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Liu W, Gao Y, Zhang R, Gong S, Wang X, Wang Y, Cai X, Zhang X, Xie X, Han X, Ji L. Predictive value of postprandial C-peptide for utilizing multiple daily injection therapy in type 2 diabetes. Endocrine 2024; 85:1162-1169. [PMID: 38622435 DOI: 10.1007/s12020-024-03820-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Accepted: 04/02/2024] [Indexed: 04/17/2024]
Abstract
PURPOSE Multiple daily injection (MDI) insulin therapy is an effective method of glycemic control and appropriate assignment to MDI therapy could minimize the risks of hypoglycemia and weight gain. The aim of the present study was to identify factors associated with indication for MDI therapy in type 2 diabetes (T2DM). METHODS We recruited 360 participants with T2DM that were admitted to the Endocrinology Department of Peking University People's Hospital between August 2017 and July 2018. They first underwent intensive insulin therapy, then were switched to an optimized, simpler insulin treatment that aimed to maintain fasting blood glucose between 4.4 and 7.2 mmol/L, without episodes of hypoglycemia. The baseline characteristics of groups administering either MDI or basal/premix insulin were compared and multivariable logistic regression analysis was used to determine the odds ratios (ORs) for factors associated with MDI therapy. Receiver operating characteristic (ROC) curves were then used to identify independent predictors of MDI insulin regimen efficacy. RESULTS The mean age of the participants was 57.6 ± 12.9 years, and diabetes duration was 14.2 ± 8.2 years. Two hundred and sixty-seven participants administered basal/premix insulin and 93 underwent MDI therapy, of whom 61.8% and 46.2% were male, respectively (p = 0.01). The duration of diabetes was significantly longer in the MDI group (13.1 ± 7.7 years vs. 17.3 ± 8.7 years; p < 0.01). Fasting plasma glucose (FPG) was higher in the MDI group than in the basal/premix group (8.3 [6.7, 11.3] mmol/L vs. 7.2 [5.7, 9.3] mmol/L; p < 0.01), while the postprandial C-peptide concentration (PCP) was significantly lower in the MDI group (2.6 [1.8, 3.5] ng/mL) compared to the basal/premix group (3.6 [2.5, 6.2] ng/mL, p < 0.01. Multivariable logistic regression analysis suggested that diabetes duration and FPG were positively associated with MDI therapy: OR (95% confidence interval [CI]) 1.06 (1.02, 1.10) and 1.12 (1.02, 1.24), respectively. In addition, PCP was negatively associated with MDI therapy (0.72 [0.60, 0.86]). ROC analysis suggested that a PCP of < 3.1 ng/mL predicted MDI therapy with 59.6% sensitivity and 72.1% specificity. CONCLUSION The results of our study suggest that longer diabetes duration, higher FPG, and lower PCP were associated with necessity for MDI insulin regimen. These findings should assist with the personalization of insulin treatment.
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Affiliation(s)
- Wei Liu
- Department of Endocrinology and Metabolism, Peking University People's Hospital, Beijing, China
| | - Ying Gao
- Department of Endocrinology and Metabolism, Peking University People's Hospital, Beijing, China
| | - Rui Zhang
- Department of Endocrinology and Metabolism, Peking University People's Hospital, Beijing, China
| | - Siqian Gong
- Department of Endocrinology and Metabolism, Peking University People's Hospital, Beijing, China
| | - Xiangqing Wang
- Department of Endocrinology and Metabolism, Peking University People's Hospital, Beijing, China
| | - Yanai Wang
- Department of Endocrinology and Metabolism, Peking University People's Hospital, Beijing, China
| | - Xiaoling Cai
- Department of Endocrinology and Metabolism, Peking University People's Hospital, Beijing, China
| | - Xiuying Zhang
- Department of Endocrinology and Metabolism, Peking University People's Hospital, Beijing, China
| | - Xiaoqi Xie
- Department of Endocrinology and Metabolism, Peking University People's Hospital, Beijing, China
| | - Xueyao Han
- Department of Endocrinology and Metabolism, Peking University People's Hospital, Beijing, China.
| | - Linong Ji
- Department of Endocrinology and Metabolism, Peking University People's Hospital, Beijing, China.
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Iwamoto Y, Kimura T, Shimoda M, Morimoto Y, Watanabe Y, Itoh T, Sasaki T, Mori S, Kubo M, Takenouchi H, Dan K, Iwamoto H, Sanada J, Fushimi Y, Katakura Y, Nakanishi S, Mune T, Kaku K, Kaneto H. C-peptide index at 2 h post-meal is a useful predictor of endogenous insulin secretory capacity and withdrawal from insulin therapy in subjects with type 2 diabetes. Diabetes Obes Metab 2024; 26:2761-2773. [PMID: 38646845 DOI: 10.1111/dom.15595] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2024] [Revised: 03/25/2024] [Accepted: 03/26/2024] [Indexed: 04/23/2024]
Abstract
AIMS To evaluate the correlation between C-peptide index (CPI) at 2 h post-meal and endogenous insulin secretory capacity and to develop clinical models to predict the possibility of withdrawal from insulin therapy in patients with type 2 diabetes. METHOD This was a single-centre retrospective study of patients with type 2 diabetes admitted to our hospital. Patients were divided into a withdrawal group (n = 72) and a non-withdrawal group (n = 75) based on whether they were able to withdraw from insulin therapy at discharge, and the correlation between CPI at 2 h after meal and diabetes-related parameters was evaluated. In addition, we created two clinical models to predict the possibility of withdrawal from insulin therapy using machine learning. RESULTS The glycated haemoglobin values of the study participants were 87.8 ± 22.6 mmol/mo. The CPI at 2 h post-meal was 1.93 ± 1.28 in the non-withdrawal group and 2.97 ± 2.07 in the withdrawal group (p < 0.001). CPI at 2 h post-meal was an independent predictor of withdrawal from insulin therapy. In addition, CPI at 2 h post-meal was a better predictor than fasting CPI. Six factors associated with insulin therapy withdrawal (age, duration of diabetes, creatinine, alanine aminotransferase, insulin therapy until hospitalization, and CPI at 2 h post-meal) were used to generate two clinical models by machine learning. The accuracy of the generated clinical models ranged from 78.3% to 82.6%. CONCLUSION The CPI at 2 h post-meal is a clinically useful measure of endogenous insulin secretory capacity under non-fasting conditions.
