17th Edition
`
`HARRISON'S
`11NTERNAL
`!MEDICINE
`
`I
`
`EDITORS
`Eugene Braunwald, MD
`Anthony S. Fauci, MO
`Distinguished Hersey Professor o f Medicine,
`Harvard Medical School; Chairman, T I MI Study Group,
`Chief, Laboratory o f Immunoregulation; Director,
`National Institute o f Allergy and Infectious Diseases,
`Brigham and Women's HospitaJ, Boston
`National Institutes o f Health, Bethesda
`Stephen L. Hauser, MD
`Dennis L. Kasper, MD
`Robert A. Fishman Distinguished Professor and Chairman,
`William Ellery Channing Professor o f Medicine,
`Department o f Neurology, University o f California,
`Professo r o f Microbiology and Molecular Genetics,
`San Francisco, San Francisco
`Harvard Medical School; Director, Channing Laboratory,
`Department o f Medicine, Brigham and Women's HospitaJ, Boston
`J. Larry Jameson, MD, PhD
`'
`Dan L. Longo, MD
`P rofessor o f Medicine;
`Vice-President fo r MedicaJ Affairs and Lewis Landsberg Dean,
`Northwestern University Feinberg School o f Medicine, Chicago
`Scientific Director, National Instit u te o n Aging,
`National Institutes o f Health, Bethesda a n d Baltimore
`Joseph Loscalzo, MD, PhD
`Hersey Professor o f the Theory and Practice o f Medicine,
`Harvard MedicaJ School; Chairman, Department o f Medicine;
`Physician-in-Chief, Brigham and Women' s HospitaJ, Boston
`
`\
`
`_,.
`
`..___.
`
`I I Medical
`
`New York Chicago San Francisco Lisbon London Madrid Mexico City
`New Delhi San Juan Seoul " 'Singapore Sydney Toronto
`
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`Tho McGraw·Hill Companies
`
`1
`
`Note: Dr. Fauci's and Dr. Longo's works as editors and authors were performed outside the scope of their
`employment as U.S. government employees. These works represe nt their personal and professional views
`and not necessarily those of the U.S. government.
`..
`
`Harrison's
`PRINCIPLES OF INTERNAL MEDICINE
`Seventeenth Edition
`Copyright© 2008, 2005, 2001, 1998, 1994, 1991, 1987, 1983, 1980, 1977, 1974, 1970, 1966, 1962, 1958 by The
`McGraw-Hi/I Companies, lnc. All rights reserved. Printed in the United States of America. Except as permit(cid:173)
`ted under the United States Copyright Act of 1976, no part of this publication may be reproduced or distrib(cid:173)
`uted in any form or by a11y means, or stored in a data base or retrieval system, without the prior written
`permission of the p ublisher.
`1234567890 DOWDOW 098
`Single Edition Set ISBN 978-0-07-146633-2; MHID 0-07-1 46633-9
`Single Edition Book ISBN 978-0-07-159991-7; MHID 0-07- 15999 I-6
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`FOREIGN LANGUAGE EDITIONS
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`This book was set in Minion, Myriad, and Dax by Silvc::rchair Science + Communications, fnc. The editors
`were James Shanahan and Mariapaz Ramos Englis; editorial assistant was Jenna Esposito. The production di(cid:173)
`rector was Phil Galea and production manager was Catherine Saggese. The index was prepared by Barbara
`Littlewood. T he text designer was Alan Barnelt of alan barnett design; cover design was by David Dell' Accio.
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`
`Library of Congress Cataloging-in-Publication Data
`Harrison's principles of internal medicine. -- 17th ed. / editors, Anthony S. Fauci ... let al.].
`p.;cm.
`Includes bibliographical references and index.
`ISBN-13: 978-0-07-146633-2 (hardcover: v. 2: alk. paper)
`ISBN- 10: 0-07- 146633-9 (hardcover: v. 2 : alk. paper)
`ISBN-13: 978-0-07-147691-l (hardcover: set: v. 2: alk. paper)
`ISBN-10: 0-07-147691-1 (hardcover: set : v. 2: alk. paper) I. Internal medicine. I. Fauci, Anthony S.,
`II. Title: Principles of inte rnal medicine.
`[DNLM: 1. lnternal Medicine. WB 115 H322 2008)
`RC46.H333 2008
`616--dc22
`
`2007012181
`
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`from biochemical screening for tumors in indi- 2275
`viduals who carry a germ-line mutation.
