[Changes in weight and diabetes compensation (HbA(1c)) in patients with diabetes mellitus type 2 after adding exenatide (Byetta) to the current treatment in 28 diabetology departments in the Czech Republic - BIBY-I study (observations lasting 3 to 12 months)]

BIBY STUDY OBJECTIVE: To obtain experience with exenatide treatment (Byetta) in patients with diabetes mellitus type 2 in a common clinical practice ofdiabetology departments. TYPE OF OBSERVATION: Observational study conducted by a randomly selected group of outpatient medical practitioners from 28 diabetology departments in the Czech Republic. OBSERVED AND ASSESSED POPULATION: 465 patients underwent at least three months of Byetta treatment; 347 persons (74.6% ofthe research population) stayed forthe extended observation of 6-12 months. Apart from the basic identification data (year of birth, sex, age when diabetes mellitus manifested, height, maximum patient weight before diabetes and when diabetes mellitus manifested), the following information was recorded in three-month intervals: weight, waistline, glycated haemoglobin (HbA(1c)), and diabetes mellitus treatment The population included 50.3% women and 49.7% men, and the average age at the time of diabetes manifestation was 48 (20-73 years). The period between the diabetes manifestation and the start of exenatide treatment was 8.3 years on average.

RESULTS

The average maximum BMI value before the detection of diabetes was 39.05 (+/- 6.73); at the time of the diabetes manifestation 37.88 (+/- 6.40); and at the start of Byetta treatment 39.01 (+/- 6.22). The BMI after three, six, and 12 months of treatment was as follows: 37.86 (+/- 6.12), 37.18 (+/- 6.0), and 36.60 (+/- 6.21); it decreased by > or = 0.5 in 83.3% patients who were under observation for 12 months. HbA(1c) value decreased in the first three months from 7.39% (+/- 1.57) to 6.41% (+/- 1.34), p < 0.0001. In the period of three-six months, the value decreased to 6.22% (+/- 1.34), and after 12 months, HbA(1c) was at 6.04 (+/- 1.20). An improvement in HbA(1c) value of 0.5-2.0% occurred after the first year in 49% of our research population. The waistline was measured on a regular basis in only 267 patients (58.9%). The average initial value of 120.7 cm was reduced within three months of the treatment to 118.3 cm, and within six and 12 months to 117.3 and 112.6 cm respectively.

CONCLUSION

Adding Byetta to the currently applied treatment of obese patients with diabetes mellitus type 2 led, in 66.8% of the population, to a statistically significant reduction in HbA(1c) levels in the first three-six months of the treatment; after 12 months of treatment, 25% of the population was still showing an improvement in HbA(1c) of > 2.0%. Of observed patients, 74.4% significantly reduced their BMI (by > 0.5) during the first three months; 39.6% of patients reduced their BMI in the period of three-six months.

The efficacy of self-monitoring of blood glucose in the management of patients with type 2 diabetes treated with a gliclazide modified release-based regimen. A multicentre, randomized, parallel-group, 6-month evaluation (DINAMIC 1 study)

AIM

To determine if therapeutic management programmes for type 2 diabetes that include self-monitoring of blood glucose (SMBG) result in greater reductions in glycated haemoglobin (HbA1c) compared with programmes without SMBG in non-insulin requiring patients.

METHODS

Multicentre, randomized, parallel-group trial. A total of 610 patients were randomized to SMBG or non-SMBG groups. Patients in both groups received the same oral antidiabetic therapy using a gliclazide modified release (MR)-based regimen for 27 weeks. The primary efficacy end-point was the difference between groups in HbA1c at the end of observation.

RESULTS

A total of 610 patients were randomized: 311 to the SMBG group and 299 to the non-SMBG group. HbA1c decreased from 8.12 to 6.95% in the SMBG group and from 8.12 to 7.20% in the non-SMBG group; between-group difference was 0.25% (95% CI: 0.06, 1.03; p = 0.0097). Symptoms suggestive of mild to moderate hypoglycaemia was the most commonly reported adverse event, reported by 27 (8.7%) and 21 (7.0%) patients in the SMBG and non-SMBG groups, respectively; the incidence of symptomatic hypoglycaemia was lower in the SMBG group.

CONCLUSION

In patients with type 2 diabetes, the application of SMBG as an adjunct to oral antidiabetic agent therapy results in further reductions in HbA1c.

[Exenatid and its position as antidiabetic drug in the treatment of type 2 diabetes mellitus]

'Incretin effect' refers to increased insulin response to oral glucose as compared to i.v. glucose response. Incretin mimetics are a new class of antidiabetic drugs lowering hyperglycaemia. Incretin mimetics mimic the natural human hormones called 'incretins' with blood glucose regulating action. Exenatide is a synthetic analogue GLP-1 which is resistant to enzymatic degradation by DPP IV. Subcutaneously administered exenatide stimulates insulin secretion, suppresses glucagon secretion, slows down stomach evacuation and reduces the weight. Its administration is safe and the most frequent side effect is mild nausea.

