Si può desiderare di provare un trattamento naturale disfunzione erettile come un diverso per i problemi di costruzione. Al giorno d oggi ci sono diverse terapie sul mercato, ma un trattamento naturale disfunzione erettile è stato confermato qualche ora e ora di nuovo per dare risultati efficienti e permanenti. Cos è la disfunzione sessuale? L incapacità di sviluppare o sostenere una costruzione abbastanza lungo per fare l amore è chiamato disfunzione erettile, ED https://farmacia-senzaricetta.it/ o (maschio) problemi di erezione. Tutti gli uomini possono avere problemi di costruzione di volta in volta e gli scienziati considerano ED essere presenti se si verificano problemi di costruzione almeno il 25% del tempo. Alcuni fatti duri: ED Può essere dovuto a problemi emotivi. Stress, pressione, giltiness, depressione, bassa autostima e ansia prestazioni può essere la causa dei vostri problemi di costruzione. La ricerca ha confermato che il 90 per cento della disfunzione erettile è fisica in origine, non emotiva. L impotenza colpisce la maggior parte degli uomini durante la loro vita e può essere dovuto a troppo colesterolo, problemi cardiaci, diabete, ipertensione, fumo o alcol. Alcuni rimedi possono essere la ragione. Le questioni legate al movimento sono collegate. Se ti occupi dei tuoi problemi di movimento, hai piu possibilita di risolvere questo problema. Qui ci sono 5 consigli facili su come aumentare la circolazione: 1. Mangia i pasti giusti. Questo ti rendera il flusso sanguigno ovvio. Una grande parte di rimanere sani e anche mantenere il flusso sanguigno ovvio è legato al vostro piano di alimentazione quotidiana e quello che si mangia. Una buona cura per la disfunzione erettile è mangiare un piano a basso contenuto di grassi e grande alimentazione di fibre. Mangiare fibre tutti i giorni e questo viene scoperto in prodotti cerealicoli cereali integrali, frutta e verdura. Evitare il più possibile pasti pronti o pasti non sani. 2. Wonder herbal rimedi. Molti rimedi vegetali per ED eseguire bene come possono migliorare il movimento. Hanno molto meno reazioni avverse rispetto ai farmaci convenzionali e si svolgono in modo efficiente per migliorare hardons e la forza, troppo. Erbe naturali come Ginkgo Biloba sono utilizzati come una strategia per ED. Gli specialisti di erboristeria credono anche che le spezie o le erbe come noce moscata, portano al movimento intorno al corpo, tra cui il pene. 3. Vitamine naturali vitali. Gli scienziati sanitari hanno scoperto che una mancanza di supplemento è tipico tra gli uomini con ED in particolare vitamina A. Se si ha una mancanza del nutriente ossido di zinco, Questo è stato confermato per portare alla disfunzione erettile. Queste inadeguatezze derivano dal fatto che molti valori nutrizionali in quello che mangiamo piano non sono sufficienti. Aggiungere al vostro fabbisogno di nutrienti aumenterà la circolazione del sistema e migliorare questa condizione. Gli integratori alimentari sono completamente naturali, quindi non dovrete preoccuparvi dei rischi di reazioni avverse. Inoltre, queste vitamine naturali sono utili per il vostro benessere over-all. Oltre a questi vantaggi benessere, disfunzione erettile vitamine naturali e integratori costano molto meno di farmaci rimedi. 4. Esercitare. Fai una mossa e non un tablet vibrante. Camminare farà di più per migliorare e sostenere hardons di qualsiasi altra compressa chimica nel lungo periodo. Il fitness fisico manterrà bassi livelli di pressione e mantenere grandi stadi di movimento. Andando per un 20-30 minuti di movimento rapido ogni giorno, può affrontare questo problema e può sostenere la vostra libido senza l uso di qualsiasi farmaco. 5. Sottolineare. Questo è il peggior attaccante per problemi di erezione. Scopri diversi metodi per riposare. Alcuni metodi tipici per riposare includono la lettura di un libro, la meditazione, un bagno rilassante o allenamenti di respirazione. Sto solo imparando alcuni semplici allenamenti di respirazione che possono migliorare significativamente il movimento nel reparto pantaloni. Una naturale disfunzione erettile soluzioni di trattamento stanno diventando sempre più popolare con gli uomini. Questi rimedi a base di erbe sono preferiti perché non hanno reazioni avverse e sono confermati essere efficiente come il farmaco. La maggior parte degli uomini combattere parlano dei loro problemi, in particolare la disfunzione erettile come c è poca discussione sui problemi di erezione. La verita e che ED ha un impatto su piu di dieci milioni di uomini solo negli Stati Uniti. Non siete soli e l aiuto è disponibile.
