenous fluids and insulin, was prescribed insulin injections on discharge, and gradually reduced the use of insulin and then discontinued it while remaining euglycemic for six months or more between episodes. Testing for antibodies against glutamic acid decarboxylase and antinuclear antibodies was negative. Values on lipid studies were as follows: serum triglycerides, 102 mg per deciliter; high-density lipoprotein (HDL) cholesterol, 50 mg per deciliter; and calculated low-density lipoprotein (LDL) cholesterol, 189 mg per deciliter. The patient strictly adhered to a low-carbohydrate diet for four Continue reading >>

Diabetic Ketoacidosis

Diabetic Ketoacidosis

Abbas E. Kitabchi, PhD., MD., FACP, FACE Professor of Medicine & Molecular Sciences and Maston K. Callison Professor in the Division of Endocrinology, Diabetes & Metabolism UT Health Science Center, 920 Madison Ave., 300A, Memphis, TN 38163 Aidar R. Gosmanov, M.D., Ph.D., D.M.Sc. Assistant Professor of Medicine, Division of Endocrinology, Diabetes & Metabolism, The University of Tennessee Health Science Center, 920 Madison Avenue, Suite 300A, Memphis, TN 38163 Clinical Recognition Omission of insulin and infection are the two most common precipitants of DKA. Non-compliance may account for up to 44% of DKA presentations; while infection is less frequently observed in DKA patients. Acute medical illnesses involving the cardiovascular system (myocardial infarction, stroke, acute thrombosis) and gastrointestinal tract (bleeding, pancreatitis), diseases of endocrine axis (acromegaly, Cushing`s syndrome, hyperthyroidism) and impaired thermo-regulation or recent surgical procedures can contribute to the development of DKA by causing dehydration, increase in insulin counter-regulatory hormones, and worsening of peripheral insulin resistance. Medications such as diuretics, beta-blockers, corticosteroids, second-generation anti-psychotics, and/or anti-convulsants may affect carbohydrate metabolism and volume status and, therefore, could precipitateDKA. Other factors: psychological problems, eating disorders, insulin pump malfunction, and drug abuse. It is now recognized that new onset T2DM can manifest with DKA. These patients are obese, mostly African Americans or Hispanics and have undiagnosed hyperglycemia, impaired insulin secretion, and insulin action. A recent report suggests that cocaine abuse is an independent risk factor associated with DKA recurrence. Pathophysiology In Continue reading >>

Diabetic Ketoacidosis Symptoms

Diabetic Ketoacidosis Symptoms

What is diabetic ketoacidosis? Diabetic ketoacidosis, also referred to as simply ketoacidosis or DKA, is a serious and even life-threatening complication of type 1 diabetes. DKA is rare in people with type 2 diabetes. DKA is caused when insulin levels are low and not enough glucose can get into the body's cells. Without glucose for energy, the body starts to burn fat for energy. Ketones are products that are created when the body burns fat. The buildup of ketones causes the blood to become more acidic. The high levels of blood glucose in DKA cause the kidneys to excrete glucose and water, leading to dehydration and imbalances in body electrolyte levels. Diabetic ketoacidosis most commonly develops either due to an interruption in insulin treatment or a severe illness, including the flu. What are the symptoms and signs of diabetic ketoacidosis? The development of DKA is usually a slow process. However, if vomiting develops, the symptoms can progress more rapidly due to the more rapid loss of body fluid. Excessive urination, which occurs because the kidneys try to rid the body of excess glucose, and water is excreted along with the glucose High blood glucose (sugar) levels The presence of ketones in the urine Other signs and symptoms of ketoacidosis occur as the condition progresses: These include: Fatigue, which can be severe Flushing of the skin Fruity odor to the breath, caused by ketones Difficulty breathing Type 2 Diabetes Diagnosis, Treatment, Medication What should I do if I think I may have, or someone I know may diabetic ketoacidosis? You should test your urine for ketones if you suspect you have early symptoms or warning signs of ketoacidosis. Call your health-care professional if your urine shows high levels of ketones. High levels of ketones and high blood sug Continue reading >>

Diagnosis And Treatment Of Diabetic Ketoacidosis And The Hyperglycemic Hyperosmolar State

Diagnosis And Treatment Of Diabetic Ketoacidosis And The Hyperglycemic Hyperosmolar State