`
`■ Sporadic
`■ NF1
`SDHD
`SDHC
`■ SDHB
`■ RET
`■ VHL
`
`0-10
`
`11-20
`
`21~0
`
`31-40
`
`41-50
`
`51- 60
`
`61- 70
`
`71- 81
`
`Age/years
`nGURl337·6 Mutation distribution in the RET, VHL, NF1, Sf;HB, SDHC, and SDHD
`nes, The bars depict the frequency of sporadic or various inherited forms of pheochromo(cid:173)
`ge oma in different age groups. The inherited disorders are much more common among
`~mger individuals presenting with pheochromocytoma. (Data from the Freiburg International
`kochromocytoma and Paraganglioma Registry.)
`
`FURTHER READINGS
`BAUSCH Bet al: Clinical and genetic character(cid:173)
`istics of patients with neurofibromatosis
`type I and pheochromocytoma. N Engl J
`Med 354:2729, 2006
`- - - et al: Germline NFl mutational spec(cid:173)
`tra and loss-of-heterozygq~ty analyses in
`patients with pheochromocytoma and neu(cid:173)
`rofibromatosis type I. J Clin Endocrinol
`Metab 92:2784, 2007
`LENDERS JW et al: Phaeochromocytoma. Lan(cid:173)
`cet 366:665, 2005
`NEUMANN HP et al: Distinct clinical features
`of paraganglioma syndromes associated
`wilh SDHB and SDHD gene mutations.
`JAMA 292:943, 2004
`- - - et al: Evidence ofMEN-2 in the origi(cid:173)
`nal description of classic pheochromocy(cid:173)
`toma. N Engl J Med 357:1 311, 2007
`- - - et al: Gernt.line mutations in nonsyn(cid:173)
`dromic pheochromocytoma. N Engl J Med
`346: 1459, 2002
`SCHOLZ T et al: Clinical review: Current treatment of malignant pheo(cid:173)
`chromocytoma. J Clin Endocrinol Metab 92: 1217, 2007
`WALZ MK et al: Laparoscopic and retroperitoneoscopic treatment of
`pheochromocytornas and retropei:itoneal paragangEomas: Results
`of 161 tumors in 126 patients. World J Surg 30:899, 2006
`
`once the underlying syndrome is diagnosed, the benefit of genetic; test(cid:173)
`ilgcan be extended to relatives. For this purpose, it is necessary to identify
`me germ-line mutation in the proband and, after genetic counseling, per(cid:173)
`lJrm DNA sequence analyses of the respo'nsible gene in relatives to deter(cid:173)
`mine if they are affected (Chap. 64). Other family members may benefit
`
`338 Diabetes Mellitus
`
`Alvin C. Powers
`
`Diabetes mellitus (pM) r~fers to a group of common metabolic disor(cid:173)
`ders that share the phenotype ofhyperglycemia. Several distinct types
`of DM exist and are caused •ty a complex interaction of genetics and
`rnvironmental factors. Depending on the etiology of the DM, factors
`<ontributing to hyperglycemia include reduced insulin secretion, de(cid:173)
`creased glucose utilization, and increased glucose production. The
`lllttabolic dysregulation associated with DM causes secondary patho(cid:173)
`~iysiologic changes in multiple organ systems that impose a tremen(cid:173)
`dous burden on the individual with diabetes and on the health care
`l)~tei~. In the United States, DM is the leading cause of end-stage re(cid:173)
`: disease (ESRD), nontraumatic lower extremity amputations, and
`. ult blindness. It also predisposes to cardiovascular diseases. With an
`:~'.easing incidence worldwide, DM will be a leading cause of mor-
`ny and mortality for th
`_ foreseeable future.