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Affiliation(s)
- Yuichiro Iwamoto
- Department of Diabetes, Endocrinology and Metabolism, Kawasaki Medical School, Kurashiki, Japan
| | - Tomohiko Kimura
- Department of Diabetes, Endocrinology and Metabolism, Kawasaki Medical School, Kurashiki, Japan
| | - Masashi Shimoda
- Department of Diabetes, Endocrinology and Metabolism, Kawasaki Medical School, Kurashiki, Japan
| | - Yuichi Morimoto
- Department of Pediatrics, Kinki University, Osakasayama, Japan
| | - Yuki Watanabe
- Department of Diabetes, Endocrinology and Metabolism, Kawasaki Medical School, Kurashiki, Japan
| | - Takashi Itoh
- Department of Diabetes, Endocrinology and Metabolism, Kawasaki Medical School, Kurashiki, Japan
| | - Taku Sasaki
- Department of Diabetes, Endocrinology and Metabolism, Kawasaki Medical School, Kurashiki, Japan
| | - Shigehito Mori
- Department of Diabetes, Endocrinology and Metabolism, Kawasaki Medical School, Kurashiki, Japan
| | - Masato Kubo
- Department of Diabetes, Endocrinology and Metabolism, Kawasaki Medical School, Kurashiki, Japan
| | - Haruka Takenouchi
- Department of Diabetes, Endocrinology and Metabolism, Kawasaki Medical School, Kurashiki, Japan
| | - Kazunori Dan
- Department of Diabetes, Endocrinology and Metabolism, Kawasaki Medical School, Kurashiki, Japan
| | - Hideyuki Iwamoto
- Department of Diabetes, Endocrinology and Metabolism, Kawasaki Medical School, Kurashiki, Japan
| | - Junpei Sanada
- Department of Diabetes, Endocrinology and Metabolism, Kawasaki Medical School, Kurashiki, Japan
| | - Yoshiro Fushimi
- Department of Diabetes, Endocrinology and Metabolism, Kawasaki Medical School, Kurashiki, Japan
| | - Yukino Katakura
- Department of Diabetes, Endocrinology and Metabolism, Kawasaki Medical School, Kurashiki, Japan
| | - Shuhei Nakanishi
- Department of Diabetes, Endocrinology and Metabolism, Kawasaki Medical School, Kurashiki, Japan
| | - Tomoatsu Mune
- Department of Diabetes, Endocrinology and Metabolism, Kawasaki Medical School, Kurashiki, Japan
| | - Kohei Kaku
- Department of Diabetes, Endocrinology and Metabolism, Kawasaki Medical School, Kurashiki, Japan
| | - Hideaki Kaneto
- Department of Diabetes, Endocrinology and Metabolism, Kawasaki Medical School, Kurashiki, Japan
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3
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Meneses MJ, Patarrão RS, Pinheiro T, Coelho I, Carriço N, Marques AC, Romão A, Nabais J, Fortunato E, Raposo JF, Macedo MP. Leveraging the future of diagnosis and management of diabetes: From old indexes to new technologies. Eur J Clin Invest 2023; 53:e13934. [PMID: 36479853 DOI: 10.1111/eci.13934] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Revised: 11/15/2022] [Accepted: 12/05/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Diabetes is a heterogeneous and multifactorial disease. However, glycemia and glycated hemoglobin have been the focus of diabetes diagnosis and management for the last decades. As diabetes management goes far beyond glucose control, it has become clear that assessment of other biochemical parameters gives a much wider view of the metabolic state of each individual, enabling a precision medicine approach. METHODS In this review, we summarize and discuss indexes that have been used in epidemiological studies and in the clinical practice. RESULTS Indexes of insulin secretion, sensitivity/resistance and metabolism have been developed and validated over the years to account also with insulin, C-peptide, triglycerides or even anthropometric measures. Nevertheless, each one has their own objective and consequently, advantages and disadvantages for specific cases. Thus, we discuss how new technologies, namely new sensors but also new softwares/applications, can improve the diagnosis and management of diabetes, both for healthcare professionals but also for caretakers and, importantly, to promote the empowerment of people living with diabetes. CONCLUSIONS In long-term, the solution for a better diabetes management would be a platform that allows to integrate all sorts of relevant information for the person with diabetes and for the healthcare practitioners, namely glucose, insulin and C-peptide or, in case of need, other parameters/indexes at home, sometimes more than once a day. This solution would allow a better and simpler disease management, more adequate therapeutics thereby improving patients' quality of life and reducing associated costs.
