Comorbidity of patients with noncommunicable diseases in general practice. Eurasian guidelines

Создание руководства поддержано Советом по терапевтическим наукам отделения клинической медицины Российской академии наук.

Comprehensive analysis of clinical and paraclinical parameters of coronary blood flow in patients with acute types of coronary artery disease and type 2 diabetes

Aim. To study clinical and paraclinical parameters and lesions of the coronary bed in patients with acute types of coronary artery disease (CAD) and type 2 diabetes (T2D).

Material and methods. The study included 102 patients of both sexes with acute CAD. Patients were analyzed in two following groups: the first (mean age, 56,6±0,96 years, men/women 34/16) consisted of 50 patients with acute coronary syndrome (ACS) and type 2 diabetes, the second (mean age, 58,7±1,01 years, men/women 37/15) — 52 patients without T2D. Along with the assessment of behavioral and biological risk factors for CVD, clinical and hemodynamic parameters and the results of coronary angiography were analyzed.

Results. In patients with ACS and T2D, the duration of T2D was 5,6±3,7 years. Somatic comorbidities were registered in 74% in the first group, and in 53,8% in the second. According to echocardiography, in the group of people with ACS and T2D, the left ventricular ejection fraction was lower, and the mean pulmonary artery pressure was higher compared to the group without T2D. Stenosis of the distal coronary artery third in patients with T2D occurred in 78% of cases, and in patients without T2D — in 42%; the differences were significant (p<0,001). Diffuse CAD also prevailed in the first group and amounted to 58%, and in the second — 27%. The SYNTAX score was higher in patients with T2D compared with the group of people without T2D — 29,2 and 22%, respectively (p<0,001).

Conclusion. In patients with ACS and T2D, the prevalence of pulmonary hypertension and left ventricular systolic dysfunction was revealed. The features of the coronary flow in patients with T2D with ACS were predominantly the distal type of lesion, as well as an increased risk of angioplasty complications, assessed using the SYNTAX score.

Anti-angiogenic therapy in the treatment of diabetic macular edema in various variants of the vitreoretinal interface

BACKGROUND: Anti-angiogenic therapy for diabetic macular edema (DME), recognized as the gold standard, is not always effective. When compensating for the general somatic status, it is necessary to search for local causes of DME resistance to anti-angiogenic therapy. AIM: To study the effectiveness and features of anti-angiogenic therapy for DME in normal and pathological vitreoretinal interface (VRI). MATERIALS AND METHODS: Patients who received anti-angiogenic therapy for 12 months, in addition to the standard examination, underwent optical coherence tomography with an assessment of morphometric parameters and VRI. RESULTS: In addition to the groups of normal and pathological VRI, a group of transformation from pathological to normal VRI was identified. Visual acuity increases with normal VRI, decreases with pathological. OCT scores decrease in both groups. In the transformation group, an increase in vision and a decrease in OCT parameters were observed only after VRI transformation. CONCLUSION: The pathologic condition of the VRI reduces effectiveness of anti-angiogenic therapy for DME, except for 10% of cases in which VRI is transformed into normal within 5-6 months from the start of treatment. These data should be taken into account when choosing a treatment strategy for DME.

[Efficacy and safety of Cytoflavin in the treatment of diabetic polyneuropathy: results of a multicenter, double-blind, placebo-controlled, randomized CYLINDER study]

OBJECTIVE

The purpose of the present double-blind, placebo-controlled, randomized clinical trial was to evaluate the efficacy and safety of Cytoflavin in patients with diabetic polyneuropathy (DPN).

MATERIAL AND METHODS

Investigational therapy was administered in two steps: intravenous infusions of experimental drug/placebo for 10 days followed by oral administration for 75 days. In 10 clinical centers, 216 patients aged 45-74 years with a diagnosis of type 2 diabetes mellitus, symptomatic distal sensorimotor DPN, confirmed no earlier than 1 year before screening, on stable therapy (no change of drugs and doses) by oral hypoglycemic drugs, intermediate-acting, long-acting or extra-long-acting insulin, and/or GLP-1 receptor agonists.

RESULTS

By the end of treatment, the change of the Total Symptom Score (TSS) in the experimental group was -2.65 points, in the placebo group -1.73 points (p<0.001). Improvement of symptoms in the experimental group was achieved regardless of the degree of compensation for type 2 diabetes (both in those with Hb1Ac <8.0% and in those with Hb1Ac ≥8.0%), but demonstrated better results in patients with less severe baseline symptoms (TSS <7.5). Improvement in the components of the TSS scale «paresthesia» and «numbness» occurred as early as on day 11 of therapy; by the end of treatment, a significant decrease in the «burning» component was also demonstrated. The experimental drug had a positive safety profile.

CONCLUSION

Cytoflavin, intravenous solution and enteric-coated tablets (SPTF Polysan Ltd.) is indicated for the symptomatic treatment of DPN.

Cardiometabolic Effects of Empagliflozin in Patients Undergoing Elective Percu-taneous Coronary Intervention for Type 2 Diabetes Mellitus

Aim      To evaluate cardiometabolic effects of empagliflozin in patients with ischemic heart disease and type 2 diabetes mellitus (DM) following elective percutaneous coronary intervention (PCI).Materials and methods Patients meeting the inclusion/non-inclusion criteria were randomized into two groups of equal number using simple randomization with successively assigned numbers. Group 1 included 37 patients (18 men and 19 women) who gave their consent for the treatment with empagliflozin 10 mg/day in addition to their previous hypoglycemic therapy. The drug administration started one month prior to the elective PCI and continued for the next 11 months (treatment duration, 12 months). Group 2 (comparison group) consisted of age- and DM duration-matched patients (37 patients; 18 men and 19 women) who continued on their hypoglycemic therapy previously prescribed by endocrinologists during the entire study period. Before the study, 36.11 % patients of the empagliflozin group and 27.03 % of the comparison group had unsatisfactory glycemic control as shown by the level of glycated hemoglobin (HbA1c).Results At 6 and 12 months of the study, fasting glycemia and HbA1c were significantly lower in the empagliflozin treatment group. The groups were comparable by the incidence of adverse outcomes: 8 (22.24 %) patients in the empagliflozin group and 10 (27.04 %) patients in the comparison group (р=0.787). The 12-month empagliflozin treatment reduced total cholesterol (C) by 5.56 % (p&lt;0.05), low density lipoprotein (LDL) C by 3.67 % (p&lt;0.05), visceral adipose tissue area (VATA) by 5.83 % (p&lt;0.05), and subcutaneous adipose tissue area (SATA) by 3.54 % (p&lt;0.05).Conclusion      The empagliflozin treatment for 30 days prior to and after elective PCI can enhance the effectiveness of myocardial revascularization due to the demonstrated beneficial cardiometabolic effects.

Predictors of success and failure in achieving glycemic control targets in patients with type 2 diabetes on basal insulin: review of the real-world evidence studies

Basal insulin (BI) is the main therapeutic option for patients with type 2 diabetes (T2D) who have not reached glycemic targets on oral antidiabetic drugs and/or glucagon-like peptide-1 receptor agonists. The results of epidemiological studies indicate that the majority of patients with T2D do not achieve the targeted parameters of glycemic control on BI in the real-world settings. In this review the results of real-world evidence studies assessing predictors of success or failure of BI therapy in patients with T2D are we summarized. A number of studies have demonstrated that delayed initiation of insulin therapy with a high level of glycated hemoglobin A1c (HbA1c) at the start of the treatment reduces achieving glycemic control targets on BI. Hypoglycemia in the first weeks or months of BI treatment may reduce the adherence and persistence to treatment and likelihood of achieving treatment targets. In real-world evidence studies, glargine 300 U/mL and degludec, the long-acting second-generation insulin analogues, have shown greater potential in reduction of HbA1c levels with a lower risk of hypoglycaemia compared to other BIs. In the DUNE, ATOS, and some others studies, a lack of insulin dose titration in newly initiated BI users and those who needed treatment intensification was demonstrated. Poor treatment adherence and persistence (missed injections, incorrect dose selection, and temporary or permanent discontinuation of insulin therapy), deviations in insulin injection technique, and formation of lipohypertrophy at the injection sites are also common problems that prevent good glycemic control in these patients. Therefore, patient education with a focus on injection technique, dose titration and prevention of hypoglycemia, as well as the use of the second-generation BI analogs, increases the chances for achieving glycemic control targets in patients with T2D who initiate or need to intensify BI therapy.