`7
`
`I
`
`(~ATION
`OM is I
`·fi
`~r
`c as_s1 ed on the basis of the pathogenic process that leads to hy-
`I
`tlie g Ycem,a, as opposed to earlier criteria such as age of onset or type of
`~apy (Fig. 338-1). The two broad categories of DM are designated
`Ph~ and type 2 (Table 338-l ). Both types of diabetes are preceded by a
`Pru of abnormal glucose homeostasis as the pathoeenic processt>s
`llili!';sse~. Type 1 diabetes_is tb.1< result of.cQJ:nplete or ~ea1";-total in(cid:173)
`lcter- efic1ency. Type 2 DM 1s a hetet-ogeneous ~oup of disorders char(cid:173)
`lttre:~d by variable degrees of insulin 1~gt~lice, impaired insulin
`~lie ~on, an~ increased glucose proauctio'fi. 'Disl-inct genetic and meta(cid:173)
`Phen efects m insulin action and/or secretion give rise to the ~ommon
`otype of hyperglycemia in type 2 DM and have importa'nt potential
`'
`
`~
`
`0
`ClJ r::r
`rt> ro V,
`:i:
`rt>
`2
`
`V>
`
`Hyperglycemia
`Pre-diabetes
`,
`Diabetes Mellitus
`Insulin
`Insulin
`Impaired fasting :
`glucose or
`: Not
`required required
`for
`for
`impaired glucose , insulin
`I requiring
`control survival
`tolerance
`
`Normal
`glucose
`tolerance
`
`I
`
`5.6-6.9 mmoVL
`<5.6 mmol/L
`(100- 125 mgldl)
`(100 mgldl)
`<7.8 mmol/L 7.8- 11 .1 mmoVL
`(140 mgldL)
`(140-199 mg/dl)
`
`~7.0mmol/L
`(126 mgldl)
`~11.1 mmolll
`(200 mgldl)
`
`---,
`
`Type of
`Diabetes
`
`Type 1
`Type2
`Other
`specific types
`Gestational
`Diabetes
`Time (years)
`
`FPG
`
`2-h PG
`
`FIGURE 338·1 Spectrum of glucose homeostasis and diabetes mel(cid:173)
`litus (OM). The spectrum from normal glucose tolerance to diabetes in
`type 1 DM, type 2 DM, other specific types of diabetes, and gestational
`DM is shown from left to right. In most types of DM, the individual
`traverses from normal glucose tolerance to impaired glucose tolerance
`to overt diabetes. Arrows indicate that changes in glucose tolerance may
`be bi-directional in some types of diabetes. For example, i--idividuals with
`type 2 DM may return to the impaired glucose tolerance category with
`weight loss; in gestational DM diabetes may revert to impaired glucose
`tolerance or even normal alucose toler;m,P ;iftpr delivrry. The fasting
`plasma glucose (FPG) and 2-h plasma glucose (PG), after a glucose chal(cid:173)
`lenge for the different categories of glucose tolerance, are shown at the
`lower part of the figu·e. These values do not apply to the diagnosis of
`gestational DM. Some types ofDM may or may not require insulin for sur(cid:173)
`vival, hence the dotte::l line. (Conventional units are used in the figure.)
`(Adapted from the American Diabetes Association, 2007.)
`
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`trM!IUII ETIOLOGIC CLASSIFICATION OF DIABETES MELLITUS
`I. Type I diabetes (13-cell destruction, usually leading to absolute insulin
`deficiency)
`A. Immune-mediated
`8. Idiopathic
`II. Type 2 diabetes (may range from predominantly insulin resistance with
`1elative insulin deficiency to a predominantly insulin secretory defect with
`insulin resistance)
`Ill. Other specific types of diabetes
`A. Genetic defects of 13 cell function characterized by mutations In:
`I. Hepatocyte nuclear transcription factor (HNF) 4a (MODY I)
`2. Glucokinase (MODY 2)
`3. HNF-1 a (MODY 3)
`4. Insulin promoter factor-1 (IPF-1; MODY 4)
`5.HNF·113 (MODY 5)
`6. NeuroDl (MODY 6)
`7. Mitochondrial DNA
`8. Subunits of ATP-sensitive potassium channel
`9. Proinsulln or insulin conversion
`B. Genetic defects in insulin action
`1. Type A insulin resistance
`2. Leprechaunism
`3. Rabson-Mendenhall syndrome
`4. Lipodystrophy syndromes
`C. Diseases of the exocrine pancreas-pancreatitis, pancreatectomy,
`neoplasia, cystic fibrosis, hemochromatosis, fibrocalculous pancreat·
`opathy, mutations in carboxyl ester lipase
`D. Endocrinopathies-acromegaly, Cushlng's syndrome, glucagonoma,
`pheochromocytoma, hyperthyroidism, wmatostatinoma,
`aldosteronoma
`E. Drug-or chemical-induced-Vacor, pentamidine, n1cotinic acid, glu·
`cocorticoids, thyroid hormone, diazoxide, 13-adrenergic agonists, thia­
`zides, phenytoin, a-interferon, protease Inhibitors, clozapine
`F. Infections-congenital rubella, cytomegalovirus, coxsackie
`G. Uncommon forms of immune-mediated diabetes-·stiff-person· syn­
`drome, anti-insulin receptor antibodies
`H. Other genetic syndromes sometimes associated with diabetes­
`Down's syndrome, Klinefelter's syndrome, Turner's syndrome, Wol•
`fram's syndrome, Friedreich's ataxia, Huntington's chorea, Laurence­
`Moon-Biedl syndrome, myotonlc dystrophy, porphyria, Prader-Willi
`syndrome
`IV. Gestational diabetes meilltus (GDM)
`Note: MODY, m.itumy onset or diabet� of the young.