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Affiliation(s)
- Maria João Meneses
- iNOVA4Health, NOVA Medical School, Faculdade de Ciências Médicas, NMS, FCM, Universidade NOVA de Lisboa, Lisbon, Portugal.,DECSIS II Iberia, Évora, Portugal
| | - Rita Susana Patarrão
- iNOVA4Health, NOVA Medical School, Faculdade de Ciências Médicas, NMS, FCM, Universidade NOVA de Lisboa, Lisbon, Portugal
| | - Tomás Pinheiro
- CENIMAT i3N, Materials Science Department, Faculty of Science and Technology, Universidade NOVA de Lisboa and CEMOP/UNINOVA, Caparica, Portugal
| | - Inês Coelho
- iNOVA4Health, NOVA Medical School, Faculdade de Ciências Médicas, NMS, FCM, Universidade NOVA de Lisboa, Lisbon, Portugal
| | | | - Ana Carolina Marques
- CENIMAT i3N, Materials Science Department, Faculty of Science and Technology, Universidade NOVA de Lisboa and CEMOP/UNINOVA, Caparica, Portugal
| | | | - João Nabais
- Comprehensive Health Research Centre (CHRC), Departamento de Ciências Médicas e da Saúde, Escola de Saúde e Desenvolvimento Humano, Universidade de Évora, Évora, Portugal
| | - Elvira Fortunato
- CENIMAT i3N, Materials Science Department, Faculty of Science and Technology, Universidade NOVA de Lisboa and CEMOP/UNINOVA, Caparica, Portugal
| | - João Filipe Raposo
- iNOVA4Health, NOVA Medical School, Faculdade de Ciências Médicas, NMS, FCM, Universidade NOVA de Lisboa, Lisbon, Portugal.,APDP - Diabetes Portugal - Education and Research Center, Lisbon, Portugal
| | - Maria Paula Macedo
- iNOVA4Health, NOVA Medical School, Faculdade de Ciências Médicas, NMS, FCM, Universidade NOVA de Lisboa, Lisbon, Portugal.,APDP - Diabetes Portugal - Education and Research Center, Lisbon, Portugal
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Ren Q, Ji LN, Lu JM, Li YF, Li QM, Lin SS, Lv XF, Wang L, Xu Y, Guo XH, Guo QY, Ma L, Du J, Chen YL, Zhao CL, Zhang QL, She QM, Jiao XM, Lu MH, Sun XM, Gao Y, Zhang J. Search for clinical predictors of good glycemic control in patients starting or intensifying oral hypoglycemic pharmacological therapy: A multicenter prospective cohort study. J Diabetes Complications 2020; 34:107464. [PMID: 31771933 DOI: 10.1016/j.jdiacomp.2019.107464] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Revised: 09/23/2019] [Accepted: 09/23/2019] [Indexed: 11/22/2022]
Abstract
AIMS Our aim was to search for clinical predictors of good glycemic control in patients starting or intensifying oral hypoglycemic pharmacological therapy. METHODS A multicenter, prospective cohort of 499 diabetic subjects was enrolled in this study: patients with newly diagnosed diabetes (NDM group) or poor glycemic control with oral antidiabetic drugs (OADs) (PDM group). All subjects then started or intensified OADs therapy and followed up for 91 days. Glycemic control was determined according to HbA1c at day 91 with HbA1c <7% considered good. RESULTS The proportions of patients with good glycemic control after follow up for 91 days were 66.9% and 34.8% in NDM group and PDM group respectively. Logistic regression analysis showed that the change in GA at 28 days was the only predictor of good glycemic control in NDM patients (OR = 1.630, 95% CI 1.300-2.044, P < 0.001). In PDM patients, changes in GA at 28 days, CPI, baseline HbA1c, diabetic duration, and BMI were all independent predictors of good glycemic control (All P < 0.05). CONCLUSIONS GA decline is a good predictor of future success in newly diagnosed patients. In patients intensifying therapy, beside GA decline, other individualized clinical characteristics should also be considered.
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Affiliation(s)
- Qian Ren
- Department of Endocrinology, Peking University People's Hospital, Beijing 100035, China
| | - Li-Nong Ji
- Department of Endocrinology, Peking University People's Hospital, Beijing 100035, China.
| | - Ju-Ming Lu
- Department of Endocrinology, Chinese PLA General Hospital, Beijing 100853, China
| | - Yu-Feng Li
- Department of Endocrinology, Pinggu Hospital, Beijing 101200, China
| | - Quan-Min Li
- Department of Endocrinology, The Second Artillery General Hospital of PLA, 100088, China
| | - Shan-Shan Lin
- Department of Endocrinology, Shijingshan Hospital, 100049, China
| | - Xiao-Feng Lv
- Department of Endocrinology, General Hospital of Beijing Military Command, Beijing 100010, China
| | - Li Wang
- Department of Endocrinology, Xuanwu Hospital of Capital Medical University, Beijing 100053, China
| | - Yuan Xu
- Department of Endocrinology, Beijing Chao-yang Hospital, Capital Medical University, Beijing 100023, China
| | - Xiao-Hui Guo
- Department of Endocrinology, Peking University First Hospital, Beijing 100034, China
| | - Qi-Yu Guo
- Department of Endocrinology, Navy General Hospital, Beijing 100048, China
| | - Li Ma
- Department of Endocrinology, Guang An Men Hospital, China Academy of Chinese Medical Science, Beijing 102600, China
| | - Jin Du
- Department of Endocrinology, Chinese PLA General Hospital, Beijing 100853, China
| | - Ying-Li Chen
- Department of Endocrinology, Peking University People's Hospital, Beijing 100035, China
| | - Cui-Ling Zhao
- Department of Endocrinology, Pinggu Hospital, Beijing 101200, China
| | - Qiu-Lan Zhang
- Department of Endocrinology, The Second Artillery General Hospital of PLA, 100088, China
| | - Qi-Mei She
- Department of Endocrinology, Shijingshan Hospital, 100049, China
| | - Xiu-Min Jiao
- Department of Endocrinology, General Hospital of Beijing Military Command, Beijing 100010, China
| | - Mei-Hua Lu
- Department of Endocrinology, Xuanwu Hospital of Capital Medical University, Beijing 100053, China
| | - Xiao-Meng Sun
- Department of Endocrinology, Beijing Chao-yang Hospital, Capital Medical University, Beijing 100023, China
| | - Ying Gao
- Department of Endocrinology, Peking University First Hospital, Beijing 100034, China