The combination of type 1 diabetes and eating disorder during pregnancy

The problem of eating disorders currently holds a special place in clinical practice. Bulimia nervosa is one of the main forms of eating disorders, characterized by the difficulty in its treatment and a long, recurrent course. Eating disorders are common in patients with type 1 diabetes mellitus (T1D), especially in adolescent girls.

In this article, we present a clinical case of a patient with T1D and bulimia nervosa, which developed before the manifestation of T1D and progressed against its background. The patient is overly concerned with controlling body weight, specifically restricted the intake of carbohydrates, forcibly caused vomiting. During pregnancy fasting ketonuria («low-carb ketone») was repeatedly detected. The minimum weight was 37 kg (BMI 15.2 kg/m2). Particular interest of this case is the course of pregnancy, which ended in the antenatal death. The possible cause could be the restriction on carbohydrate food and prolonged stay in ketosis, that might lead to the development of pregnancy pathology. Additional examination also revealed multiple complications of diabetes and recurrent depressive disorder, which requires conjoint monitoring by an endocrinologist and a psychiatrist.

Combination of T1D and eating disorder in a pregnant patient should be considered as an atypical course of the disease.

The effect of a structured non-pharmacological treatment of type 2 diabetes on glycated hemoglobin and body weight: a randomized controlled trial

BACKGROUND: Non-pharmacological treatments are an integral part of the treatment of all patients with type 2 diabetes (T2D). However, due to many factors, doctors and patients themselves tend to underestimate or completely neglect such effective methods in managing the course of the disease. Despite the high level of evidence of the effectiveness of this type of treatment for T2D, every year scientists around the world continue to actively study the effect of various non-drug methods on the course of the disease.

AIM: To study the effect of a 24-week structured non-pharmacological treatment program on glycated hemoglobin reduction and weight loss in middle-aged patients with compensated T2D taking metformin.

MATERIALS AND METHODS: A two-group, randomized, parallel-group, blinded trial was designed. Patients with an established diagnosis of T2D in the stage of compensation (HbA1c ≤7%), aged 45–59 years, taking metformin, were randomized to receive either standard non-pharmacological treatment of diabetes according to clinical protocol of T2D treatment in Kazakhstan, or an intensive course of non-pharmacological treatment according to a structured program developed by researchers. The duration of the intervention was 24 weeks. Primary outcomes were glycated hemoglobin, body weight. Secondary outcomes: blood pressure, waist circumference, insulin resistance index (HOMA-IR), lipid profile: total cholesterol, high and low density lipoproteins, triglycerides. The outcomes of the participants in both groups were assessed at baseline, 12 and 24 weeks after randomization. The study is registered with ClinicalTrials.gov NCT04632823.

RESULTS: The study included 200 patients, 67 patients completed the study: intervention group n=33, control group n=34. After 24 weeks of observation, patients in the intervention group showed a significant decrease in HbA1c from 6.34% to 6.22%, p<0.001, while for the control group the level of HbA1c remained the same at 6.5% (p=0.703). Patients in both groups significantly reduced body weight, however, the decrease in the intervention group was more significant: by 6.7% of the initial level, while in the control group, only 1.1%. LDL, triglycerides, cholesterol level, HOMA-IR 2, and diastolic blood pressure did not decline significantly in the control group. All biochemical characteristics except triglycerides and LDL decreased significantly in the intervention group.

CONCLUSION: The use of a structured program of non-pharmacological treatment of type 2 diabetes mellitus among compensated (HbA1c ≤7%) middle-aged patients who took metformin significantly reduced body weight and glycated hemoglobin in 24 weeks.

Analysis of specialized care for patients with diabetic foot syndrome in St. Petersburg for 2010–2021

BACKGROUND: A decrease in the frequency of amputations due to diabetic foot syndrome (DFS) is one of the parameters that determine the quality of medical care for patients with diabetes mellitus.

AIM: Our aim was to study the indicators characterizing medical care for patients with lower limb pathology in diabetes mellitus in St. Petersburg from 2010 to 2021.

MATERIALS AND METHODS: Annual reports on the treatment of patients with DFS in city hospitals specializing in the surgical treatment of DFS and in outpatient offices «Diabetic foot» (DFO) from 2010 to 2021 were analyzed.

RESULTS: The average number of patients per year admitted to the DFO was 18,527 (34,440 visits). Proportion of patients with foot ulcers — 8,9%, with Charcot’s arthropathy — less than 1%. Before 2020, the frequency of above the foot amputations decreased from 48.3% to 8.6%, hospital mortality — from 11.7 to 5.7%, the number of revascularizations increased from 37 to 642 per year. The increase in operational activity was not accompanied by a decrease in the frequency of amputations (59.3% in 2019). Of all amputations, 11.3% were patients referred from DFO. During the epidemic, the number of visits and patients admitted to the DFO decreased by 27,3% and 31%, respectively. The proportion of foot ulcers and the frequency of amputations have not changed. Inpatient care was characterized by a decrease in operational activity, a decrease in the availability of revascularization, a 2-fold increase in the proportion of high amputations and an increase in hospital mortality from 5.7% in 2019 to 14.9% in 2021.

CONCLUSION: An analysis of the statistics of specialized care for patients with DFS over 12 years showed the reduction of the frequency of high amputations, but revealed an increase in the frequency of surgical interventions in DFS against the background of an almost unchanged proportion of amputations in the structure of all operations. Despite significant quantitative indicators, the outpatient service seems to be insufficiently effective in reaching the target population. The negative impact of the epidemic has led to a significant increase in the frequency of high amputations and mortality.

Analysis of myocardial revascularization and endpoints after a 1-year follow-up of patients with acute and chronic coronary artery disease, depending on diabetes presence

Aim. To analyze myocardial revascularization in patients with acute and chronic coronary artery disease (CAD) and with different glycemic status, as well as to evaluate complications after a 1-year follow-up.

Material and methods. This prospective comparative clinical study included 202 patients of both sexes with acute and chronic coronary artery disease. Depending on the glycemic status and CAD type, the patients were divided into four groups: acute CAD and type 2 diabetes (T2D); acute CAD without T2D (control group); chronic CAD and T2D; chronic CAD without DM2 (control group). Depending on the clinical condition and the results of coronary angiography, patients underwent various types of myocardial revascularization: balloon angioplasty without stenting, stenting, coronary artery bypass grafting, stenting + coronary artery bypass grafting. One year after discharge, all patients were contacted to evaluate complications and endpoints, which included recurrent myocardial infarction, cerebrovascular accident, readmission, revascularization, and death. Total indicator of endpoints was assessed.

Results. Up to 80% of patients with acute and chronic CAD, regardless of glycemic status, underwent revascularization, mainly stenting. The prevalence of stenting among persons without T2D with acute and chronic CAD was significantly higher compared with patients with T2D. The absolute number of patients with coronary artery bypass grafting, including in combination with stenting, was higher in the T2D groups. In groups without T2D, the number of patients with one stent was 2-2,5 times higher compared to groups with T2D — acute CAD (p=0,041) and chronic CAD (p=0,017). The prevalence of implantation of ≥2 stents did not differ between the groups. Within 1 year after discharge, there were more hospitalizations and reoperations among people with acute and chronic CAD and T2D. The groups did not differ in the number of non-fatal and fatal complications, although the absolute numbers of these indicators were higher in patients with T2D. The total number of endpoints in T2D people, regardless of the CAD type, were 2 times higher compared to the corresponding control groups (p<0,001).

Conclusion. Most patients with acute and chronic CAD, regardless of glycemic status, underwent myocardial revascularization. In patients without T2D, stenting prevailed, most often of one coronary artery. Patients with T2D, along with stenting, underwent coronary bypass grafting, as well as a combination of these two procedures. After a year of follow-up, the number of complications in patients with T2D was 2 times higher compared to patients without type 2 diabetes, which emphasizes the importance of secondary prevention, including complex drug treatment.