Diabetes.day web.indd
Early diagnosis and intensive treatment to maintain optimal glycaemic control reduce the morbidity and mortality associated with type 2 diabetes. To sustain glucose concentrations as near normal as possible — and make the Quality and Outcomes Framework diabetes targets achievable — generally requires use of more than one antidiabetic agent, which necessitates attention to licensing indications, as Dr Caroline Day explains.
diabetes is now being diagnosed in younger population groups, including children3. To reduce
At least 95 per cent of people with diabetes
in the UK have type 2 diabetes. It has long been associated with maturity, corpulence,
the onset and severity of diabetes-related
inactivity and ageing, and more recently an excess
complications, it is important to rapidly achieve and
prevalence has been observed in some ethnic groups. maintain good glycaemic control and to treat other
In 1993, a survey suggested a diabetes prevalence of
conditions that increase vascular risk4.
3.1 per cent in people >15 years old, which more than
doubled (6.5 per cent) in those >75 years1. A report
covering the period 1991–2001 noted a >50 per cent
increase in prevalence of type 2 diabetes over that
The value of good diabetes management has been
decade2. Although the proportion of older people in
recognised by the new General Medical Services
the population increased during that time, so too had (nGMS) contract allocating the condition nearly
the prevalence of excess adiposity — a well
one-fi fth of the total clinical points available within
recognised risk factor for type 2 diabetes. The
the Quality and Outcomes Framework (QOF)5,6.
‘obesity epidemic’ has no regard for age, and type 2
Achieving these points is based mainly on attaining
february 2007 / midlife and beyond / geriatric medicine
specifi c targets for glycaemic control, parameters for
Table 1. Oral antidiabetic agents
increased vascular risk such as blood pressure and
Classes of oral antidiabetic agents, their main modes of action and glucose lowering
monitoring of microvascular disease6. The provision
of evidence-based treatment targets by learned
societies has become increasingly common as guides
for the provision of optimal treatment. The nGMS QOF targets use the carrot and stick principle to
encourage appropriate investigations, monitoring
and delivery of treatment. Whether care provision
has been improved by the nGMS contract is
debatable, but comparing 2004/5 with 2005/6 the
total QOF points achieved have risen from >90 per
cent to >95 per cent across England, Scotland, Wales
and Northern Ireland with concomitant increases in
*not widely used in UK = decrease = increase
points achieved for diabetes (>93 per cent to ~98 per cent) and associated vascular risk areas7.
morbidity — both microvascular and macrovascular — continuously decrease with progression to normoglycaemia. The Joint British Societies’ (JBS2)
guidelines has recommended an HbA ≤6.5 per
The aim of treatment is to achieve glycaemic control
cent while the National Institute for Health and
that is as near to normal as possible as this reduces the Clinical Excellence (NICE) has opted for a less incidence, progression and severity of complications.