Go to: Pathogenesis In both DKA and HHS, the underlying metabolic abnormality results from the combination of absolute or relative insulin deficiency and increased amounts of counterregulatory hormones. Glucose and lipid metabolism When insulin is deficient, the elevated levels of glucagon, catecholamines and cortisol will stimulate hepatic glucose production through increased glycogenolysis and enhanced gluconeogenesis4 (Fig. 1). Hypercortisolemia will result in increased proteolysis, thus providing amino acid precursors for gluconeogenesis. Low insulin and high catecholamine concentrations will reduce glucose uptake by peripheral tissues. The combination of elevated hepatic glucose production and decreased peripheral glucose use is the main pathogenic disturbance responsible for hyperglycemia in DKA and HHS. The hyperglycemia will lead to glycosuria, osmotic diuresis and dehydration. This will be associated with decreased kidney perfusion, particularly in HHS, that will result in decreased glucose clearance by the kidney and thus further exacerbation of the hyperglycemia. In DKA, the low insulin levels combined with increased levels of catecholamines, cortisol and growth hormone will activate hormone-sensitive lipase, which will cause the breakdown of triglycerides and release of free fatty acids. The free fatty acids are taken up by the liver and converted to ketone bodies that are released into the circulation. The process of ketogenesis is stimulated by the increase in glucagon levels.5 This hormone will activate carnitine palmitoyltransferase I, an enzyme that allows free fatty acids in the form of coenzyme A to cross mitochondrial membranes after their esterification into carnitine. On the other side, esterification is reversed by carnitine palmitoyltransferase I Continue reading >>

Is Keto Healthy? Ketosis Vs Ketoacidosis

Is Keto Healthy? Ketosis Vs Ketoacidosis

Is Keto Healthy? Ketosis vs Ketoacidosis When looking at a ketogenic diet and ketosis, it’s common for some people to confuse the process with a harmful, more extreme version of this state known as diabetic ketoacidosis. But there are a lot of misconceptions out there about ketosis vs ketoacidosis, and it’s time to shed some light on the subject by looking at the (very big) differences between the two. An Overview of Ketosis A ketogenic, or keto, diet is centered around the process of ketosis, so it’s important to understand exactly what ketosis is first before we get into whether or not it’s safe (spoiler: it is): Ketosis is a metabolic state where the body is primarily using fat for energy instead of carbohydrates. Burning carbohydrates (glucose) for energy is the default function of the body, so if glucose is available, the body will use that first. But during ketosis, the body is using ketones instead of glucose. This is an amazing survival adaptation by the body for handling periods of famine or fasting, extreme exercise, or anything else that leaves the body without enough glucose for fuel. Those eating a ketogenic diet purposely limit their carb intake (usually between 20 and 50 grams per day) to facilitate this response. That’s why the keto diet focuses on very low carb intake, moderate to low protein intake, and high intakes of dietary fats. Lower protein is important because it prevents the body from pulling your lean muscle mass for energy and instead turns to fat. Ketone bodies are released during ketosis and are created by the liver from fatty acids. These ketones are then used by the body to power all of its biggest organs, including the brain, and they have many benefits for the body we’ll get into later. But first, let’s address a common mi Continue reading >>

Understanding And Treating Diabetic Ketoacidosis

Understanding And Treating Diabetic Ketoacidosis

Diabetic ketoacidosis (DKA) is a serious metabolic disorder that can occur in animals with diabetes mellitus (DM).1,2 Veterinary technicians play an integral role in managing and treating patients with this life-threatening condition. In addition to recognizing the clinical signs of this disorder and evaluating the patient's response to therapy, technicians should understand how this disorder occurs. DM is caused by a relative or absolute lack of insulin production by the pancreatic b-cells or by inactivity or loss of insulin receptors, which are usually found on membranes of skeletal muscle, fat, and liver cells.1,3 In dogs and cats, DM is classified as either insulin-dependent (the body is unable to produce sufficient insulin) or non-insulin-dependent (the body produces insulin, but the tissues in the body are resistant to the insulin).4 Most dogs and cats that develop DKA have an insulin deficiency. Insulin has many functions, including the enhancement of glucose uptake by the cells for energy.1 Without insulin, the cells cannot access glucose, thereby causing them to undergo starvation.2 The unused glucose remains in the circulation, resulting in hyperglycemia. To provide cells with an alternative energy source, the body breaks down adipocytes, releasing free fatty acids (FFAs) into the bloodstream. The liver subsequently converts FFAs to triglycerides and ketone bodies. These ketone bodies (i.e., acetone, acetoacetic acid, b-hydroxybutyric acid) can be used as energy by the tissues when there is a lack of glucose or nutritional intake.1,2 The breakdown of fat, combined with the body's inability to use glucose, causes many pets with diabetes to present with weight loss, despite having a ravenous appetite. If diabetes is undiagnosed or uncontrolled, a series of metab Continue reading >>