`Source: Adaptl!ii lrom Amerw:an Diabetes Association, 2007
`
`2276
`
`~
`
`r-r,
`;::,
`c..
`0 ,-,
`;::,
`£.
`0
`I.C
`-<
`OJ
`=> c..
`3:
`ro cu er
`
`0
`
`V ,
`
`3
`
`0
`
`The P..mericas
`2000�33 �illion.._
`2030: 66.lhnillion';,-).
`
`0
`
`OOo 0
`
`2000:7
`2030: 18.
`
`8
`
`EPIDEMIOlOGY
`
`��u':'��o��%s. •
`wilh diabetes, are:
`India China
`USA
`Indonesia
`Japan
`Pakistan
`1::=J3.5 �6-8 ->8
`Russia
`Brazil
`2000=number of people with diabetes in 2000
`2030=number of people with diabetes in 2030
`Italy Banaladesh
`FIGURE 338·2 Worldwide prevalence of diabetes mellitus. The prevalence of diabetes in 2000
`and the projected prevalence in 2030 are shown by geographical region. (Used with permission from
`
`Cl
`
`In persons 35-64 years
`
`therapeutic implications now that pharmacologic agents arc av
`target specific metabolic derangements. Type 2 DM is preceded
`riod of abnormal glucose homeostasis classified as impaired f:
`cose (JFG) or impaired glucose tolerance ()GT).
`Two features of the current classification of DM diverge fro
`ous classifications. F irst, the terms insulin-dependent diabetes II\.
`(IDDM) and nonins11/i11-depende11t diabetes mellitus (NIDD�l
`solete. Since many individuals with type 2 DM eventually re
`sulin treatment for control of glycemia, the use of the terrn quj
`generated considerable confusion. A second difference is th�
`not a criterion in the classification system. Although type I D�
`commonly develops before the age of 30, an autoimmune beta
`structive process can develop at any age. It is estimated that be
`a�d 1�% of individuals who d�velop DM after �ge_30 have tyPc 1
`L1kew1se, type 2 DM more typically develops with mcreasingag
`now being diagnosed more frequently in children and young f
`particularly in obese adolescents.
`OTHER TYPES OF OM
`Other etiologies for DM include specific genetic defects in insulin
`tion or action, metabolic abnormalities that impair insulin secretion,
`tochondrial abnormalities, and a host of conditions that impair gl1111e,
`tolerance (Table 338-1). Maturity onset diabetes of the young (MODY)
`subtype of DM characterized by autosomal dominant inheritance,flltt
`onset of hyperglycemia (usually <25 years), and impairment in insufa
`secretion (discussed below). Mutations in the insul in receptor cause
`group of rare disorders characterized by severe insulin resistance.
`DM can res_ult from pancreatic exocrine disease when the majom,
`of pancreatic islets are destroyed. Hormones that antagonize insullll
`action can also lead to DM. Thus, DM is often a feature of endocn­
`nopathies such as acromegaly and Cushing's disease. Viral infoctiOIII
`have been implicated in pancreatic islet destruction but are an e,,
`tremely rare cause of DM. A form �f acute onset of type I diabete,
`termed f11/mi11ant diabetes, has been noted in Japan and may be relabd
`to viral infection of islets.
`GESTATIONAL DIABms MELLITUS (GDM)
`Glucose intolerance may develop during pregnancy. Insulin resistanct
`is related to the metabolic changes of late pregnancy, and the increased
`insulin requirements may lead to IGT. GOM occurs in -4% of preg•
`nancies in the United States; most wom
`en revert to normal glucose toleranct
`post-partum but have a substanti�l �
`(30-60%) of developing OM later m hfe.
`The worldwide prevalence of
`OM has risen dramatically over
`the past two decades, from ;
`estimated 30 million cases in 1985 10 Ids,
`million in 2000. Based on current tr�nbe­
`>360 million individuals will have dia N­
`tes by the year 2030 (Fig. 3)S-Z)j and
`though the prevalence of both ty��
`the
`type 2 DM is increasing wor!d_wi e, ch
`M · rising 11111
`is
`prevalence of type 2 D
`. obdl
`more rapidly because of increasing ntrid
`ty and reduced act ivity levels ash��s tflll
`. I' d T JS I
`become more industna ize · h top 10
`in most countries, and 6 of \: are ill
`countries with the highest r� \,ers (at
`Asia. In the United States, the. t (CDC}
`d p venuon
`.
`:e. 1
`Disease Control an
`ersons, ?'
`estimated that 20.8 miJho� �iabeto il1
`7% of the population, ha . 'th diabetd
`2005 (-30% of individuals"'.'
