Friday, June 10, 2011


It has been known for a long time that though we understand that diabetes is a "sugar" disease, due to the inability of the body to handle a glucose load, diabetes is actually a cardiovascular disease, because patients with diabetes dies from cardiovascular complications or heart attacks, strokes, peripheral vascular disease, renal vascular disease and eye vasculopathies. Yes, before the days of insulin, some diabetics die from high blood sugar with coma. True, nowadays, some patients, treated over aggressively die from low blood sugar. But the majority of diabetics nowadays, die from cardiovascular complications. If fact, in our circle, it is commonly debated that diabetes is a cardiovascular disease and diabetologist should be a part-time cardiologist. many of our cardiac meetings will spend a large portion of our time discussing diabetes and its effect on patients.
In the May 26 issue of Diabetes ( the journal ), Dr Naila Rabbani explains why, in a paper published by her group from the University of Warwick, UK. We all know about total cholesterol and LDL-cholesterol ( bad cholesterol ). We also know that there are many forms of bad cholesterol, some rather aggressive and some more benign. The aggressive LDL-Cholesterol, are usually small and dense. Dr Naila and group found that in diabetics, particularly the poorly controlled ones, the circulating LDL-cholesterol is easily glucated ( attached with glycine-like molecule to change its structure ), by methylglyoxal. This glycated LDL-Cholesterol, becomes small, dense and sticks very easily to the arterial wall, thereby initiating the process of atherosclerosis, or furthering the process of atherosclerosis.
They also found that the diabetic drug, metformin ( good, old and cheap) reduces the glycation of LDL-cholesterol, meaning that patients on metformin, is likely to have less of the small dense LDL-cholesterol.
This kind of basic science discovery is very useful, as it allows us to understand the disease process better and also to manage it better. This will explain in large part why metformin did so well as a drug in reducing major adverse cardiac events, in diabetics, like in UKPDS.
So, not all LDL-C are the same. The small ones are more aggressive and sticks to arterial walls causing trouble. Metformin, if tolerated, is a good drug to counter this.

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