[Incretin strategy in the treatment of type 2 diabetes mellitus--the DPP-IV inhibitor sitagliptin]

Sitagliptin, distributed under the brand name of Januvia, has been the first and so far the only dipeptidyl peptidase IV (DPP-IV) inhibitor introduced in clinical practice. The results of published clinical studies clearly demonstrate its effectiveness and safety as an oral antidiabetic. Apart from increasing the insulin level, Sitagliptin reduces the level ofglucagon. The principal advantages of Sitagliptin from the clinical point of view are: a) the ability to reduce both fasting and non-fasting glycaemia and improve the HbA(1c) values, b) the fact that it does not provoke weight increase, c) the fact that the risk of hypoglycaemia is significantly lower as compared with sulfonylurea derivatives, d) good tolerability.

[Incretin strategy in the treatment of type 2 diabetes mellitus--DPPIV]

Administration ofGLP-1 analogue resistant to DPPIV or therapeutic inhibition ofthe enzymes, allowing for an increase in the levels of GLP-1, are the very new approaches to the treatment of type 2 diabetes mellitus. Incretin therapy has an immense potential of improving unsatisfactory compensation in diabetic patients thus reducing the risk of manifestation of all arterial complications. Low fasting circulating levels of GLP-1 (and also GIP) grow rapidly after eating and are subsequently degraded to inactive forms by dipeptidyl peptidases IV (DPPIV). DPPIV are enzymes widely present in the body which proteolytically degrade GLP-1 and GIP (as well as other active substances). The preventing of their inactivation effect by administering DPPIV inhibitors allows for increasing the GLP-1 levels, which are reduced in type 2 diabetic patients, and subsequently improves glucose homeostasis in such patients. DPPIV inhibitors represent the principal new class of PAD, and their metabolic profile offers a number of unique clinical advantages for the treatment of patients with type 2 diabetes mellitus.

[Rosiglitazon in treatment of Type II diabetes mellitus--experience of diabetologists in the Czech Republic. Part I: compensation of diabetes, sugar metabolism]

Thiazolidindione derivates (glitazones) make a very promising group of peroral antidiabetic drugs. They are represented by rosiglitazon which is available on our market to type II diabetics. As far as sugar metabolism is concerned, rosiglitazon can reduce glycaemia and insulin level both when fasting and postprandially.

GOAL

The goal of the authors' work was to gain their own experience with rosiglitazon treatment in type II diabetics in the Czech Republic.

SAMPLE

The monitored sample consisted of 388 patients with insufficiently compensated type II diabetes when treated by sulphonylurea compounds or metformine.

METHODS

95 diabetologists from diabetology medical offices started a 6-month-long treatment with rosiglitazon (Avandia) dose of 4 mg a day as stated in European recommendations. In order to assess changes in sugar metabolism (compensation of diabetes) glycaemia and C peptide were monitored when fasting and postpradially and HbA1c was monitored in 2-month-long intervals.

RESULTS

Weight, waist-hip ratio (WHR) and C-peptide levels remained unchanged. Statistically significant (p < 0.0001) was a HbA1c decrease over 6 month from 9.61% to 8.48%. Fasting glycaemia decreased by 2.49 and postprandial glycaemia by 2.71 mmol/l. No significant side effects were identified.

CONCLUSION

Rosiglitazon administration combined with administration of sulphonylurea compounds or metformine significantly improved compensation of diabetes compared to initial therapy.

[Gastrointestinal complications in diabetes mellitus]

Impaired function of the gastrointestinal tract related to diabetes mellitus (DM) results from diabetic autonomous neuropathy, impaired sensory innervation and a direct effect of chronic hyperglycaemia. Another possible connection between DM and the gastrointestinal tract can be infrequent autoimmune diseases associated with type I DM (celiac disease, autoimmune gastropathy, autoimmune chronic pancreatitis). Functional or organic changes resulting from diabetes can be seen in every organ of the gastrointestinal tract. Some of the diabetic gastrointestinal tract difficulties affect almost 60% of patients with long lasting diabetes. On one side, impaired function of individual organs in diabetics can significantly influence level of diabetes compensation and vice versa. On the other side, unsatisfactory diabetes compensation can result in manifestation of digestive problems. The most frequent and the most serious clinical complication is diabetic gastroparesis (DG). The highest incidence of impaired evacuation and motility of the stomach (and the small intestine) is described in diabetics with long lasting unsatisfactory diabetes compensation, microangiopathic complications, and diabetic neuropathy (55-75% in type I diabetes and 15-20% in type II diabetes). Symptoms accompanying impaired motility and emptying of the stomach (feeling of early fullness, eructation, nausea, vomiting and abdominal pains) can be only temporary or can be missing in some patients. Hyperglycaemia accompanied by slowing down evacuation of the stomach is different in patients with an empty stomach--glycaemia over 7.8 mmol/l, and postprandially--antral motility decreases after blood glucose levels get over 9.7 mmol/l. Treatment options for symptomatic diabetic gastroparesis are limited. Achieving normoglycaemia usually improves diabetic gastroparesis but in up to 80% of cases simultaneous administration of prokinetics is necessary.