Clinical Practice Guidelines of the Russian Scientific Liver Society, Russian Gastroenterological Association, Russian Association of Endocrinologists, Russian Association of Gerontologists and Geriatricians and National Society for Preventive Cardiology on Diagnosis and Treatment of Non-Alcoholic Liver Disease

Aim:present clinical guidelines, aimed at general practitioners, gastroenterologists, cardiologists, endocrinologists, comprise up-to-date methods of diagnosis and treatment of non-alcoholic fatty liver disease.Key points.Nonalcoholic fatty liver disease, the most wide-spread chronic liver disease, is characterized by accumulation of fat by more than 5 % of hepatocytes and presented by two histological forms: steatosis and nonalcoholic steatohepatitis. Clinical guidelines provide current views on pathogenesis of nonalcoholic fatty liver disease as a multisystem disease, methods of invasive and noninvasive diagnosis of steatosis and liver fibrosis, principles of nondrug treatment and pharmacotherapy of nonalcoholic fatty liver disease and associated conditions. Complications of nonalcoholic fatty liver disease include aggravation of cardiometabolic risks, development of hepatocellular cancer, progression of liver fibrosis to cirrhotic stage.Conclusion.Progression of liver disease can be avoided, cardiometabolic risks can be reduced and patients' prognosis — improved by the timely recognition of diagnosis of nonalcoholic fatty liver disease and associated comorbidities and competent multidisciplinary management of these patients.

Pathomorphological and pathochemical characteristic of the osteomyelitis focus in patients with diabetic osteoarthropathy (Charcot foot)

BACKGROUND: Osteomyelitis in diabetic osteoarthropathy occurs in 65 % of cases, and it is the main cause of non-traumatic amputations. The choice of optimal treatment technologies should be based on understanding the pathogenetic characteristics of this disease.

AIM: To study the pathomorphological and pathochemical picture of osteomyelitic focus in patients with diabetic neuroosteoarthropathy.

MATERIALS AND METHODS: Object — 20 patients (55.3±9.33 years) with Type 2 diabetes mellitus, diabetic neuroosteoarthropathy, chronic osteomyelitis of the foot bones. The treatment consisted in surgical debridement of the purulent focus with the material collection for pathomorphological and biochemical studies, and in reposition and alignment of bone fragments with the leg and foot fixation using the Ilizarov fixator in order to form bone ankylosis of the compromised joint.

RESULTS: Subacute and acute course of chronic osteomyelitis was registered in 80 % of cases. As for the pathohistological changes in bone tissue, the following ones were the most significant: necrosis and the presence of an inflammatory infiltrate of varying severity depending on the phase of the inflammatory process. The articular cartilage structure was broken in all the cases. Activation of osteoclasts was observed in the osteomyelitis focus, especially in the subchondral zone. There was no subchondral bone plate in most cases, or only its fragments remained. Pathohistological examination of the soft tissues associated with the osteomyelitis focus indicated the presence of mirocirculatory and denervation disorders due to necrosis and hyalinosis of a significant part of microvessels against the background of compensatory hypervascularisation and chronic inflammation, narrowing and obliteration of the lumens of feeding arteries, almost complete absence of nerve elements in the tissues or their destructive changes. An increase in the activity of lytic enzymes was revealed in the interstitial environment of the tissues surrounding the osteomyelitis focus (138-fold increase in the activity of acid phosphatase, interstitial osteolytic index was 7.2-fold higher than blood serum index).

CONCLUSION: The pathomorphological signs of chronic osteomyelitis subacute and acute processing were observed in most patients. Breaking the articular cartilage structure was accompanied by invasion of vessels, inflammatory infiltrate, and by activation of osteoclasts in the subchondral zone. Destructive changes of vessels and nerves in the soft tissues associated with the osteomyelitis focus can be etiopathogenetic factors of this disease development. The technologies for stopping this process should be based on obligatory debridement of the focus with sequestrnecrectomy, with regular monitoring of the operated segment condition.

The incidence and aggravating factors of male hypogonadism in type 2 diabetes

BACKGROUND: Male hypogonadism is associated with type 2 diabetes mellitus (T2DM), therefore, it is of interest to study its frequency. The clinical symptoms of hypogonadism are not specific, and laboratory diagnostics is the basis for its detection. The optimal method for this diagnostics is isotope dilution liquid chromatography/tandem mass spectrometry, which was used in our study.

 AIMS: Assessment of the incidence and aggravating factors of male hypogonadism in type 2 diabetes

MATERIALS AND METHODS: A full-design, cross-sectional, screening, single-center, non-interventional study included men with T2DM, who were he was treated in Endocrinology Research Centre, Moscow. The study was conducted from October 2021 to January 2022. Medical history assessment, physical examination with determination of body mass index (BMI), measurement estimation of total testosterone by isotope dilution liquid chromatography/tandem mass spectrometry, glycated hemoglobin (HbA1c) and lipid profiles were performed. The groups were compared using the Mann-Whitney U-test for quantitative indicators and χ² with Yates’ correction for qualitative ones. Differences were considered statistically significant with p0,05.

RESULTS: Hypogonadism was detected in 355 (70.3%) men with T2DM. Patients with hypogonadism had statistically significantly higher BMI, worse glycemic control, lower HDL levels, and higher triglycerides than eugonadal men. An additional comparative analysis among non-obese individuals showed the presence of statistically significant differences in the level of HbA1c (higher in hypogonadal men) and HDL (lower in hypogonadal men). An analysis of hypogonadal patients depending on the presence of obesity showed statistically significant differences between groups in the level of total testosterone (lower in obese men) and triglycerides (higher in obese men).

CONCLUSIONS: The prevalence of male hypogonadism in type 2 diabetes was 70,3%. Its development was associated with obesity and poor glycemic control.

Factors associated with high glucose variability in patients with type 1 diabetes

BACKGROUND: High glucose variability (GV) is recognized as a risk factor for vascular diabetic complications and hypoglycemia. Factors affecting GV in patients with diabetes needed to be clarified.

AIM: To determine the factors associated with high GV in adult patients with type 1 diabetes.

MATERIALS AND METHODS: We conducted a single center cross-sectional observational study. In-patients with type 1 diabetes aged 18 to 65 years on basal bolus insulin therapy were included. Day-time and nocturnal Coefficient of Variation (CV), Mean Amplitude of Glycemic Excursions (MAGE), Mean Absolute Glucose (MAG) were calculated from continuous glucose monitoring data. The values of CV, MAGE, MAG within the upper quartile were considered high.

RESULTS: The study included 400 individuals, including 111 on continuous subcutaneous insulin infusion (CSII). Patients with high GV had lower fasting and postprandial C-peptide levels and higher insulin doses. According to ROC analysis, daily insulin dose >0.69 U/kg and estimated glomerular filtration rate (eGFR) ≥90.5 ml/min×1.73 m2 were associated with high nocturnal CV values. Dose of basal insulin >0.292 U/kg and bolus insulin >0.325 U/day were associated with nocturnal MAGE. Body mass index (BMI) ≤23.2 kg/m2, waist circumference ≤80.5 cm, daily insulin dose ≥0.69 U/kg, HbA1c ≥8.3%, eGFR ≥89.5 ml/ min×1.73m2 increased risk of high MAG at night. High day-time CV values were associated with daily insulin dose ≥0.675 U/kg and daily dose of BI ≥0.286 U/kg. The risk of high MAGE was increased with HbA1c ≥8.24% and basal insulin dose ≥0.286 U/kg. BMI ≤23.2 kg/m2, waist circumference ≤80.5 cm, daily insulin dose ≥0.69 U/kg, daily dose of bolus and basal insulin ≥0.325 and ≥0.29 U/kg respectively, and HbA1c ≥8.33% were the risk factors for high day-time MAG. Patients on CSII had lower MAGE (p<0.001) and MAG (p=0.008) compared to those on multiple daily injections.

CONCLUSION: In type 1 diabetes, high GV is associated with undetectable residual insulin secretion, normal or reduced body weight, preserved kidney function, supraphysiological doses of insulin, and non-target HbA1c. Patients on CSII have a lower GV than those on multiple daily injections. 