| | - Jie Zhang
- Department of Endocrinology, Guang An Men Hospital, China Academy of Chinese Medical Science, Beijing 102600, China
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Wakasaki H, Shono T, Nakao R, Yamamoto S, Minaga T, Fukuda S, Matsumoto R, Ohoshi T, Naka K, Nanjo K. Clinical Utility of the Meal Tolerance Test in the Care of Patients with Type 2 Diabetes Mellitus. Intern Med 2020; 59:2229-2235. [PMID: 32938850 PMCID: PMC7578608 DOI: 10.2169/internalmedicine.4591-20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Objective The measurement of C-peptide immunoreactivity (CPR) is essential for evaluating the pancreatic β-cell function and selecting appropriate therapeutic agents in patients with diabetes mellitus. The meal tolerance test (MTT) is simple to administer physiological insulin-stimulating test. Previous studies have reported that several CPR-related indices are useful markers for predicting insulin requirement in type 2 diabetes. In the present study, we investigated the serum CPR response during the MTT in hospitalized patients with type 2 diabetes mellitus in order to clarify the clinical utility of the MTT. Methods We performed the MTT using a test meal with timed measurements of the serum CPR level based on the oral glucose tolerance test over 180 minutes and tested the correlation of various CPR-related indices and clinical factors in patients with type 2 diabetes mellitus. Patients The subjects were patients with type 2 diabetes mellitus who had been admitted to our hospital for diabetes management and education. The final study population consisted of 68 patients. Results The fasting CPR level was correlated with the 24-hour urinary CPR excretion and body mass index. The serum CPR level at 120 minutes in the MTT was strongly correlated with the area under the curve of CPR during the MTT. The patients who needed insulin therapy at 6 months after hospitalization showed a significant lower incremental CPR value from 0 to 120 minutes in the MTT than those who did not need insulin therapy. Conclusion The plasma C-peptide levels at 0 and 120 minutes in the MTT provide essential information for the clinical management of patients with type 2 diabetes mellitus.
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Affiliation(s)
- Hisao Wakasaki
- Department of Internal Medicine, Wakayama Rosai Hospital, Japan
| | - Takeshi Shono
- Department of Internal Medicine, Wakayama Rosai Hospital, Japan
| | - Ryutaro Nakao
- Department of Internal Medicine, Wakayama Rosai Hospital, Japan
| | - Shohei Yamamoto
- Department of Internal Medicine, Wakayama Rosai Hospital, Japan
| | - Takamasa Minaga
- Department of Internal Medicine, Wakayama Rosai Hospital, Japan
| | - Sakiko Fukuda
- Department of Internal Medicine, Wakayama Rosai Hospital, Japan
| | - Reika Matsumoto
- Department of Internal Medicine, Wakayama Rosai Hospital, Japan
| | - Takashi Ohoshi
- Department of Internal Medicine, Wakayama Rosai Hospital, Japan
| | - Keigo Naka
- Department of Internal Medicine, Wakayama Rosai Hospital, Japan
| | - Kishio Nanjo
- Department of Internal Medicine, Wakayama Rosai Hospital, Japan
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Cai X, Xia L, Pan Y, He D, Zhu H, Wei T, He Y. Differential role of insulin resistance and β-cell function in the development of prediabetes and diabetes in middle-aged and elderly Chinese population. Diabetol Metab Syndr 2019; 11:24. [PMID: 30873220 PMCID: PMC6402147 DOI: 10.1186/s13098-019-0418-x] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2018] [Accepted: 02/19/2019] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND The prevalence of diabetes and prediabetes were estimated to be 10.9% and 35.7% in the Chinese adult population, respectively, and the middle-aged and elderly Chinese are at even higher risk of diabetes and prediabetes than younger population. With the increasing trend of aging in China, the burden of diabetes and related complications will be aggravated. OBJECTIVES Through comparing the indices of insulin resistance and β-cell function between subjects with different glucose metabolic status, to analyze the differential role of insulin resistance and β-cell function in the development of prediabetes and type 2 diabetes (T2DM) in the middle-aged and elderly Chinese population. METHODS In this cross-sectional study, we enrolled 512 participants aged 50 and over. The indices of insulin resistance (homoeostasis model assessment of insulin resistance (HOMA-IR) and adipose tissue insulin resistance (Adipo-IR), and indices of β-cell function [HOMA-β), fasting C-peptide to glucose ratio (FCPRI) and postprandial C-peptide to glucose ratio (PCPRI)] were calculated. Association of insulin resistance and β-cell function with prediabetes or T2DM were evaluated by multivariate logistic regression analysis, in which potential confounding factors were adjusted. RESULTS Of the 509 participants with complete information, 263 (51.7%) had normal glucose tolerance (NGT), 161 (31.6%) were in prediabetic status and 85 (16.7%) were overt T2DM. With the advancing of unfavorable glucose metabolism, the insulin resistance (HOMA-IR and Adipo-IR) and β-cell function (FCPRI, PCPRI) deteriorated (P trend < 0.05 for all indices). We found that increase in insulin resistance expressed by Adipo-IR and HOMA-IR is associated with increased risk of prediabetes, whereas decrease in β-cell function expressed by HOMA-β and PCPRI is associated with increased risk of T2DM. We also demonstrated that Adipo-IR was more closely associated with developing prediabetes than HOMA-IR, and PCPRI was most closely related with developing T2DM among the indices of β-cell function used in this study. CONCLUSIONS Insulin resistance is the main determinant of developing prediabetes, whereas β-cell function is the main determinant of developing T2DM.