demanding HbA of 6.5–7.5 per cent11,12. However,
Indeed, the value of intensive intervention has been
the American Diabetes Association (ADA) and
highlighted by the United Kingdom Prospective
European Association for the Study of Diabetes
Diabetes Study (UKPDS), which has shown that over
(EASD) consensus document states the goal for
treatment should be as near to normal (HbA <6.1
substantially reduces morbidity and mortality8. The
cost effectiveness of obtaining and sustaining optimal glycaemic control should not be underestimated,
The QOF clinical indicator DM20 sets an HbA1c
especially when considering that at least 25 per cent of of ≤7.5 per cent and recommends individual patient patients have vascular complications at the time of
targets should be set at 6.5–7.5 per cent, but QOF
diagnosis of type 2 diabetes9. The insidious onset of
recognises that reaching tighter levels of control is
type 2 diabetes mitigates against early detection, thus
diffi cult and has also set a less stringent target
people may have degenerating glucose control —
(DM7) of ≤10 per cent to encourage and reward
impaired fasting glucose (IFG) or impaired glucose
efforts to ‘achieve the impossible’6. However, some
tolerance (IGT), type 2 diabetes — for a decade
patients will not achieve QOF targets and exception
prior to diagnosis in which time vascular damage
reporting prevents a practice being penalised for
factors outside its control (eg, adverse response to statins, informed opt-out).
The clustering of cardiovascular risk factors
(including glucose intolerance) that constitute the metabolic syndrome should create an index of
suspicion for the presence of co-morbidities in
Type 2 diabetes is a progressive disease characterised
people being treated for at least one of the risk
by insulin resistance and deteriorating ß-cell
factors. For example, in a primary care setting
function. The conventional approach to treatment is
screening for type 2 diabetes among older
based on lifestyle modifi cation (eat less, move more)
hypertensive and ischaemic heart disease (IHD)
onto which is added oral antidiabetic drugs that
patients without diabetes revealed two per cent and
target different lesions of the condition and when
2.5 per cent respectively with type 2 diabetes and a
adequate insulin secretion can no longer be
further 18.5 per cent and 12.4 per cent respectively
sustained, insulin therapy is introduced (Table 1).
had IGT and/or IFG10. Identifi cation and treatment
The ADA-EASD consensus document recommends
of patients early in the pathogenesis of type 2
initiating treatment with metformin in addition to
diabetes greatly improves their prognosis.
lifestyle modifi cation and moving to the next treatment strategy if an HbA of <seven per cent
It is well recognised that diabetic mortality and
cannot be achieved and maintained13. At diagnosis
geriatric medicine / midlife and beyond / february 2007 Table 2. Main precautions associated with oral antidiabetic agents
aif liver or renal disease select SU with appropriate pharmacokinetics and monitor. Caution drug interactions
if liver or renal disease select SU with appropriate pharmacokinetics and monitor. Cau
bexcluded by renal impairment, serious liver disease and any condition predisposing to hypoxia,ccheck liver function (eg, serum alinine transaminase) before treatment and at intervals thereafterdavoid in intestinal disease etake with meals and titrate slowly to reduce gastrointestinal effectsfmonitor glucose with all antidiabetic drugs, especially during titration to avoid hypoglycaemiagcheck creatinine and vitamin B12 or haemoglobin annually
CHF = congestive heart failure/disease, GI = gastrointestinal, LFT = liver function test
an HbA <eight per cent may be effectively treated
therapy may be helpful14,15,16. The most common triple
by monotherapy with a sulphonylurea or metformin
combination is metformin plus a sulphonylurea plus a
(especially in overweight patients) whereas an HbA
thiazolidinedione. It is important that triple therapy is
>10 per cent is indicative of hyperglycaemia that is
not used in lieu of insulin therapy, which is necessary
unlikely to be lowered to the target range using
if there is rising hyperglycaemia on two agents,
monotherapy. Provided the individual does not have
possibly accompanied by unintentional weight loss,
late-onset type 1 diabetes, early use of combination
therapy may achieve an adequate fall in HbA 4,13.
appropriateness of the agent, the presence of
When monotherapy ceases to maintain adequate
contraindications and possible adverse events
glycaemic control the use of two antidiabetic agents
associated with the added drug. Main precautions
with different modes of action can produce
associated with oral antidiabetic agents are shown in
complementary and additive benefi ts that will
Table 2. When introducing a drug to achieve optimal
improve glycaemic control and other aspects of
glycaemic control, it is recommended the agent be
cardiovascular risk14-16. The addition of a second agent
titrated to maximal effi cacy/tolerated dose to reduce
typically reduces HbA by a further 0.6–1.5 per
the risk of adverse events such as hypoglycaemia.