[Contraception in adolescents with obesity and diabetes mellitus]

Today most adolescents have their first sexual experience at the age of 15-19. However, only 44% of girls and young women (15-24 years old) report about contraception at that moment. A decision on pregnancy in adolescence is a difficult choice and any scenario may cause serious medical and social problems. Complications after an artificial abortion have a negative impact on a woman's fertility. Diabetes mellitus type 1 and arterial hypertension accompanied with obesity within the metabolic syndrome are defined by the World Health Organization (WHO) as diseases, which increase risk of an unplanned pregnancy. The article consoders problems of interaction of a doctor and a teenage girl with endocrinopathy, when discussing her sexual health, the analysis of the literature reflecting the influence of contraception on the course of the underlying pathology is presented. The authors formed a list of drugs acceptable for use in diabetes and obesity based on assessment of risks and preferences from the use of different methods of fertility control. The work contains information about the procedure of starting contraception, the rules of future dynamic monitoring of the patient.

[Features of steroidogenesis in men with hypogonadism and type 2 diabetes]

BACKGROUND

Type 2 diabetes mellitus (DM2) in men is associated with a high incidence of hypogonadism. Testosterone is a steroid hormone and one of the final metabolites of steroidogenesis, which causes interest in assessing the content of key steroid hormones, their precursors and metabolites in hypogonadal and eugonadal men with T2DM.

AIMS

Assessment of the features of steroidogenesis in men with hypogonadism in T2DM using tandem mass spectrometry.

MATERIALS AND METHODS

A full-design, cross-sectional, screening, single-center, non-interventional study included men with T2DM, who were he was treated in Endocrinology Research Centre, Moscow. The study was conducted from October 2021 to January 2022. Medical history assessment, physical examination with determination of body mass index (BMI), measurement of key steroid hormones, their precursors and metabolites by isotope dilution liquid chromatography/tandem mass spectrometry, glycated hemoglobin (HbA1c) were performed. The groups were compared using the Mann-Whitney U-test for quantitative indicators and χ² with Yates' correction for qualitative ones. Correlation analysis was performed by the Spearman correlation method. When determining the criterion of statistical significance, the Bonferroni correction was applied.

RESULTS

Patients with hypogonadism had statistically significantly more pronounced obesity compared with eugonadal men. In a comparative analysis of patients, depending on the presence of hypogonadism, there were statistically significantly lower levels of androgen precursors 17-hydroxypregnenolone and 17-hydroxyprogesterone in hypogonadal men. At the same time, a positive statistically significant correlation was found between total testosterone and 17-hydroxyprogesterone. In addition, 17-hydroxyprogesterone, although to a lesser extent, but positively correlated with other androgens - androstenedione (r=0,328; p<0,001) and dehydroepiandrosterone (r=0,183; p=0,004). >< 0,001) and dehydroepiandrosterone (r=0,183; p=0,004).

CONCLUSIONS

In this investigation the prevalence of male hypogonadism in type 2 diabetes, determined by high-precision tandem mass spectrometry, was 69,5%. There was no effect of the disease on the mineralocorticoid and glucocorticoid links of adrenal steroidogenesis. Hypogonadism was associated with decreased levels of a number of testosterone precursors. The most significant of them was 17-hydroxyprogesterone, which can be considered as a marker of testicular steroidogenesis.

The Impact of Hypoglycemic Therapy on the Prognosis for Acute Coronary Syndrome in Patients with Type 2 Diabetes

The article discusses particular circumstances of acute coronary syndrome (ACS) in patients with type 2 diabetes (T2D). In addition, the available literature data and clinical guidelines reflecting the role of hypoglycemic therapy as a cardioprotection factor in ACS are analyzed. The article considers possible protective molecular mechanisms of various groups of drugs in ischemic cardiomyocytes.

[Evaluation of FreeStyle Libre in pediatric t1dm: improved glycemic control, reduction in diabetic ketoacidosis and severe hypoglycemia]

BACKGROUND

Self-monitoring of blood glucose (SMBG) with glucometers provides only a snapshot of the glycemic profile and is accompanied by significant psychological discomfort and pain, especially in children. Flash Glucose Monitoring System - FreeStyle Libre (FSL) overcomes many of the barriers associated with glucose measurement and improves metabolic control.

AIM

To evaluate the efficacy of FSL in children with type 1 diabetes mellitus (T1DM) in terms of glycemic control, episodes of severe hypoglycemia (SH) and diabetic ketoacidosis (DKA).

MATERIALS AND METHODS

A multicenter, prospective, observational study in real clinical practice was carried out. A total of 469 subjects (258 boys and 211 girls) aged 4-18 were included in the study. The median age was 11.3 (8.4-14.6) years, duration of T1DM - 4.2 (2.1-7.1) years. After FSL start, patient was followed up for 6 months.

RESULTS

After 3 and 6 months of FSL use, HbA1c significantly decreased from 7.4% to 7.1% and 7.2%, respectively (p&lt;0.001). The number of children with HbA1c &gt;&lt;7.5% increased from 51% to 60% and 58% at 3 and 6 months, respectively (p&gt;&lt;0.001). The incidence of DKA and SH, as well as the proportion of patients experiencing at least one episode of DKA and SH, were significantly reduced after 6 months of FSL use compared with baseline (p&gt;&lt;0.001).

CONCLUSION

The Study demonstrated a significant improvement in metabolic control in children with T1DM 6 months after FSL start: decrease in HbA1c, accompanied by reduction in incidence of DKA and SH.

[The effectiveness of eradication therapy of the 1st line of Helicobacter pylori infection in patients with type 2 diabetes mellitus]

AIM

Evaluation of the efficacy and safety of eradication therapy of infection Helicobacter pylori in patients with H. pylori- associated pathology of the upper gastrointestinal tract and concomitant type 2 diabetes mellitus (DM).

MATERIALS AND METHODS

The prospective randomized study involving 180 patients (87 men and 93 women) with H. pylori- associated pathology of the upper gastrointestinal tract was carried out. The patients were divided into four groups of 45 people: 1 patients without diabetes who received the classic triple eradication therapy; 2 patients with type 2 DM who received the classic triple eradication therapy; 3 patients without DM who underwent quadrotherapy with bismuth preparations; 4 patients with type 2 DM who underwent quadrotherapy with bismuth preparations. Eradication therapy was carried out for 14 days. Evaluation of the effectiveness of eradication using a breath test was carried out 4 weeks after completion of the course of treatment. Eradication success was assessed separately for ITT and PP analyzes.

RESULTS

The effectiveness of classical triple eradication therapy in patients with concomitant type 2 DM is 64.4% in the ITT group and 69.05% in the PP: quadrotherapy 73.34 and 80.49%, respectively. The effectiveness of first line eradication therapy is higher in patients without DM compared with groups of patients with concomitant type 2 DM: ITT 83.33%, PP 88.23% and ITT 68.89%, PP 74.70%, respectively. The incidence of side effects in patients with type 2 DM: with the use of classical triple therapy 22.23%, quadrotherapy 31.12%.

CONCLUSION

The data of the study of the efficacy and safety of line I eradication therapy make it possible to recommend the four-component therapy based on bismuth for use in clinical practice, especially in patients with DM.

[Optimization of an integrated approach to voice correction for endocrinopathies (analytical review)]

Dysphonia is a symptom of many endocrine pathologies. Hoarseness, voice fatigue, decrease of the voice pitch, reduce of the range are typical complaints for hypothyroidism, caused by an increased amount of polysaccharides and accumulation of fluid in the lamina propria of the vocal folds. An excess of growth hormone causes an overproduction of insulin-like growth factor-1, which leads to abnormalities in the craniofacial region and proliferation of the upper respiratory tract tissues, including thickening of the laryngeal cartilages, vocal folds and decreasing of the voice pitch. Hyperglycemia, changes in the balance of fluid and electrolytes in diabetes mellitus can indirectly affect the voice: xerostomia complicates phonation due to impaired hydration of the laryngeal mucosa, diabetic neuropathy often disrupts the work of the laryngeal muscles involved in voice formation. Voice changes are observed not only in endocrine disorders, but also during puberty, the phases of the menstrual cycle and during menopause. Laryngeal structures are modified under the influence of hormones and external factors, which generally changes pitch and intensity of the voice, timbre and resonance, articulation and prosodic characteristics. The purpose of this review is to summarize and systematize data on physiological and pathological voice changes in patients of different age groups and sex. The possibilities of a multidisciplinary approach to rational voice correction are demonstrated.