`telY I,)
`A Proioll13
`were undiagnosed). P
`
`Prevalence of diabetes
`
`(%)
`
`-
`
`Diabetes Action Now: An Initiative of the World Health Organization and the International Diabetes Fed·
`eration, 2004, as adapted from 5 Wild et al: Diabetes Care 27: 1047, 2004.)
`
`DIYI II
`;,
`
`.
`
`d
`
`. dividuals (>20 years) were newly diagnosed with diabetes in
`• 11 '.� • icreases with aging. In 2005, the prevalence of DM in the
`5 was estimated to be 0.22% in those <20 years an 9.6% 111
`1.:J�ie ears. In individuals >60 years, the prevalence of DM was
`e 72
`1 yprevalence is similar in men and women throughout most
`f!1&. 1
`' 1\ [0.5% and 8.8% in individuals >20 years) but is slightly
`rJn�es ien >60 years. Worldwide estimates project that in 2030 the
`,.,er 10 �nber of individuals with diabetes will be 45-64 years of age.
`�1csl 11•0 considerable geographic variation in the incidence of both
`'fllere; type 2 DM. Scandinavia has the highest incidence of type I
`� I 311 in Finland, the incidence is 35/100,000 per year). The Pacific
`�(,.g., much lower rate (in Japan and China, the incidence is 1-3/
`Jii11 has ;,er year) of type I DM; Northern Europe and the United
`t<O,� ve an intermediate rate (8-17/100,000 per year). Much of the
`,ii" ; 1 isk of type I OM is believed to reflect the frequency of high­
`��LA alleles among ethnic groups iJ1 different geographic loca­
`,). The prevalence of type 2 DM and its harbinger, !GT, is highest
`1!1'5· in Pacific islands, intermediate in countries such as IncUa and
`�l�ted States, and relatively low in Russia. This variability is likely
`� n enetic, behavioral, and environmental factors. DM prevalence
`llJe lOS
`.
`.
`. h'
`h .
`d'f"'
`I
`1 ,erent et me popu at10ns wit 111 a given country. •
`ies among
`�;;, the CDC estimated that the prevalence of DM in the United
`• (age> 20 years) was 13.3% in African Americans, 9.5% in Lati-
`5111�5.1% in Native Americans (American Indians and Alaska na­
`:), and 8.7% in n�n-Hispanic whit�s. Indivi?uals be!?nging _to
`,\tiln-American or Pacific-Islander ethmc groups 111 Hawau are twice
`�kely to have diabetes compared to non-Hispanic whites. The onset
`If type 2 DM occurs, on average, at an earlier age in ethnic groups
`iaer than non-Hispanic whites.
`Diabetes is a major cause of mortality, but several studies indicate
`.cdiabetes is likely underreported as a cause of death. In the United
`SUte.,diabetes was listed as the sixth-leading cause of death in 2002; a
`�nt estimate suggested that diabetes was the fifth leading cause of
`lltth worldwide and was responsible for almost 3 million deaths an­
`awi)' (1.7-5.2% of deaths worldwide).
`IIA6NOSIS
`111c National Diabetes Data Group and World Health Organization
`Ille issued diagnostic criteria for DM (Table 338·+) based on the fol­
`'awir,g premises: (1) the spectrum of fasting plasma glucose (FPG)
`Dlthe response to an oral glucose load (OGTI-oral glucose toler­
`llkttest) varies among normal \ndividuals, and (2) DM is defined as
`1111 level of glycemia at which diabetes-specific complications occur
`llhtr than on deviations from a population-based mean. For exam­
`ik, the prevalence of retinopathy in Native Americans (Pima Indian
`fel>ulation) begins to increase at a FPG > 6.4 mmol/L ( 116 mg/dL)
`ig,338-3).
`�lucose tolerance is classified into three categories based on the
`'l\l(Fig. 338-1): (I) FPG < 5.6 mmol/L (100 mg/dL) is considered
`llilnnal; (2) FPG = 5.6-6.9 mmol/L (100-125 mg/dL) is defined as
`:;and (3) FPG 2:7.0 mmol/L ( 126 mg/dL) warrants the diagnosis of
`�Based on the OGTT, !GT is defined as plasma glucose levels be-
`7.s and I 1.1 mmol/L (140 and 199 mg/dL) and diabetes is de-
`tallll CRITERIA FOR TKE DIAGNOSIS OF DIABETES MELLITUS
`�Ptoms or diabetes plus random blood glucose concentration � 11. 1
`a� (200 mg/dLJ0 or
`l ing plasma glucose � 7.0 mmol/L ( 126 mg/dl)0 o,
`'lio-hour plasma glucose � 11 I mmol/L (200 mg/dl) during an oral
`0se tolerance test<
`Is defined as without r�ard 10 time since the las1 meat
`'i
`1"9 ,s de0ned as no caloric Intake for at least 8 h.