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Affiliation(s)
- Xueli Cai
- Department of Neurology, Lishui Municipal Central Hospital, Lishui, Zhejiang China
| | - Lili Xia
- Editorial Office of Hepatobiliary and Pancreatic Diseases International, the First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Yuesong Pan
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Dian He
- Department of Epidemiology and Biostatics, School of Public Health, Capital Medical University, Beijing, China
| | - Huiping Zhu
- Department of Epidemiology and Biostatics, School of Public Health, Capital Medical University, Beijing, China
| | - Tiemin Wei
- Department of Neurology, Lishui Municipal Central Hospital, Lishui, Zhejiang China
| | - Yan He
- Department of Epidemiology and Biostatics, School of Public Health, Capital Medical University, Beijing, China
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7
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Stidsen JV, Henriksen JE, Olsen MH, Thomsen RW, Nielsen JS, Rungby J, Ulrichsen SP, Berencsi K, Kahlert JA, Friborg SG, Brandslund I, Nielsen AA, Christiansen JS, Sørensen HT, Olesen TB, Beck-Nielsen H. Pathophysiology-based phenotyping in type 2 diabetes: A clinical classification tool. Diabetes Metab Res Rev 2018; 34:e3005. [PMID: 29697198 DOI: 10.1002/dmrr.3005] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2017] [Revised: 02/10/2018] [Accepted: 03/14/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND Type 2 diabetes may be a more heterogeneous disease than previously thought. Better understanding of pathophysiological subphenotypes could lead to more individualized diabetes treatment. We examined the characteristics of different phenotypes among 5813 Danish patients with new clinically diagnosed type 2 diabetes. METHODS We first identified all patients with rare subtypes of diabetes, latent autoimmune diabetes of adults (LADA), secondary diabetes, or glucocorticoid-associated diabetes. We then used the homeostatic assessment model to subphenotype all remaining patients into insulinopenic (high insulin sensitivity and low beta cell function), classical (low insulin sensitivity and low beta cell function), or hyperinsulinemic (low insulin sensitivity and high beta cell function) type 2 diabetes. RESULTS Among 5813 patients diagnosed with incident type 2 diabetes in the community clinical setting, 0.4% had rare subtypes of diabetes, 2.8% had LADA, 0.7% had secondary diabetes, 2.4% had glucocorticoid-associated diabetes, and 93.7% had WHO-defined type 2 diabetes. In the latter group, 9.7% had insulinopenic, 63.1% had classical, and 27.2% had hyperinsulinemic type 2 diabetes. Classical patients were obese (median waist 105 cm), and 20.5% had cardiovascular disease (CVD) at diagnosis, while insulinopenic patients were fairly lean (waist 92 cm) and 17.5% had CVD (P = 0.14 vs classical diabetes). Hyperinsulinemic patients were severely obese (waist 112 cm), and 25.5% had CVD (P < 0.0001 vs classical diabetes). CONCLUSIONS Patients clinically diagnosed with type 2 diabetes are a heterogeneous group. In the future, targeted treatment based on pathophysiological characteristics rather than the current "one size fits all" approach may improve patient prognosis.
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Affiliation(s)
- Jacob V Stidsen
- Diabetes Research Centre, Department of Endocrinology, Centre for Individualized Medicine in Arterial Diseases, Odense University Hospital, Odense, Denmark
| | - Jan E Henriksen
- Diabetes Research Centre, Department of Endocrinology, Centre for Individualized Medicine in Arterial Diseases, Odense University Hospital, Odense, Denmark
| | - Michael H Olsen
- Department of Internal Medicine, Holbaek Hospital, and Centre for Individualized Medicine in Arterial Diseases (CIMA), Odense University Hospital, University of Southern Denmark, Denmark
| | - Reimar W Thomsen
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | - Jens S Nielsen
- Diabetes Research Centre, Department of Endocrinology, Centre for Individualized Medicine in Arterial Diseases, Odense University Hospital, Odense, Denmark
| | - Jørgen Rungby
- Department for Diabetes Research, Gentofte University Hospital, Gentofte, Denmark
- Department of Biomedicine, Aarhus University, Aarhus, Denmark
| | - Sinna P Ulrichsen
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | - Klara Berencsi
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | - Johnny A Kahlert
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | - Søren G Friborg
- Diabetes Research Centre, Department of Endocrinology, Centre for Individualized Medicine in Arterial Diseases, Odense University Hospital, Odense, Denmark
| | - Ivan Brandslund
- Department of Biochemistry, Center Hospital Lillebaelt, Vejle, Denmark
| | - Aneta A Nielsen
- Department of Biochemistry, Center Hospital Lillebaelt, Vejle, Denmark
| | - Jens S Christiansen
- Department of Internal Medicine and Endocrinology, Aarhus University Hospital, Aarhus, Denmark
| | - Henrik T Sørensen
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | - Thomas B Olesen
- Diabetes Research Centre, Department of Endocrinology, Centre for Individualized Medicine in Arterial Diseases, Odense University Hospital, Odense, Denmark
| | - Henning Beck-Nielsen
- Diabetes Research Centre, Department of Endocrinology, Centre for Individualized Medicine in Arterial Diseases, Odense University Hospital, Odense, Denmark
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Mu PW, Liu DZ, Lin Y, Liu D, Zhang F, Zhang YJ, Lin S, Wang LQ, Wang MM, Shu J, Zeng LY, Chen YM. The Postprandial-to-Fasting Serum C-Peptide Ratio is a Predictor of Response to Basal Insulin-Supported Oral Antidiabetic Drug(s) Therapy: A Retrospective Analysis. Diabetes Ther 2018; 9:963-971. [PMID: 29564716 PMCID: PMC5984910 DOI: 10.1007/s13300-018-0404-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2018] [Indexed: 11/26/2022] Open
Abstract
INTRODUCTION Basal insulin is widely recommended for the treatment of type 2 diabetes mellitus (T2DM) patients who are unable to achieve glycemic control with oral antidiabetic drug(s) (OADs). However, some patients are still unable to control their blood glucose levels even when on basal insulin-supported OAD(s) therapy (BOT). The aim of this study was to investigate the factor(s) predicting patient response to BOT. METHODS A total of 212 patients with T2DM, ranging in age from 18 to 65 years, admitted to the university hospital of Sun Yat-sen University, Guangzhou, China, were enrolled in the study between January 2013 and July 2016. All patients had fasting blood glucose levels of ≥ 10.0 mmol/L despite receiving OAD(s) treatment. According to study design, these patients first received intensive insulin therapy for 2 weeks to attain and maintain their glycemic goals and then were switched to BOT. Responders were defined as subjects who maintained their glycemic targets with BOT for at least 3 months; all others were considered to be non-responders. The characteristics between responders and non-responders were compared. RESULTS Compared with non-responders, responders had a shorter duration of diabetes (5.1 ± 5.0 vs. and 10.1 ± 3.2 years; P < 0.001) and a higher 2-h postprandial C-peptide-to-fasting C-peptide ratio (2 h-PCP/FCP: 1.95 ± 0.51 vs. 1.67 ± 0.32; P < 0.01). Responders showed a lower proportion of previous treatment with insulin (69/100 vs 40/3; P < 0.001) and sulfonlureas or glinides (116/50 vs 40/0; P <0.001) than non-responders. Multivariate logistic regression analysis showed that previous insulin treatment (odds ratio [OR] 17.677, 95% confidence interval [CI] 5.205-60.027; P < 0.001) and the 2 h-PCP/FCP ratio (OR 0.241, 95% CI 0.058-0.679; P = 0.007) had predictive value. CONCLUSIONS A higher 2 h-PCP/FCP ratio and a lack of previous insulin treatment increase the likelihood of BOT success.