Variability of arterial pressure and cardiac rhythm in patients with coronary heart disease and diabetes mellitus: Effect of sodium-glucose co-transporter 2 inhibitor

Introduction: A factor that worsens the course of coronary heart disease (CHD) in patients with type 2 diabetes mellitus (DM2) is cardiovascular autonomic neuropathy (CAN), in which the risk of sudden death increases fivefold. The prevalence of CAN in patients with both CHD and DM2 may reach 60%. Classic cardiovascular tests (CCT) do not permit identification of CAN at the preclinical stage. A modern method of treatment for DM2 uses sodium-glucose co-transporter 2 inhibitors, which have confirmed cardioprotective effects. Aim: To analyze the prevalence of alterations of arterial pressure variability (APV) and of heart rhythm variability (HRV) in patients with both CHD and DM2 and the effect of empagliflozin on these parameters. Materials and methods: A total of 210 patients aged 64.5 6.7 years (103 men) with both CHD and DM2 were examined (group1). Anthropometric and biochemical parameters were analyzed, electrocardiogram and arterial pressure were monitored daily, and CCT was performed. For comparison, 64 patients with CHD with no alterations in the carbohydrate metabolism were examined (group2, n=64, aged 66.4 2.3 years). Further, among patients in group1, patients with impaired HRV and APV were selected, but they had CCT scores 4.0, and they were divided into group1G (n=22) where empagliflozin was added (1025 mg/day) and group1C (n=20) where the previous therapy was continued. Results: CAN was detected in 22% of patients with CHD and DM2, and all patients had impaired HRV and ADV. Deviations of HRV and APV parameters with normal CCT scores ( 4.0) were detected in 43% of the patients. Within 6 months of treatment with empagliflozin, the HbA1c level decreased from 8.38% 0.56% to 6.9% 0.26% (p 0.05); in the groupwithout empagliflozin treatment, it decreased from 8.28% 0.32% to 7.30% 0.29% (p 0.05). In the empagliflozin group, the average heart rate per day decreased from 86.7 2.4 to 76.7 2.1 beats/min (p 0.05), the circadian index increased from 1.19 0.02 to 1.30 0.01 (p 0.05), the SDNN increased from 106.1 2.21 to 114.03 2.34 ms (p 0.05), and the systolic arterial pressure variability index decreased from 22.9% 1.7% to 16.4% 1.9% at daytime (p 0.05) and from 16.8% 2.2% to 12.3% 2.6% at nighttime (p 0.05). Conclusion: The identified alterations of HRV and APV parameters may be manifestations of CAN, and CCT score 4.0 may indicate the preclinical stage. Positive dynamics of HRV and APV was recorded with empagliflozin therapy, which improved the functional condition of the autonomic nervous system.

[Modern concepts of pathogenesis of diabetic retinopathy]

This literature review presents modern view on the pathogenesis of diabetic retinopathy (DR) paying particular attention to the molecular mechanisms leading to its development, as well as the manifestations of retinal neurodegeneration in such patients. Assessment of this condition and its clinical manifestations makes it possible to diagnose DR at the stage of absent initial vascular changes. Investigating the neurodegeneration mechanisms could supplement the existing understanding of the disease pathogenesis and could possibly help find new ways of treatment and prevention of DR.

Сlinical and hemodynamic characteristics and coronary blood flow in patients with chronic coronary artery disease and type 2 diabetes

Aim. To assess the features of clinical and hemodynamic characteristics and the severity of coronary involvement in patients with chronic coronary artery disease (CAD) with and without diabetes.

Material and methods. The study included 100 patients with stable CAD, which were divided into two groups: group I (mean age, 57,9-1,04 years, male/female 35/14) — 49 patients with CAD and type 2 diabetes, II — (60,2-0,9 years, 34/17) — 51 patients without SD. Along with behavioral and biological risk factors, clinical and hemodynamic characteristics were analyzed. All patients underwent coronary angiography.

Results. The presence of diabetes in patients with CAD was associated with abdominal obesity and comorbidity of somatic diseases. Among group I patients, electrocardiographic signs of left ventricular hypertrophy, conduction abnormalities, accompanied by a decrease in the left ventricular ejection fraction, impaired diastolic function, and high mean pulmonary artery pressure were significantly more often detected. In patients with CAD and type 2 diabetes, significant right coronary artery (CA) stenoses were more often recorded (39%), while in patients without diabetes, the anterior descending artery was the most susceptible to atherosclerosis. In group I, stenosis of the distal CA third was detected 1,5 times more often (p<0,001), and their diffuse multivessel lesion prevailed by 28% (73% and 45%, respectively, p<0,005). The average SYNTAX score in patients with and without diabetes was 29,2±0,8 vs 22±0,7, respectively (p<0,0005).

Conclusion. In patients with CAD and diabetes, more pronounced atherosclerotic coronary involvement (diffuse multivessel CAD) was revealed, which should be taken into account when planning further treatment. The risk of adverse cardiovascular events will always be present with percutaneous coronary interventions.

Epidemiological characteristics of diabetes mellitus in the Russian Federation: clinical and statistical analysis according to the Federal diabetes register data of 01.01.2021

BACKGROUND. One of the priority directions in the development of the health care system is to reduce the medical and social damage caused by the increase in the prevalence of diabetes mellitus (DM). From this point of view, the development of a diabetes register is very important as the main information and analytical platform for clinical and epidemiological monitoring of diabetes in the Russian Federation (RF).

AIMS. The aim of our study was to analyze a dynamic (2016–2020) of the epidemiological characteristics of diabetes mellitus in the Russian Federation (prevalence, morbidity, mortality), the prevalence of complications, the level of HbA1c and the dynamics of the structure of glucose-lowering therapy (GLT) according to the Federal Diabetes Register (FDR).

MATERIALS AND METHODs. The database of FRD (http://diaregistry.ru) 84 regions of the RF. The data are presented in dynamics 2016→2020.

RESULTS. The total number of DM patients in the RF as of 01.01.2021 was 4,799,552 (3.23% of the population), including: Type 1 (T1) — 5.5% (265.4 ths) , T2 — 92.5% (4.43 million), other DM types — 2.0% (99.3 ths). The dynamics of prevalence was 168.7→180.9/100 ths people with T1, and 2709 → 3022/100 ths people with T2; morbidity in T1 10.5→7.7/100 ths population, in T2 219.6→154.2/100 ths population. Age and sex characteristics: the proportion of men in T1 — 54%, in T2 — 30%; the max proportion of patients with T1 at the age of 30–39 years, T2 65–69 years. Mortality: T1 3.0 → 2.7/100 ths population, T2 87.7→93.9/100 ths of the population, the main cause of death was cardiovascular: in T1 38,1% cases, in T2 — 52,0%. Life expectancy (average age of death of patients): T1 was 53.2years, the dynamics in males 50.7 → 50.5years, ­females 58.7→55.2years; in T2 — 73.5 years, males 70.2→70.1years, females 75.7→75.4 years. The dynamic of DM duration until the death: in T1 17.4→19.0 years; in T2 11→11.4 years. The incidence of diabetic complications in T1 and T2 patients: neuropathy 43.3% and 24.4%, nephropathy (CKD) 25.9% and 18.4%, retinopathy 31.7% and 13.5%, respectively. The ­proportion of ­patients with HbA1c <7%: in T1 32.3%→36.9%, in T2 51.9%→52.1%, with HbA1c ≥ 9.0% in T1 23.1%→18.7% , in T2 8.9%→8.0%. The structure GLT in T2 patients: glucose lowering medications (GLM) — 76.2% (monotherapy — 44.1%; ­combination of  2 GLM — 28.9%, 3 GLM — 3.2%), insulin therapy in 18,8%, without drug therapy in 4.9%.