Diabetic Ketoacidosis A Risk After Bariatric Surgery

Diabetic Ketoacidosis A Risk After Bariatric Surgery

Diabetic Ketoacidosis a Risk after Bariatric Surgery Researchers at the Cleveland Clinic have found that while bariatric surgery is considered a safe and effective treatment for obesity and its comorbidities, diabetic ketoacidosis (DKA) can occur in diabetic patients following weight-loss procedures. The findings were recently published in Diabetes Care. The investigators, led by Ali Aminian, MD, point out that the characteristics of DKA following bariatric surgery have not been explored, so they analyzed 12 patients who from January 2005 to December 2015 developed DKA within 90 days of surgery. Eight of these patients had type 1 diabetes (T1D), while four had type 2 diabetes (T2D), and three of them had a past history of DKA. Six patients had undergone laparoscopic Roux-en-Y gastric bypass, four underwent laparoscopic sleeve gastrectomy, and two had laparoscopic adjustable gastric banding. One patient even developed two episodes of postoperative DKA. The authors also point out that eight of these patients had inadequate insulin therapy or were non-compliant, and three of these patients developed DKA before they were even discharged from the hospital following their weight-loss procedures, which they write could be explained by the combination of undertreatment with insulin and surgical stress. The median time between surgery and DKA was 12 days. Infection was a precipitating factor for the development of DKA in four (33%) patients, the authors write. Poor oral intake (for several days) could be a contributing factor in three (25%) patients. Aminian and his team note that this is the largest case series of this kind to date. Based on what they observed in this study, as well as the literature, they conclude that its not uncommon for patients with poorly controlled T1D Continue reading >>

Euglycemic Diabetic Ketoacidosis Sometimes Seen With Sglt2 Inhibitors

Euglycemic Diabetic Ketoacidosis Sometimes Seen With Sglt2 Inhibitors

Craig Cocchio, PharmD, BCPS, is an Emergency Medicine Clinical Pharmacist at Trinity Mother Frances Hospital in Tyler, Texas. Follow on Twitter @iEMPharmD and on his blog at empharmd.blogspot.com Diabetic ketoacidosis (DKA) in patients with presenting serum blood glucose <200 mg/dL isn’t common. More often, it’s seen in patients with type 1 diabetes in conjunction with starvation and acute illness.1 It’s difficult to determine an incidence of euglycemic DKA (euDKA) among all DKA cases in the literature, given the migration of the serum glucose cutoff from ≤300 mg/dL to ≤200 mg/dL. The best estimation based on an analysis of case reports suggests an incidence anywhere between 0.8% and 7.5%.1 However, the sodium-glucose cotransporter-2 (SGLT2) inhibitors canagliflozin, dapagliflozin, and empagliflozin can apparently induce this once-rare form of DKA.2,3 SGLT2 inhibitors are a class of oral hypoglycemic drugs indicated only for type 2 diabetes. Their novel mechanism of action prevents glucose reabsorption from the proximal renal tubules, resulting in increased glucosuria and decreasing plasma glucose. SGLT2 inhibitors lower serum glucose and HBA1C levels, and even produce weight loss. However, the increased glucose concentration in the bladder is a terrific incubation environment for fungi and bacteria, so much so that the FDA stuck a post-marketing warning on the drug class for the increased risk of serious urinary tract infections and urosepsis, in addition to euglycemic DKA. The proposed mechanism suggests that while SGLT2 inhibitors lower serum glucose, they also reduce insulin secretion from pancreatic beta cells in a negative feedback fashion. The lower serum insulin coupled with lower serum glucose consequently shifts energy metabolism to antilipolytic act Continue reading >>

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