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Affiliation(s)
- Pan-Wei Mu
- Department of Endocrinology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, 510630, People's Republic of China
| | - De-Zhao Liu
- Department of Anesthesia, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, 510630, People's Republic of China
| | - Ying Lin
- Department of Gastroenterology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, 510630, People's Republic of China
| | - Dong Liu
- Department of Endocrinology, The Fifth Affiliated Hospital of ZUNYI Medical University, Zhuhai, 519170, People's Republic of China
| | - Fan Zhang
- Department of Endocrinology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, 510630, People's Republic of China
| | - Yong-Jun Zhang
- Department of Endocrinology, The Fifth Affiliated Hospital of ZUNYI Medical University, Zhuhai, 519170, People's Republic of China
| | - Shuo Lin
- Department of Endocrinology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, 510630, People's Republic of China
| | - Lin-Qin Wang
- Nansha Hospital of Traditional Chinese Medicine, Guangzhou, 511462, People's Republic of China
| | - Man-Man Wang
- Department of Endocrinology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, 510630, People's Republic of China
| | - Jiong Shu
- Department of Endocrinology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, 510630, People's Republic of China
| | - Long-Yi Zeng
- Department of Endocrinology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, 510630, People's Republic of China
| | - Yan-Ming Chen
- Department of Endocrinology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, 510630, People's Republic of China.
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Yabe D, Ambos A, Cariou B, Duvnjak L, Evans M, González-Gálvez G, Lin J, Nikonova EV, de Pablos-Velasco P, Yale JF, Ahrén B. Efficacy of lixisenatide in patients with type 2 diabetes: A post hoc analysis of patients with diverse β-cell function in the GetGoal-M and GetGoal-S trials. J Diabetes Complications 2016; 30:1385-92. [PMID: 27267268 DOI: 10.1016/j.jdiacomp.2016.05.018] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2016] [Revised: 05/11/2016] [Accepted: 05/20/2016] [Indexed: 12/19/2022]
Abstract
AIMS To evaluate the impact of β-cell function on the efficacy of lixisenatide, a once-daily prandial glucagon-like peptide-1 receptor agonist, in patients with type 2 diabetes (T2D). MATERIALS AND METHODS In this post hoc analysis, patients from the Phase 3 GetGoal-M and GetGoal-S clinical trials randomized to lixisenatide 20μg once daily were stratified into quartiles by baseline β-cell function, as measured by the secretory units of islet in transplantation (SUIT) index. RESULTS Patients (N=437) were distributed evenly among SUIT index quartiles 1 to 4 (lowest to highest β-cell function). Clinical outcomes improved from baseline across all SUIT quartiles; mean changes at week 24 were: glycated hemoglobin (HbA1c; % [mmol/mol]), -0.99 (-10.8), -0.87 (-9.5), -0.86 (-9.4), -0.83 (-9.1); and postprandial plasma glucose (PPG; mmol/L), -7.9, -5.6, -5.5, -4.3 (overall effect P<0.0001). Furthermore, postprandial glucagon was reduced in all SUIT quartiles, while insulinogenic index improved only in patients with higher baseline SUIT (overall effect P=0.0286). No severe symptomatic hypoglycemic events were reported. CONCLUSIONS Lixisenatide treatment resulted in reductions in HbA1c and PPG levels across all SUIT quartiles. This suggests that non-insulin-related actions of lixisenatide contribute to improved glycemic control in T2D.