CONCLUSIONS. The performed analysis demonstrates the importance of dynamic assessment of epidemiological characteristics and monitoring of clinical data on patients with diabetes through a registry for assessing the quality of diabetes care and the prospects for its development.

Drug Therapy and Adherence in Patients With Coronary Heart Disease: Results of the Russian Part of the EUROASPIRE V International Multicenter Study

Aim      To study the practice of drug treatment of ischemic heart disease (IHD) and the consistency of this practice with the established guidelines.Material and methods  Results of the Russian part of the EUROASPIRE V study were compared with the general European population of the study. At ≥6 mos. and &lt;2 years after the discharge from the hospital, patients were invited to visit the site for an interview. The drug therapy recommended upon discharge and taken by patients in the long-term as well as the patients' compliance with the treatment were analyzed. In Russian centers, 699 patients were registered, and 399 of them visited the centers for the interview.Results             Upon discharge from the hospital, patients of the Russian cohort and of the entire study population were prescribed acetylsalicylic acid or other antiplatelet drugs (99.2% and 94.1%, respectively); beta-blockers (87.2 and 81.6%, respectively); angiotensin-converting enzyme (ACE) inhibitors (69.9% and 61.1%, respectively); sartans (16.5% and 14.2 %, respectively); calcium channel blockers (19.3 and 19.4 %, respectively); nitrates (8.0% and 22.5 %, respectively); diuretics (31.1 and 32.5 %, respectively); statins (98.0% and 85.0 %, respectively); and anticoagulants (6.6 and 8.3 %, respectively). For the long-term treatment, patients of the Russian cohort and of the entire study population took antiplatelets (94.7 % and 92.5 %, respectively); beta-blockers (83.2% and 81.0 %, respectively); ACE inhibitors (60.2% and 57.3 %, respectively); sartans (19.3% and 18.4 %, respectively); calcium antagonists (21.1% and 23.0 %, respectively); nitrates (9.0% and 18.2 %, respectively); diuretics (31.8% and 33.3 %, respectively); statins (88.2% and 80.8 %, respectively); and anticoagulants (8.8% and 8.2 %, respectively). High intensity hypolipidemic therapy was prescribed to 54.0 % of patients in Russian centers and 60.3 % of patients in the entire study. Both Russian and international patients evaluated their compliance with the prescribed medication as high.Conclusion      According to results of the EUROASPIRE V study as compared to earlier studies, the practice of drug therapy in Russian patients with IHD has significantly approached European indexes. Further optimization is possible by a more extensive use of high intense hypolipidemic treatment and antidiabetic drugs with a documented positive effect on prognosis of cardiovascular diseases.

[Viscodissection with staining of epiretinal membranes in surgery of proliferative diabetic retinopathy]

PURPOSE

To develop a method of viscodissection involving staining of epiretinal membranes, and to evaluate its efficacy and safety in surgical treatment of proliferative diabetic retinopathy (PDR).

MATERIAL AND METHODS

The study included 30 patients with type 1 diabetes mellitus and PDR with tractional retinal detachment (TRD). All patients were divided into two groups. In the first (main) group, at the initial stages of the operation, viscodissection with staining of epiretinal structures was performed, followed by segmentation and removal of membranes; in the second (control) group, segmentation and removal of membranes was performed using a vitreotome and endovitreal forceps.

RESULTS

During the follow-up, all patients showed positive trends of morphological and functional indicators. While the number of intraoperative stages was the same in both groups, the total operation time in patients of the main group was significantly lower (p≤0.001) than in patients of the control group (main - 41.3±2.8 min; control - 53.8±6.2 min). With equal number of posterior hyaloid membrane to inner limiting membrane (PHM to ILM) fixation points in both groups, iatrogenic retinal rupture occurred significantly less frequently in patients of the main group (main - 0.6±0.7, control - 3.1±2.9) (p≤0.001). In this regard, among the patients of the control group, in the overwhelming majority of cases, it was necessary to use a silicone oil tamponade (60%) or gas-air mixture (33%), while in the first group the main postoperative media were sterile BSS solution (73%) and gas-air mixture (27%).

Diagnostic capabilities of different methods of laser doppler flowmetry spectral indexes assessment in patients with diabetic microangiopathy

The article contains the results of a study of two different methods for calculating the spectral parameters of laser Doppler flowmetry in patients with diabetic microangiopathy caused by type 2 diabetes mellitus (main group) and those with excluded diabetes mellitus (control group). Spectral indices were calculated using either average or maximum amplitudes of the frequency ranges. When comparing the contribution of respiratory and pulse fluxmotions using average amplitudes, there were significant (p < 0.05) differences between the main and control groups. On the contrary, when using the maximum amplitudes, no significant differences were noted (p > 0.05). Also, significant correlations were found between the contributions of respiratory and pulse fluxmotions and the estimated glomerular filtration rate in the main group, using both calculation methods. These studies indicate the feasibility of using a technique based on the analysis of average amplitudes to increase the specificity of laser Doppler flowmetry as a method for diagnosing diabetic microangiopathy.

Comparative evaluation of empagliflozin, canagliflozin and sitagliptin cardioprotective properties in rats with experimental type 2 diabetes mellitus

Background: Myocardial infarction (MI) is one of the leading causes of mortality in patients with type 2 diabetes mellitus (DM), therefore it is essential to give preference to a glucose-lowering drug having optimal cardioprotective properties. A comparative study of the various sodium-glucose co-transporter inhibitors representatives’ protective effects in experimental MI was not carried out within the framework of one study.

Aim: To evaluate the influence of empagliflozin (EMPA) and canagliflozin (CANA), in comparison with sitagliptin (SITA), on hemodynamic parameters and myocardial damage area in rats with diabetes type 2 model in experimental MI.

Materials and methods: Type 2 DM was modelled in Wistar rats by means of 4-week high-fat diet followed by nicotinamide 230 mg/kg and streptozotocin 60 mg/kg administration. 4 weeks after DM induction the following groups were made: «DM+SITA» — treatment with SITA 50 mg/kg, «DM+EMPA» — treatment with EMPA 2 mg/kg, «DM+CANA» — treatment with CANA 25 mg/kg per os once daily for 8 weeks. Animals in «DM» group remained untreated for the following 8 weeks. Rats in control group were fed with standard chow. 16 weeks after the experiment beginning transient global myocardial ischemia was modelled in all rats. Hemodynamic parameters and myocardium necrosis area were evaluated.

Results: The necrosis area was larger in «DM» group, than in control one (p=0.018). Infarction size in «DM+SITA» did not differ from that in «DM» group (62.92(41.29;75.84) and 57.26(45.51;70.08)%, р=0.554). Necrosis area in «DM+EMPA» and «DM+CANA» groups was smaller than in «DM» group (37.90(20.76;54.66)%, 46.15(29.77;50.55) vs 57.26(45.51;70.08)%, р=0.008 and р=0.009, respectively). Necrosis size did not differ between «DM+EMPA» and «DM+CANA» groups (p=0.630). Ischemic contracture in «DM+CANA» group was less prominent than under the use of all other glucose-lowering drugs. We observed increase of coronary blood flow in «DM+EMPA» group, in comparison with «DM», «DM+CANA» and «DM+SITA» groups.

Conclusions: SITA does not have cardioprotective effect in ischemia-reperfusion injury in diabetic rats. EMPA and CANA have similarly prominent infarct-limiting properties. EMPA is able to increase coronary blood flow, whereas cardioprotective action of CANA is associated with ischemic contracture diminishing.

Advantages of the use of metformin in patients with impaired uric acid metabolism

Metformin is one of the oldest and at the same time relevant and effective drugs for the treatment of type 2 diabetes. At the same time, the mechanism of the hypoglycemic effect was not completely clear until recently. Current data suggest that the mechanism of action of metformin contributes to the development of an anti-inflammatory effect, as well as a decrease in the level of uric acid, and its use can be potentially useful in patients with hyperuricemia and gout.