cent14. When adding another oral agent it is important
Titration strategies for monotherapy and
to consider the time period you would expect to
combination therapy are carefully documented in
achieve maximal effect. For example, sulphonylureas
Bailey and Feher15. An advantage of combination
show a rapid effect evident on the fi rst day of therapy
therapy is that glycaemic control may be achieved
with the near-maximal effect of a single dose being
with lower doses of both agents than with either as
achieved in two weeks15. Meglitinides target
monotherapy, thereby reducing the potential for side
postprandial hyperglycaemia, have a faster onset and
shorter duration of action, exhibiting near maximal effi cacy by one week. In contrast, the thiazolidinediones (rosiglitazone and pioglitazone)
act via PPARg (peroxisome proliferator activated
Most people with type 2 diabetes will also be
receptor gamma) and therefore have a more slowly
receiving a statin, possibly low-dose aspirin and
generated glucose lowering effect and may take from
antihypertensives — to reduce vascular risk — and
six weeks to three months to exert maximal effi cacy in older people are likely to receive treatment for people who respond to this treatment (up to 30 per
other chronic conditions as well as therapies for
cent of patients may be non-responders)15–17.
intercurrent illness. The increasing pill burden raises the issue of compliance. Among patients
If combination therapy with two differently acting
prescribed a free combination of metformin and a
agents does not achieve glycaemic control, triple
sulphonylurea only 13 per cent showed adequate
february 2007 / midlife and beyond / geriatric medicine Table 3. Approved combination therapy drugs
Only four such preparations have received regulatory approval for UK marketing (Table 3).
Insulin resistance is an underlying feature of type 2
diabetes initially compensated by unsustainable
hyperinsulinaemia. Eventually the islet ß-cells lose
the ability to respond adequately to oral agents and
insulin replacement therapy is necessary to achieve
glycaemic control. The range of insulins, insulin
*Actoplus Met **Avandaryl and ***Duetact in USA
injection devices and the advent of inhaled insulin have made insulin therapy less daunting and provides an opportunity to more closely mimic physiological
concordance, and only about one-third of patients
insulin secretion15,17,23. Hypoglycaemia is the main side
on metformin or sulphonylurea monotherapy were
effect associated with insulin therapy and this
taking adequate medication14,19,20. This highlights
potential may compromise — but should not preclude
the importance of building a positive therapeutic
— its use in the elderly, particularly those living alone.
alliance so both patient and physician are ‘singing
Patient education is critical to the success of insulin
therapy and it is recommended that family/carers are similarly informed15,18.
The selection of an appropriate insulin regimen is
Patients on a once-daily sulphonylurea regimen
an important issue which often warrants consultation
showed greater adherence compared with those on >2
with a specialist, particularly in the care of the elderly
doses per day20, highlighting the value of simple
amongst whom treatment is more likely to be
dosing strategies. Several preparations are suited to
complicated by the presence of co-morbidities such as
once-daily dosing; for example, metformin SR which
renal and hepatic impairment15,17. It is generally
can be useful for overcoming metformin-associated
recommended that insulin therapy is initiated with a
low dose (eg, 10–12 units/day) in association with
administration of the sulphonylureas gliclazide MR or regular glucose monitoring to avoid hypoglycaemia. glimepiride produced a mean HbA of ≤7.5 per cent
The dose is gradually up-titrated by 2–4 units/day to
within nine weeks and by 27 weeks about 50 per cent
achieve target control. If HbA is <eight per cent it is
of patients achieved an HbA <7 per cent21.
advisable to start on a lower dose of six units/day17.