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Affiliation(s)
- Daisuke Yabe
- Kansai Electric Power Hospital, 2-1-7 Fukushima, Fukushima-ku, Osaka 553-0003, Japan; Kansai Electric Power Medical Research Institute, 1-5-6 Minatojimaminamimachi, Chuo-ku, Kobe 650-0047, Japan; Kobe University Graduate School of Medicine, 1-5-6 Minatojimaminamimachi, Chuo-ku, Kobe 650-0047, Japan.
| | - Anu Ambos
- North Estonia Medical Center, 19 Sütiste Street, 13419 Tallinn, Estonia.
| | - Bertrand Cariou
- The Thorax Institute, CHU Nantes, Boulevard Jacques Monod, F-44093 Nantes, France.
| | - Lea Duvnjak
- Vuk Vrhovac Clinic-Merkur University Hospital, University of Zagreb, Dugi dol 4a, 10000 Zagreb, Croatia.
| | - Marc Evans
- University Hospital Llandough, Penlan Road Llandough, CF64 2XX, UK.
| | | | - Jay Lin
- Novosys Health, 7 Crestmont Court, Flemington, NJ 08822, USA.
| | - Elena V Nikonova
- Artech Information Systems, LLC, 360 Mt. Kemble Ave. #2000, Morristown, NJ 07960, USA.
| | - Pedro de Pablos-Velasco
- Research Institute of Biomedical and Health Sciences (IUIBS), University of Las Palmas de Gran Canaria, Barranco de la Ballena sn, 35010 Las Palmas de Gran Canaria, Spain.
| | | | - Bo Ahrén
- Lund University, Sölvegatan 19, SE-22184 Lund, Sweden.
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Sankoda A, Takahashi K, Matsuoka T. Clinical characteristics of patients aged 65 and older with newly developed type 1 diabetes: An analysis of elderly patients at our hospital. Nihon Ronen Igakkai Zasshi 2016; 53:143-51. [PMID: 27250221 DOI: 10.3143/geriatrics.53.143] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
AIM We herein investigated the clinical features of elderly patients with newly developed type 1 diabetes with respect to onset age, frequency of islet-associated antibodies, and other clinical markers. METHODS One hundred and ninety-nine patients aged 65 and older with new-onset diabetes, who were admitted to our hospital between July 2000 and June 2013, were classified into 4 types of diabetes. In addition, 85 patients with newly diagnosed type 1A diabetes among all age ranges admitted during the same period were divided into two groups: a younger group (less than 65 years, n=71) and an elderly group (65 years and older, n=14). Clinical features including mode of onset, frequency of islet-associated antibodies, and serum C-peptide (CPR) levels were compared between these groups. The elderly group was further divided into two age groups (less than 75 years, n=7; 75 years and older, n=7), and the frequency of autoantibodies was compared. RESULTS The patients (n=199) were classified into type 1 (n=16, 8%), type 2 (n=155, 78%), pancreatic (n=22, 11%), and other type (n=6, 3%) diabetes. Between the younger and elderly groups with type 1 diabetes, no significant difference in the CPR levels, frequency of autoantibodies, or other clinical features were observed. Positivity for IA-2 antibody was higher in the younger group (53.5%) than in the elderly group (35.7%), however, it was also considerably high (57.1%) in the oldest age group (75 years and older). CONCLUSIONS Type 1 diabetes may develop in the elderly, and an IA-2 antibody test may be useful for diagnosing type 1 diabetes in older patients.
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Affiliation(s)
- Akiko Sankoda
- Department of Diabetic Medicine, Kurashiki Central Hospital
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11
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Postprandial C-Peptide to Glucose Ratio as a Marker of β Cell Function: Implication for the Management of Type 2 Diabetes. Int J Mol Sci 2016; 17:ijms17050744. [PMID: 27196896 PMCID: PMC4881566 DOI: 10.3390/ijms17050744] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2016] [Revised: 05/07/2016] [Accepted: 05/11/2016] [Indexed: 02/07/2023] Open
Abstract
C-peptide is secreted from pancreatic β cells at an equimolar ratio to insulin. Since, in contrast to insulin, C-peptide is not extracted by the liver and other organs, C-peptide reflects endogenous insulin secretion more accurately than insulin. C-peptide is therefore used as a marker of β cell function. C-peptide has been mainly used to assess the presence of an insulin-dependent state for the diagnosis of type 1 diabetes. However, recent studies have revealed that β cell dysfunction is also a core deficit of type 2 diabetes, and residual β cell function is a key factor in achieving optimal glycemic control in patients with type 2 diabetes. This review summarizes the role of C-peptide, especially the postprandial C-peptide to glucose ratio which likely better reflects maximum β cell secretory capacity compared with the fasting ratio in assessing β cell function, and discusses perspectives on its clinical utility for managing glycemic control in patients with type 2 diabetes.
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12
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Lind M, Hirsch IB, Tuomilehto J, Dahlqvist S, Ahrén B, Torffvit O, Attvall S, Ekelund M, Filipsson K, Tengmark BO, Sjöberg S, Pehrsson NG. Liraglutide in people treated for type 2 diabetes with multiple daily insulin injections: randomised clinical trial (MDI Liraglutide trial). BMJ 2015; 351:h5364. [PMID: 26512041 PMCID: PMC4624838 DOI: 10.1136/bmj.h5364] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
STUDY QUESTION What are the effects of liraglutide, an incretin based treatment, on glycaemic control in people with type 2 diabetes treated with multiple daily insulin injections? METHODS The study was a randomised, double blind, placebo controlled trial with a parallel group design carried out at 13 hospital based outpatient clinics and one primary care unit in Sweden. Patients were considered eligible for inclusion if they had type 2 diabetes and inadequate glycaemic control (HbA1c concentrations ≥ 58 mmol/mol (7.5%) and ≤ 102 mmol/mol (11.5%)), a body mass index of 27.5-45 kg/m(2), and required multiple daily insulin injections. Overall, 124 participants were randomised 1:1 to subcutaneous liraglutide or placebo by minimisation allocation. The main outcome measure was change in HbA1c level from baseline to week 24. STUDY ANSWER AND LIMITATIONS Liraglutide was associated with a significant reduction of 16.9 mmol/mol (1.5%) in HbA1c versus 4.6 mmol/mol (0.4%) for placebo, difference -12.3 mmol/mol (95% confidence interval -15.8 to -8.8 mmol/mol; -1.13%, -1.45 to -0.81 mmol/mol). Body weight was significantly reduced in participants in the liraglutide compared with placebo group (3.8 v 0.0 kg, difference -3.8, -4.9 to -2.8 kg), and total daily insulin doses were significantly reduced, by 18.1 units and 2.3 units (difference -15.8, -23.1 to -8.5 units). Reductions in mean and standard deviation of glucose levels estimated by masked continuous glucose monitoring were significantly greater in the liraglutide group than placebo group (-1.9 and -0.5 mmol/L). Neither group experienced severe hypoglycaemic events nor were there any significant differences in symptomatic or asymptomatic non-severe hypoglycaemia (<4.0 or <3.0 mmol/L). The mean number of non-severe symptomatic hypoglycaemic events (<4.0 mmol/L) during follow-up was 1.29 in the liraglutide group and 1.24 in the placebo group (P=0.96). One of the study's limitations was its relatively short duration. Sustained effects of liraglutide have, however, been found over lengthier periods in connection with other treatment regimens. Cardiovascular safety and potential adverse events during longer exposure to liraglutide need to be evaluated. Nausea was experienced by 21 (32.8%) participants in the liraglutide group and 5 (7.8%) in the placebo group and 3 (5%) and 4 (7%) participants in these groups, respectively, had any serious adverse event. WHAT THIS STUDY ADDS Adding liraglutide to multiple daily insulin injections in people with type 2 diabetes improves glycaemic control without an increased risk of hypoglycaemia, reduces body weight, and enables patients to lower their insulin doses. FUNDING, COMPETING INTERESTS, DATA SHARING This study was an investigator initiated trial, supported in part by Novo Nordisk and InfuCare. Potential competing interests have been reported and are available on the bmj.com. STUDY REGISTRATION EudraCT 2012-001941-42.