Current Guidelines for the Treatment of Arterial Hypertension in Patients with Diabetes Mellitus and Chronic Kidney Disease

The current understanding of the management of patients with diabetes mellitus (DM) based on the concept of the cardiovascular continuum involves not only the prevention and treatment of cardiovascular diseases (CVD), but also the prevention and treatment of chronic kidney disease (CKD). The fact is that patients with DM and CKD represent a special group of patients with a very high risk of CVD and cardiovascular mortality. Such patients require early diagnosis and timely identification of risk factors for the development and progression of CKD for their adequate correction. Arterial hypertension, along with hyperglycemia, is the main risk factor for the development and progression of CKD in patients with diabetes. In this regard, the choice of antihypertensive therapy (AHT) in patients with diabetes is of particular importance. The basis of AHT in diabetes and CKD is the combination of a blocker of the renin-angiotensin-aldosterone system (an angiotensin-converting enzyme inhibitor [ACE inhibitor] or an angiotensin II receptor blocker [ARB]) and a calcium channel blocker (CCB) or a thiazide / thiazide-like diuretic. The task of the performed AHT is to achieve the target level of blood pressure (BP). At the same time, the optimal blood pressure values in patients with diabetes and CKD are blood pressure values in the range of 130-139/70-79 mm Hg. If the target blood pressure is not achieved, it is necessary to intensify antihypertensive therapy by adding a third antihypertensive drug to the therapy: CCB or a diuretic (thiazide / thiazide-like or loop). In case of resistant hypertension, it is necessary to consider the possibility of adding antagonists of mineralocorticoid receptors, other diuretics or alpha-blockers to the conducted AHT. Beta-blockers can be added at any stage of therapy if the patient has exertional angina, a history of myocardial infarction, atrial fibrillation, and chronic heart failure. The need to normalize blood pressure parameters by prescribing combined antihypertensive therapy in patients with diabetes and CKD is explained by a decrease in renal and cardiovascular risks, and, therefore, a decrease in the risk of mortality in this cohort of patients.

Improved Method of Contrast-enhanced Ultrasound examination of the Kidneys in Patients with Type 2 Diabetes Mellitus

Aim of the research. Тo evaluate the diagnostic efficacy of the contrast-enhanced ultrasound examination of kidneys in patients with type 2 diabetes mellitus with a dose of 0.5 ml of contrast agent administered.

Materials and methods. We examined 12 patients with a verified diagnosis of type 2 diabetes. The age of the examined patients was 31–59 years, the mean age was 49 ± 1.3 years. All patients underwent complex diagnostics, including ultrasound examination of the kidneys in B-mode with further renal vessels color Doppler imaging to assess vessels hemodynamics. A contrast-enhanced ultrasound examination of the kidneys was carried out using Sonovue contrast agent at the doses of 2.5 ml (according to the European Good Clinical Practice Recommendations for Contrast-Enhanced Ultrasound) and 0.5 ml (an improved technique of contrast agent intravenous bolus administration).

Results. The improved technique (0.5 ml of contrast agent intravenous bolus administration) in comparison with the European Recommendations technique (2.5 ml of contrast agent intravenous bolus administration) used in patients with type 2 diabetes showed no or minor differences in the qualitative and quantitative indicators of contrast-enhanced ultrasound examination which did not affect the interpretation of the results.

Conclusion. The improved contrast-enhanced ultrasound examination technique using 0.5 ml of a contrast agent showed its possibilities in diagnosing diabetic nephropathy in patients with type 2 diabetes, and also revealed the potential of an economically beneficial distribution of a contrast agent without losing the quality and information content of the study.

[Atherosclerotic Cardiovascular Diseases and Type 2 Diabetes Mellitus - new Developments in the Treatment]

Despite obvious success in the management of patients with type 2 diabetes mellitus, incidence of myocardial infarction, stroke, critical ischemia, and lower extremity amputation remains high. Results of clinical studies of new hypoglycemic drugs have demonstrated their high efficacy in decreasing mortality, incidence of cardiovascular complications, and progression of chronic heart failure. At the same time, prevention of atherothrombotic complications is essential for this patient category. Traditionally, the antiaggregant therapy with acetylsalicylic acid (ASA) is administered to patients with stable atherosclerotic diseases to reduce the risk. Attempts of reducing additionally the risk with ASA combinations with other antiplatelet drugs did not produce an expected result. Theoretical prerequisites suggested that anticoagulant supplements would increase the treatment efficacy in prevention of atherothrombotic complications in patients with cardiovascular diseases. Recently emerged oral anticoagulants can be administered at a considerably lower dose. In the COMPASS study, a combination of rivaroxaban 2.5 mg twice a day and ASA 100 mg/day compared to ASA 100 mg/day significantly reduced the total risk of stroke and cardiovascular death by 24 % and incidence of stroke and cardiovascular death by 42% and 22 %, respectively. Patients with peripheral artery disease showed for the first time improvement of prognosis, decreased number of amputations, major complications of lower extremity disease. Results of the COMPASS study confirmed the validity of influencing simultaneously the platelet and the coagulation components of hemostasis in patients with stable atherosclerotic cardiovascular diseases.

[Development of destructive thyroiditis and diabetes mellitus after three injections of pembrolizumab for skin melanoma]

The exponential rise in the use of immune checkpoint inhibitors (Ipilimumab, Nivolumab, Pembrolizumab, Atezolizumab, Durvalumab, and Avelumab) as the new standard for cancer treatment increase the incidence the immune-related adverse events due to immune activation. Endocrine immune-related adverse events are the third most commonly reported. Thyroid gland is most susceptible to autoimmune dysfunctions from immune checkpoint inhibitors and associated with the use of anti-PD-1 monoclonal antibodies. Hypophysitis develops more often during therapy with anti-CTLA-4 monoclonal antibodies. But such immune-related adverse events as diabetes mellitus, hypoparathyroidism are rare (about 1% of cases).We present a clinical case of the patient with skin melanoma who was prescribed therapy with immune checkpoints inhibitors (Pembrolizumab). Immune-related adverse events developed with damage to the endocrine organs after 3 Pembrolizumab injections. Of greatest interest is the development of two endocrine immune-related adverse events at once: destructive thyroiditis (with a short phase of thyrotoxicosis and subsequent persistent hypothyroidism) and diabetes mellitus. We tried to reflect the chronology of diseases and their features as fully as possible for endocrinologists, oncologists, therapists, family doctors and other medical doctors of related specialties.

[Insulin therapy is a personalized approach to glycemic management in diabetes]

Type 2 diabetes is characterized by chronic hyperglycemia and varying degrees of insulin resistance and insulinopenia. Achieving targeted glycemic control in diabetic patients is important to reduce the risk of late complications, and many patients with type 2 diabetes ultimately require insulin therapy to maintain adequate glycemic control. Timely administration of insulin can prevent the progression of diabetes, reduce the development of complications, and have fewer side effects. Basal insulin is the preferred option in most cases when glycemic control is not achieved. However, there is considerable therapeutic inertia in clinical practice, both with respect to initiation of insulin therapy and titration of the basal insulin dose. The longer duration of action, reduced glucose variability and a lower risk of hypoglycemia seen with the latest generation of basal insulin analogs compared to the previous generation simplify titration and may increase patient compliance.

[Early intensification of glucose-lowering therapy: VERIFY lessons and real clinical practice on the example of the Moscow region diabetes register data]

BACKGROUND

The prevalence of T2DM is steadily increasing not only among the elderly, but also at a young age. T2DM is preceded by a long period of significant metabolic changes with the development of insulin resistance and в-cell dysfunction. To reduce the prevalence of complications, treatment is needed which affects several pathophysiological mechanisms underlying the disease. Monotherapy with metformin at the onset of T2DM is often insufficient. The VERIFY study demonstrated the advantage of early administration of a combination of vildagliptin and metformin in relation to the glycemic durability compared to the sequential intensification of metformin with vildagliptin in patients with type 2 diabetes.

AIMS

To assess the current situation in terms of the incidence of T2DM complications and the structure of the prescribing glucose lowering drugs based on the data from the Diabetes Register (DR) of the Moscow Region. To demonstrate the advantages of early combination therapy in patients with newly diagnosed T2DM using clinical cases.