`. �!sh
`� ·
`,
`0\Jld be performed using a gluwse 103d contam_;')9 t� �u1valent of 75 g
`.
`:,s Qlucose dissolved 1n wat�; not recommended fQr iii.tine clinical use.
`lhe ab5ence of unequivocal hyperglycem1a and at\Jte me1abolk decompen­
`�'�se criteria should be confirmed by repeat testing on a differenI day
`• Adapted from American Diabetes Association. 2007
`
`----------------
`
`2277
`
`0 a:;· O­ro
`..... ro V'I 3: !P_. ;:::;: C:
`
`V,
`
`A
`
`15
`10
`5
`
`>-
`� a:
`
`Q.
`0
`C:
`
`70· 89-
`FPG (mg/dl)
`93. 97. 100- 105- 109- 116· 136· 226-
`2-h PG (mg/dl)
`38-
`94· 106· 116· 126· 138· 156- 185- 244- 364-
`HbA1c (%)
`3.4· 4.8-
`5.0· 5.2- 5.3· 5.5· 5.7· 6.0· 6.7· 9.5·
`FIGURE 338·3 Relationship of diabetes-specific complication and
`glucose tolerance. This figure shows the incidence of retinopathy in
`Pima Indians as a function of the fasting plasma glucose (FPG), the 2-h
`plasma glucose after a 75-g oral glucose challenge (2-h PG), or gly­
`cated hemoglobin (A 1 C). Note that the incidence of retinopathy
`greatly increases at a fasting plasma glucos�1,> 116 mg/dl, or a 2-h
`plasma glucose of 185 mg/dl, or a A 1C >6.0%. (Blood glucose values
`are shown in mg/dL; to convert to mmol/L, divide value by 18.) (Copy­
`
`right 2002, American Diabetes Association. From Diabetes Care 25(5uppl
`I): 55-520, 2002.)
`
`fined as a glucose > I I.I mmol/L (200 mg/dL) 2 h after a 75-g oral
`glucose load (Table 338-2). Some individuals have both IFG and !GT.
`Individuals with IFG and/or IGT, recently designated pre-diabetes by
`the American Diabetes Association (ADA), are at substantial risk for
`developing type 2 DM (25-40% risk over the next 5 years) and have an
`increased risk of cardiovascular disease.
`The current criter ia for the diagnosis of DM emphasize that the FPG
`is the most reliable and convenient test for identifying DM in asympto­
`matic individuals. A random plasma glucose concentration :i. I 1.1
`mmol/L (200 mg/dL) accompanied by classic symptoms of DM (poly­
`uria, polydipsia, weight loss) is sufficient for the diagnosis of DM (Ta­
`ble 338-2). Oral glucose tolerance testing, although still a valid means
`for diagnosing DM, is not recommended as part of routine care.
`Some investigators have advocated the hemoglobin A 1 C (A IC) as a
`diagnostic test for DM. Though there is a strong correlation between
`elevations in the plasma glucose and the AlC (discussed below), the
`relationship between the FPG and the AIC in individuals with normal
`glucose tolerance or mild glucose intolerance is less clear, and thus the
`use of the AIC is not currently recommended to diagnose diabetes.
`The diagnos is of OM has profound implications for an individual
`from both a medical and financial standpoint. Thus, these diagnostic
`cr iteria must be satisfied before assigning 1he diagnosis of DM. Abnor­
`malities on screening tests for diabetes should be repeated before mak­
`ing a definitive diagnosis of DM, unless acute metabolic derangements
`or a markedly elevated plasma glucose are present (Table 338-2). The
`revised criteria also allow for the diagnosis of DM to be withdrawn in
`situations where the PPG reverts to normal.
