What is the optimal time for measuring glucose concentration to detect steroid-induced hyperglycemia in patients with rheumatic diseases?

Steroid-induced diabetes in lupus nephritis patients: Classic risk factors or a different type of diabetes?

BackgroundGlucocorticoids are frequently employed in systemic lupus erythematosus (SLE) patients and play a critical role in the induction therapy of lupus nephritis (LN), despite their many side effects, including steroid-induced diabetes (SID). Information regarding SID in SLE patients is quite scant.PurposeThe aim of this study was to determine risk factors associated with the development of SID in patients with LN.Research Design A nested case-control study was conducted.Study sampleWe included patients with biopsy-proven LN, who received induction treatment with steroids.Data Collection and/or AnalysisOut of the total of 358 patients, 35 (9.7%) developed SID.ResultsPatients with SID had more metabolic risk factors, including the metabolic score for insulin resistance (METS-IR); more factors related with lupus activity, with higher SLEDAI and SLICC-DI scores; and lower cumulative pre-induction steroid dose. A higher percentage of patients who developed SID received steroid pulses and a lower percentage received antimalarials. After logistic regression, the variables significantly associated with the development of SID were the SLEDAI index (OR 1.25 [95% CI 1.04-1.50], p 0.01), SLICC-DI (OR 4.93 [95% CI 2.14-11.3], p < 0.001), METS-IR (OR 1.17 [95% CI 1.04-1.32], p 0.009), delta METS-IR at 6 months (OR 1.20 [95% CI 1.03-1.39], p 0.01), and the use of antimalarials (OR 0.14, [95% CI 0.02-0.85], p 0.03). After propensity score matching, METS-IR remained a significant predictor of SID. Patients with METS-IR >36.8 were at higher risk (OR: 2.83, 95% CI: 1.09-7.36, p = 0.034).ConclusionsIn conclusion, SDI development in patients receiving induction therapy for LN is associated with both classic metabolic risk factors and SLE-specific factors, and antimalarial use could be associated with a protective effect. Rheumatologists should be aware of this potential complication, in order to implement appropriate management strategies.

Diagnostic and Therapeutic Approaches for a Diabetic Patient Presenting with Secondary Syphilis and Severe Odynophagia

Syphilis, an infectious disease caused by the spirochete Treponema pallidum, represents a pervasive global epidemic. Secondary syphilis is typically marked by the emergence of highly contagious mucocutaneous manifestations, including non-pruritic rashes on the palms and soles of the feet, alopecia, mucous patches, and condyloma lata. Here, we report a rare case of a 30-year-old male with newly discovered type 2 diabetes mellitus who presented with severe odynophagia due to secondary syphilis, confirmed by both nontreponemal VDRL/RPR and treponemal TPHA tests. Following the administration of a single-dose intramuscular injection of benzathine penicillin G 2.4 million units, the symptoms gradually decreased, allowing the patient to regain his health.

Microneedles with Two-Stage Glucose-Sensitive Controlled Release for Long-Term Insulin Delivery

Diabetes patients cannot complete effective blood glucose regulation due to their impaired pancreatic function. At present, subcutaneous insulin injection is the only treatment for patients with type 1 and severe type 2 diabetes. However, long-term subcutaneous injection will cause patients with intense physical pain and lasting psychological burden. In addition, subcutaneous injection will lead to hypoglycemia risk to a large extent because of the uncontrollable release of insulin. In this work, we developed a glucose-sensitive microneedle patch based on phenylboronic acid (PBA)-modified chitosan (CS) particles and poly(vinyl alcohol) (PVA)/poly(vinylpyrrolidone) (PVP) hydrogel for the efficient delivery of insulin. Meanwhile, through the double glucose-sensitive response process of CS-PBA particle and external hydrogel, the sudden release of insulin was well restrained, and a more persistent blood glucose control was achieved. Finally, the painless, minimally invasive, and efficient treatment effect of the glucose-sensitive microneedle patch indicated its great advantages as a new generation of injection therapy.

Myeloperoxidase as an important predictor of cardiovascular risk in individuals with rheumatoid arthritis

BACKGROUND

Rheumatoid arthritis is an inflammatory disease with joint manifestations. In the presence of extra-articular manifestations, the morbidity and severity of the disease increase. Glucocorticoid is used as a treatment and may result in side effects related to cardiovascular risk.

METHODS

This was a cross-sectional study including 59 volunteers with rheumatoid arthritis receiving treatment at a hospital of Campos Gerais that aimed to establish the relation between cardiovascular risk, glucocorticoid treatment and myeloperoxidase in these patients. Subjects were divided into two groups: using (n = 39) and without glucocorticoids (n = 20). They underwent clinical evaluation, physical examination and blood samples were taken. Statistical analysis was performed using Student's t test and Mann-Whitney test. Logistic regression was performed to assess the cardiovascular risk. The significance level was 5% (α = 0.05). Calculations were performed using the Statistical Package for the Social Science version 21.0.

RESULTS

There has been a significant difference between groups in blood glucose values (p = 0.012), which can be explained by the different percentage of diabetic patients in the groups. When assessing cardiovascular risk using the predictors of glucocorticoid dose, time of glucocorticoid use, myeloperoxidase, and C-reactive protein together, these were responsible for significantly predicting this risk (p = 0.015).

CONCLUSION

A significant relation between the predictor myeloperoxidase alone was also demonstrated (p = 0.037), it may be an important predictor of cardiovascular risk among individuals with rheumatoid arthritis.

How should rheumatologists manage glucocorticoid-induced hyperglycemia?

Glucocorticoid-induced hyperglycemia (GIH) is an important complication to be managed by rheumatologists as it can affect morbidity and mortality of patients. Before administration of glucocorticoids, risk for the development of GIH should be assessed in every patient. A meta-analysis identified male gender, older age, family history of diabetes mellitus, current smoking history, past history of hypertension, higher body mass index, higher fasting plasma glucose (PG) and higher hemoglobin A1c (HbA1c) levels as risk factors for GIH. Then, rheumatologists need to carefully monitored PG levels including 2-h after meals because glucocorticoids particularly affect postprandial glucose metabolism. Fasting PG level ≥ 126 mg/dL and/or post-meal PG level ≥ 200 mg/dL are considered as GIH regardless of HbA1c level. Treatment strategy for GIH should center on insulin injection since the effectiveness of oral hypoglycemic agents for GIH has been uncertain. But, rheumatologists may try oral hypoglycemic agents in advance of insulin therapy for mild GIH, whereas diabetologists should be consulted in case of intractable GIH. More strict control of GIH could be possible using intensive insulin protocol. Rheumatologists are encouraged to be interested in the management of GIH for providing patients superior care, working closely with diabetologists.