Hypoglycaemia is a recognised risk in the battle to optimise glycaemic control and it is the main side
Insulin resistance in type 2 diabetes necessitates
effect of sulphonylurea therapy. Use of sulphonylureas higher insulin dosages compared to people with type in the elderly is therefore a caution since they are
1 diabetes. In some patients insulin therapy is added
more likely to live alone and have less regular meal
to ongoing oral treatments — for example, insulin to
habits. In this study signifi cantly fewer patients on
a sulphonylurea regimen may reduce insulin dose
gliclazide MR (3.7 per cent) than glimepiride (8.9 per
and improve control while ß-cell function remains,
cent) noted hypoglycaemic symptoms and no third
or addition of metformin to insulin therapy may
party assistance was required21; a further study using
improve glycaemic control, reduce the weight gain
gliclazide MR over two years also exhibited a good
and insulin dose15-17. Detailed approaches to
safety profi le, notably in the elderly and in patients
initiating insulin therapy in primary care have been
described by Hirsch et al24 and PCT guidelines can be accessed via the National Diabetes Support Team website25. Some oral agents are not licensed for use
with insulin so it is important to consult the current
Fixed-dose combination tablets offer the
convenience of two differently acting agents in a single tablet, thereby reducing the pill burden14. The cautions attached to each of the component
medications need to be considered when moving
Improvements in glycaemic control are associated
from monotherapy to 2.4.1 combination treatment.
with improvements to components of the metabolic
february 2007 / midlife and beyond / geriatric medicine Key points References
• Type 2 diabetes is a progressive disease.
therapies? Diabetes & Primary Care 2006; 8(3), 124-132
• Maintaining glycaemic control as near normal as
possible reduces morbidity and mortality.
• Presence of a cardiovascular risk factor should
prompt investigation for associated conditions.
2004; 27:7-4
• Conditions which increase vascular risk should be
Practice 2005; 55: 589-95
• Advancing age does not preclude treating to target. Dis 2001; 1(1): 37-43
syndrome and some classes of drugs offer additional
et al. Earlier intervention in type
benefi ts — for example, metformin and the
333:1200-
thiazolidinediones improve aspects of rheology and
some lipid parameters15. While these changes may not
59(11): 1309-16.
be statistically signifi cant, they stack the balance in
favour of the patient and assist in achieving QOF
Diabetes Vasc Dis 2003; 3: Dis 2003; 3(1): 54-6
Excess adiposity is associated with type 2 diabetes
as recognised by DM2 and production of a practice
obesity (BMI ≥30) register for patients ≥16 years now
warrants eight QOF points (OB1)6. Obesity is a major
Diabetes & Primary Care 2006;
19(4); 263-4
cause of insulin resistance and weight loss, with or
8(4): 204-6
without pharmacological intervention, improves
8. Stratton IM, Adler AI, Neil HA et
glycaemic control and other metabolic syndrome
conditions. Indeed, the recently introduced
antiobesity agent rimonabant appears to offer ‘greater
than weight loss alone’ benefi ts to these parameters23.
2004; 34: S35-42 321: 405-12
The care of people with type 2 diabetes requires a
Dis Res 2006; 3: 145-6
holistic approach and medication strategies need
Metab 2004; 6(6):414-21
to address hyperglycaemia and associated
hypertension, dyslipidaemia and procoagulation
Diabetes Nursing 2006; 3(3):
— as well as the monitoring and treatment of
Vasc Dis 2003; 3: 414-16
complications. However, circumstances might
warrant deviating from treating to target as part of
individualising patient care. Non-governmental
consensus publications, provide targets for optimal
treatment outcomes. Such targets provide a gold
standard for treatment and should not be
undermined by lesser targets which, though easier
to achieve, do not necessarily serve the best
Dis 2006; 6(4): 147-148 Confl ict of interest: none declared. Vasc Dis 2006; 6: 121-5
geriatric medicine / midlife and beyond / february 2007
Personal Identity as a Sociological Category Words such as personal identity, individual identity and the like are of relatively recent origin. Yet they express concepts that inherited many of the conceptual and theoretical connotations associated with the older notions of individuality and individualism. From the eighteenth to the twentieth century these notions marked the terms of the intell