`SCREENING
`Widespread use of the PPG as a screening test for type 2 OM is recom­
`mended because: ( l) a large number of individuals who meet the cur­
`rent criteria for DM are asymptomatic and unaware that they have the
`disorder, (2) epidemiologic studies suggest that type 2 DM may be
`present for up to a decade before diagnosis, (3) as many as 50% of in­
`dividuals with type 2 DM have one or more diabetes-specific compli­
`cations at the time of their diagnosis, and (4) treatment of type 2 OM
`may favorably alter the natural history of DM. The ADA recommends
`screening all individuals >45 years every 3 years and screening indi­
`viduals at an earlier age if they are overweight (body mass index
`(BM!) > 25 km/m2] and have one additional risk factor for diabetes
`"'
`
`MPI EXHIBIT 1026 PAGE 4
`
`Apotex v. Novo - IPR2024-00631
`Petitioner Apotex Exhibit 1026-0004
`
`

`

`trM!IUII ETIOLOGIC CLASSIFICATION OF DIABETES MELLITUS
`I. Type I diabetes (13-cell destruction, usually leading to absolute insulin
`deficiency)
`A. Immune-mediated
`8. Idiopathic
`II. Type 2 diabetes (may range from predominantly insulin resistance with
`1elative insulin deficiency to a predominantly insulin secretory defect with
`insulin resistance)
`Ill. Other specific types of diabetes
`A. Genetic defects of 13 cell function characterized by mutations In:
`I. Hepatocyte nuclear transcription factor (HNF) 4a (MODY I)
`2. Glucokinase (MODY 2)
`3. HNF-1 a (MODY 3)
`4. Insulin promoter factor-1 (IPF-1; MODY 4)
`5.HNF·113 (MODY 5)
`6. NeuroDl (MODY 6)
`7. Mitochondrial DNA
`8. Subunits of ATP-sensitive potassium channel
`9. Proinsulln or insulin conversion
`B. Genetic defects in insulin action
`1. Type A insulin resistance
`2. Leprechaunism
`3. Rabson-Mendenhall syndrome
`4. Lipodystrophy syndromes
`C. Diseases of the exocrine pancreas-pancreatitis, pancreatectomy,
`neoplasia, cystic fibrosis, hemochromatosis, fibrocalculous pancreat·
`opathy, mutations in carboxyl ester lipase
`D. Endocrinopathies-acromegaly, Cushlng's syndrome, glucagonoma,
`pheochromocytoma, hyperthyroidism, wmatostatinoma,
`aldosteronoma
`E. Drug-or chemical-induced-Vacor, pentamidine, n1cotinic acid, glu·
`cocorticoids, thyroid hormone, diazoxide, 13-adrenergic agonists, thia­
`zides, phenytoin, a-interferon, protease Inhibitors, clozapine
`F. Infections-congenital rubella, cytomegalovirus, coxsackie
`G. Uncommon forms of immune-mediated diabetes-·stiff-person· syn­
`drome, anti-insulin receptor antibodies
`H. Other genetic syndromes sometimes associated with diabetes­
`Down's syndrome, Klinefelter's syndrome, Turner's syndrome, Wol•
`fram's syndrome, Friedreich's ataxia, Huntington's chorea, Laurence­
`Moon-Biedl syndrome, myotonlc dystrophy, porphyria, Prader-Willi
`syndrome
`IV. Gestational diabetes meilltus (GDM)
`Note: MODY, m.itumy onset or diabet� of the young.
`Source: Adaptl!ii lrom Amerw:an Diabetes Association, 2007
`
`The P..mericas
`2000�33 �illion.._
`2030: 66.lhnillion';,-).
`
`OOo 0
`
`2000:7
`2030: 18.
`
`8
`
`EPIDEMIOlOGY
`
`Cl
`
`therapeutic implications now that pharmacologic agents arc av
`target specific metabolic derangements. Type 2 DM is preceded
`riod of abnormal glucose homeostasis classified as impaired f:
`cose (JFG) or impaired glucose tolerance ()GT).
`Two features of the current classification of DM diverge fro
`ous classifications. F irst, the terms insulin-dependent diabetes II\.
`(IDDM) and nonins11/i11-depende11t diabetes mellitus (NIDD�l
`solete. Since many individuals with type 2 DM eventually re
`sulin treatment for control of glycemia, the use of the terrn quj
`generated considerable confusion. A second difference is th�
`not a criterion in the classification system. Although type I D�
`commonly develops before the age of 30, an autoimmune beta
`structive process can develop at any age. It is estimated that be
`a�d 1�% of individuals who d�velop DM after �ge_30 have tyPc 1
`L1kew1se, type 2 DM more typically develops with mcreasingag
`now being diagnosed more frequently in children and young f
`particularly in obese adolescents.
`OTHER TYPES OF OM
`Other etiologies for DM include specific genetic defects in insulin
`tion or action, metabolic abnormalities that impair insulin secretion,
`tochondrial abnormalities, and a host of conditions that impair gl1111e,
`tolerance (Table 338-1). Maturity onset diabetes of the young (MODY)
`subtype of DM characterized by autosomal dominant inheritance,flltt
`onset of hyperglycemia (usually <25 years), and impairment in insufa
`secretion (discussed below). Mutations in the insul in receptor cause
`group of rare disorders characterized by severe insulin resistance.