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Affiliation(s)
- Marcus Lind
- Institute of Medicine, University of Gothenburg, Gothenburg, Sweden Department of Medicine, Uddevalla Hospital, NU Hospital Group, 451 80 Uddevalla, Sweden
| | | | - Jaakko Tuomilehto
- Centre for Vascular Prevention, Danube-University, Krems, Austria; Department of Chronic Disease Prevention, National Institute for Health and Welfare, Helsinki, Finland; Diabetes Research Group, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Sofia Dahlqvist
- Department of Medicine, Uddevalla Hospital, NU Hospital Group, 451 80 Uddevalla, Sweden
| | | | | | - Stig Attvall
- Institute of Medicine, University of Gothenburg, Gothenburg, Sweden
| | | | | | | | - Stefan Sjöberg
- Karolinska Institutet, Karolinska University Hospital Huddinge, Stockholm, Sweden; Department of Medicine, Halland County Hospital, Halmstad, Sweden
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Suzuki T, Takahashi K, Fujiwara D, Shii M, Takekawa S, Matsuoka T. A reliable serum C-peptide index for the selection of an insulin regimen to achieve good glycemic control in obese patients with type 2 diabetes: an analysis from a short-term study with intensive insulin therapy. Diabetol Int 2015; 7:235-243. [PMID: 30603269 DOI: 10.1007/s13340-015-0239-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2015] [Accepted: 09/16/2015] [Indexed: 11/30/2022]
Abstract
Insulin regimens achieving favorable glycemic control in patients with type 2 diabetes are expected to closely relate to residual insulin secretory ability. We herein attempted to identify a reliable C-peptide immunoreactivity (CPR) index as an insulin secretory marker that would contribute to the selection of an appropriate insulin regimen for patients with type 2 diabetes. We near-normalized blood glucose in 246 obese patients with type 2 diabetes using our protocol (which included short-term intensive insulin therapy, IIT), and administered an oral hypoglycemic agent (OHA). Based on responsiveness to OHA, patients were classified into three therapy groups: non-insulin therapy (n = 78), basal-insulin supported oral therapy (BOT) (n = 109), and multiple daily insulin injection (MDI) therapy (n = 59). Glucagon-loading CPR increment (ΔCPR), fasting CPR (FCPR), CPR2h after breakfast (CPR2h), ratio of FCPR to fasting plasma glucose (CPI), CPI2h after breakfast (CPI2h), and secretory unit of islets in transplantation (SUIT) were assessed with receiver operating characteristic (ROC) and multiple logistic analyses to discriminate the MDI group from the other therapy groups. ROC analysis revealed that CPR2h had the greatest area under the curve and specificity. Multiple logistic analysis identified CPR2h and CPI2h as the most significant explanatory variables for identifying patients assigned to the MDI group. A postprandial serum CPR marker such as CPR2h or CPI2h was shown to be the best index for predicting an appropriate insulin regimen to achieve good glycemic control in obese patients with type 2 diabetes.
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Affiliation(s)
- Takahiro Suzuki
- Diabetes Division, Department of Internal Medicine, Kurashiki Central Hospital, 1-1-1 Miwa, Kurashiki, Okayama 710-8602 Japan
| | - Kenji Takahashi
- Diabetes Division, Department of Internal Medicine, Kurashiki Central Hospital, 1-1-1 Miwa, Kurashiki, Okayama 710-8602 Japan
| | - Daisuke Fujiwara
- Diabetes Division, Department of Internal Medicine, Kurashiki Central Hospital, 1-1-1 Miwa, Kurashiki, Okayama 710-8602 Japan
| | - Masakazu Shii
- Diabetes Division, Department of Internal Medicine, Kurashiki Central Hospital, 1-1-1 Miwa, Kurashiki, Okayama 710-8602 Japan
| | - Sato Takekawa
- Diabetes Division, Department of Internal Medicine, Kurashiki Central Hospital, 1-1-1 Miwa, Kurashiki, Okayama 710-8602 Japan
| | - Takashi Matsuoka
- Diabetes Division, Department of Internal Medicine, Kurashiki Central Hospital, 1-1-1 Miwa, Kurashiki, Okayama 710-8602 Japan
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