MATERIALS AND METHODS

The data from the DR of the Moscow region, which is part of the National Diabetes Register of the Russian Federation, were used for the analysis. The data of 6,096 patients with T2DM who died in 2019 were evaluated for building the structure of the causes of death of patients with T2DM. The pattern of glucose-lowering therapy was analyzed based on data of 226,327 patients with T2DM (for 2020), as well as separately of 14,379 patients with newly diagnosed T2DM in 2019. Clinical cases are described based on the data of two patients with T2DM, available in the DR database and outpatient records.

RESULTS

In patients with young onset T2DM (&lt;40 years), the prevalence of severe complications is higher than in the general population of patients with T2DM: blindness is in 5.9 times, end-stage chronic renal failure in 2.9 times, lower limb amputations in 6.4 times more. When prescribing glucose lowering drugs, monotherapy is prevalent, mostly metformin. In double combination, metformin is used in 96.22% of cases. In the structure of glucose lowering drugs, with newly diagnosed T2DM, combination therapy is used less frequently than in patients with T2DM in general. Of the drugs of the IDP-4 group, vildagliptin is most often prescribed - 46.25% (including of a fixed combination with metformin - 12.22%). Clinical cases reflect a rapid clinical outcome: a decrease in HbA1c to the target in 6 months, the absence of hypoglycemia or other side effects, and positive weight dynamics.

CONCLUSIONS

A fairly large propotion of patients with T2DM are on monotherapy with glucouse lowering drugs. Early prescription of the combination of metformin plus vildagliptin provides a longer maintenance of glycemic control without increasing the risk of hypoglycemia and weight gain for patients with newly diagnosed T2DM.

[Semaglutide for the Management of type 2 Diabetes: Clinical Evidence, Cardioprotective Effects, and Guidelines]

Cardiovascular diseases remain a leading cause for unfavorable outcomes, including death, in patients with type 2 diabetes mellitus (DM2). In the recent decade, novel drugs, including glucagon-like peptide-1 receptor agonists (GPP-1-RA) and sodium-glucose cotransporter-2 inhibitors, have convincingly demonstrated their ability to reduce risk of cardiovascular complications in patients with DM2. This review discusses one of GPP-1-RA, semaglutide, with a special focus on the evidence-based data on its use, cardioprotective properties, and algorithms of administration consistent with current clinical recommendations.

Management of patients with comorbidity during novel coronavirus (COVID-19) pandemic. National Consensus Statement 2020

The pandemic of the novel coronavirus infection (COVID-19), caused by SARS‑CoV‑2, has become a challenge to healthcare systems in all countries of the world. Patients with comorbidity are the most vulnerable group with the high risk of adverse outcomes. The problem of managing these patients in context of a pandemic requires a comprehensive approach aimed both at the optimal management in self-isolated patients not visiting medical facilities, and management of comorbidities in patients with COVID-19. The presented consensus covers these two aspects of managing patients with cardiovascular disease, diabetes, chronic obstructive pulmonary disease, gastrointestinal disease, and also pay attention to the multiple organ complications of COVID-19.

[Current trends in the screening for diabetic retinopathy]

The incidence of diabetes in the world is steadily increasing, and so is growing the number of cases of vision loss and blindness resulting from diabetic retinopathy (DR). This pathology is asymptomatic in the initial stages, but only the early treatment can be effective. In this regard, DR screening is an important and actual problem. This article reviews the principles, criteria, and problems of the currently run DR screening programs that are based on digital photography of the fundus. Special attention is paid to the displayed biomarkers and their role in DR screening. Various research methods are described, such as fluorescence angiography, optical coherence tomography, optical coherence tomography agniography, laser scanning ophthalmoscopy, which can be used to visualize pathological changes in the retina associated with DR. These changes were considered as potential screening biomarkers for DR. The review also describes new areas of screening based on telemedicine, artificial intelligence, and mobile photo-registering devices.

[The role of internal limiting membrane peeling in the treatment of diabetic macular edema]

Analysis of the current understanding of the role of internal limiting membrane in the pathogenesis of diabetic macular edema and the feasibility of its surgical removal is based on data from domestic and international literature on pathogenesis, clinical manifestations, outcomes of multicenter studies of treatment and prognosis of this disease. The advantages and disadvantages of both peeling and preservation of the inner limiting membrane are described. The limitations and inconsistencies of data provided by the authors of each theory requires more complete functional studies in the pre- and postoperative periods, increasing the selection of patients, modifying the criteria for inclusion in groups, and microscopic examination of removed membranes. Thus, this issue requires further study due to the ambiguity of the conclusions and the lack of comparative data on the long-term prospects of each of the methods.

The Peculiarity of Process and Treatment of Arterial Hypertension in Patients with Type 2 Diabetes Mellitus

Arterial hypertension (AH) is powerful and modifying factor of developing macrovascular and microvascular complications of diabetes. Patients with AH and diabetes belong to group with high and very high levels risk of developing cardiovascular complications and chronic kidney disease. The combination of type 2 diabetes mellitus and AH dramatically increases the risk of developing terminal stages of microvascular and macrovascular diabetic complications: blindness, end-stage chronic kidney disease, amputation of the lower extremities, myocardial infarction, cerebral stroke, worsens the patients prognosis and quality of life. There is ample evidence that blood pressure control in diabetic patients may be critical for improving long-term prognosis. This observation does not lose its relevance even with the emergence of new antidiabetic drugs with proven cardio- and nephroprotective effects. Modern clinical researchers and meta-analysis show the priority of combined antihypertensive therapy, which increases the efficacy of blood pressure correction and prophylaxis of long-term complications in patients with type 2 diabetes. In this article we want to pay attention to features of AH in patients with diabetes, to bi-directional pathogenic mechanisms, to discuss the new algorithms of the treatment and therapeutic needs of these patients. It is important to accent the understanding of the integrity and unity of pathogenic mechanisms which are needed in correction. Innovative antihyperglycemic therapy demonstrates the ability of blood pressure decrease. The synergy of effects let us successfully realize the strategy of multi-factor control and reduce a risk of micro- and macrovascular complications.

[Specific features of the use of alogliptin in various groups of patients with type 2 diabetes mellitus: additional results of the ENTIRE study]

BACKGROUND

Since the obtaining of data on the effect of Alogliptin towards the lipid profile, body weight and blood pressure (BP) of patients, the additional analysis of the results of the ENTIRE study, completed in the Russian Federation in 2018, was conducted.

AIMS

Assess the dynamics of HbA1c, body weight, fats indices, blood pressure (BP), and characterize the profile of the patient who received the maximum clinical benefit on treatment of Alogliptin therapy in the ENTIRE study.

MATERIALS AND METHODS

A prospective non-interventional observational study that included patients aged 18 years and older with first-onset type 2 diabetes mellitus (T2DM) or patients with T2DM who did not achieve their glycemic targets during the previous therapy.

RESULTS

A decrease in glycated hemoglobin (HbA1c) by more than 0.5% was detected in 73.5% of patients. The most significant absolute decrease of HbA1c was noticed in patients with initially higher values. Younger patients with a shorter duration of T2DM showed the more often compensation of carbohydrate metabolism. The average loss of weight was -2.6&plusmn;4.2 kg. 76.6% of patients showed the loss of weight. The most significant decrease in body weight was noticed in patients with a large initial body mass index and a shorter duration of the disease. 74.7% of patients showed a decrease of the level of low-density lipoproteins (LDL). The most significant absolute decrease in LDL was noticed in patients with initially higher values and more often in younger people with a shorter duration of T2DM. The average decrease in systolic blood pressure (BP) was 5.9&plusmn;0.3 mm Hg; the average decrease in diastolic blood pressure (BP) was 2.7&plusmn;0.2 mm Hg. 59% of patients showed decrease of blood pressure during the group analyzing. The most frequent BP reduction was observed in younger patients with shorter duration of T2DM. At the same time, a more significant absolute decrease in blood pressure was noticed in patients with initially higher indicators, and an increase, on the contrary, was observed in patients with initially lower indicators.

CONCLUSIONS

The intensification of Alogliptin therapy allowed to achieve the compensation of carbohydrate metabolism, moderate decrease of body weight, blood pressure and LDL indices within the majority of patients with T2DM. The most frequent achievement of HbA1c targets was noticed in young patients with a shorter duration of T2DM.