`DM can res_ult from pancreatic exocrine disease when the majom,
`of pancreatic islets are destroyed. Hormones that antagonize insullll
`action can also lead to DM. Thus, DM is often a feature of endocn­
`nopathies such as acromegaly and Cushing's disease. Viral infoctiOIII
`have been implicated in pancreatic islet destruction but are an e,,
`tremely rare cause of DM. A form �f acute onset of type I diabete,
`termed f11/mi11ant diabetes, has been noted in Japan and may be relabd
`to viral infection of islets.
`GESTATIONAL DIABms MELLITUS (GDM)
`Glucose intolerance may develop during pregnancy. Insulin resistanct
`is related to the metabolic changes of late pregnancy, and the increased
`insulin requirements may lead to IGT. GOM occurs in -4% of preg•
`nancies in the United States; most wom
`en revert to normal glucose toleranct
`post-partum but have a substanti�l �
`(30-60%) of developing OM later m hfe.
`The worldwide prevalence of
`OM has risen dramatically over
`the past two decades, from ;
`estimated 30 million cases in 1985 10 Ids,
`million in 2000. Based on current tr�nbe­
`>360 million individuals will have dia N­
`tes by the year 2030 (Fig. 3)S-Z)j and
`though the prevalence of both ty��
`the
`type 2 DM is increasing wor!d_wi e, ch
`M · rising 11111
`is
`prevalence of type 2 D
`. obdl
`more rapidly because of increasing ntrid
`ty and reduced act ivity levels ash��s tflll
`. I' d T JS I
`become more industna ize · h top 10
`in most countries, and 6 of \: are ill
`countries with the highest r� \,ers (at
`Asia. In the United States, the. t (CDC}
`d p venuon
`.
`:e. 1
`Disease Control an
`ersons, ?'
`estimated that 20.8 miJho� �iabeto il1
`7% of the population, ha . 'th diabetd
`2005 (-30% of individuals"'.'
`telY I,)
`A Proioll13
`were undiagnosed). P
`
`��u':'��o��%s. •
`wilh diabetes, are:
`India China
`USA
`Indonesia
`Japan
`Pakistan
`1::=J3.5 �6-8 ->8
`Russia
`Brazil
`2000=number of people with diabetes in 2000
`2030=number of people with diabetes in 2030
`Italy Banaladesh
`FIGURE 338·2 Worldwide prevalence of diabetes mellitus. The prevalence of diabetes in 2000
`and the projected prevalence in 2030 are shown by geographical region. (Used with permission from
`
`Prevalence of diabetes
`
`(%)
`
`In persons 35-64 years
`
`Diabetes Action Now: An Initiative of the World Health Organization and the International Diabetes Fed·
`eration, 2004, as adapted from 5 Wild et al: Diabetes Care 27: 1047, 2004.)
`
`DIYI II
`;,
`
`.
`
`d
`
`. dividuals (>20 years) were newly diagnosed with diabetes in
`• 11 '.� • icreases with aging. In 2005, the prevalence of DM in the
`5 was estimated to be 0.22% in those <20 years an 9.6% 111
`1.:J�ie ears. In individuals >60 years, the prevalence of DM was
`e 72
`1 yprevalence is similar in men and women throughout most
`f!1&. 1
`' 1\ [0.5% and 8.8% in individuals >20 years) but is slightly
`rJn�es ien >60 years. Worldwide estimates project that in 2030 the
`,.,er 10 �nber of individuals with diabetes will be 45-64 years of age.
`�1csl 11•0 considerable geographic variation in the incidence of both
`'fllere; type 2 DM. Scandinavia has the highest incidence of type I
`� I 311 in Finland, the incidence is 35/100,000 per year). The Pacific
`�(,.g., much lower rate (in Japan and China, the incidence is 1-3/
`Jii11 has ;,er year) of type I DM; Northern Europe and the United
`t<O,� ve an intermediate rate (8-17/100,000 per year). Much of the
`,ii" ; 1 isk of type I OM is believed to reflect the frequency of high­
`��LA alleles among ethnic groups iJ1 different geographic loca­
`,). The prevalence of type 2 DM and its harbinger, !GT, is highest
`1!1'5· in Pacific islands, intermediate in countries such as IncUa and
`�l�ted States, and relatively low in Russia. This variability is likely
`� n enetic, behavioral, and environmental factors. DM prevalence
`llJe lOS
`.
`.
`. h'
`h .
`d'f"'
`I
`1 ,erent et me popu at10ns wit 111 a given country