[Diabetes mellitus in chronic pancreatitis]

Diabetes mellitus (DM) in chronic pancreatitis (ChP) is considered a unique clinical and metabolic unit. Compared to type I DM it has many different properties: glycemic lability, more frequent hypoglycaemic episodes, and minimum incidence of ketoacidosis. The need of insulin administration to achieve satisfying diabetes mellitus compensation is significantly lower and response of peripheral tissues to endogenous and exogenous insulin significantly higher compared to type I diabetics. These clinical differences result from decreased but always preserved insulin secretion, decreased glucagon production, impaired external pancreatic secretion, and also excessive alcohol use or insufficient or irregular food intake of the patients. Secondary DM in ChP is accompanied by chronic, microangiopathic and neuropathic complications analogous to other DM types. Nonpharmacological treatment measurements of the first choice are elimination of alcohol, sufficient and adequate nutrition, and simultaneous treatment of impaired exocrinal secretion. A pharmacology treatment is insulin therapy! It is a substitution treatment for insulin deficiency. Insulin doses must be chosen very carefully because of the risk of hypoglycaemia. The most frequent cause of secondary diabetes mellitus in patients with pancreatic diseases in Europe is chronic alcoholic pancreatitis and in tropical countries and India non-alcoholic tropical calcific pancreatitis (TCP).

Anti-GAD-positive patients with type 1 diabetes mellitus have higher prevalence of autoimmune thyroiditis than anti-GAD-negative patients with type 1 and type 2 diabetes mellitus

The aim of our study was to evaluate antibodies against thyroglobulin (anti-TG) and thyroid peroxidase (anti-TPO) - markers of autoimmune thyroiditis - in several groups of adult patients with type 1 and type 2 diabetes mellitus (DM). We were particularly interested whether the presence of thyroid antibodies is related to the positivity of glutamic acid decarboxylase antibodies (anti-GAD). We found elevated anti-GAD in 46 % (97/210) patients with type 1 DM. All patients with type 2 diabetes were anti-GAD-negative. At least one thyroid antibody (anti-TG and/or anti-TPO) was found in 30 % (62/210) patients with type 1 DM and 27 % (22/83) type 2 diabetes patients. The patients with type 1 DM were further grouped according to their anti-GAD status. The anti-GAD-positive patients had a higher prevalence of anti-TG antibodies than the anti-GAD-negative patients (25 % vs. 12 %, p=0.03) as well as anti-TPO antibodies (32 % vs. 12 %, p<0.001). At least one thyroid antibody was detected in 39 % (38/97) of anti-GAD-positive but only in 21 % (24/113) of anti-GAD-negative patients with type 1 DM (p=0.006). No significant difference in the frequency of thyroid antibodies was found between anti-GAD-negative patients with type 1 and type 2 DM (21 % vs. 27 %, p=0.4). The groups with or without thyroid antibodies in both type 1 and type 2 diabetic patients did not differ in actual age, the age at diabetes onset, duration of diabetes, body mass index or HbA1c level. Patients with elevated thyroid antibodies had significantly higher levels of TSH than those without thyroid antibodies (1.86 vs. 3.22 mIU/l, p=0.04 in type 1 DM; 2.06 vs. 4.89 mIU/l, p=0.003 in type 2 DM). We conclude that there is a higher frequency of thyroid-specific antibodies in anti-GAD-positive adult patients with type 1 DM than in anti-GAD-negative patients or in patients with type 2 DM. Patients with or without thyroid antibodies do not differ in age, DM onset and duration, BMI or HbA1c. Thyroid antibodies-positive patients have higher levels of thyroid stimulating hormone (TSH).

[Postprandial hyperglycemia]

Chronic hyperglycaemia, confirmed with HbA1c levels, is a leading cause of diabetic complications. Recent studies point to a significant effect of postprandial glycaemia which results from an impaired ability of early secretion of insulin in type II diabetes. Postprandial hyperglycaemia is a frequent phenomenon in people with diabetes with satisfactory control of diabetes based on checks of HbA1c levels. Many authors demonstrate statistically more significant correlations between postprandial hyperglycaemia and HbA1c levels, compared to correlation of fasting glycaemia. Monitoring of postprandial glycaemia is a significant means for improving co-operation with a patient and provides a physician with a possibility of choice between an appropriate type of peroral antidiabetic or insulin.

[Women and diabetes]

The objective of the work was to assess, based on the results of studies conducted abroad and the author's own results from the Prague register of diabetic patients, whether there exist differences in the epidemiology, clinical course of diabetes mellitus (DM) and its complications between female and male diabetics. As far as type 1 DM is concerned there are significant differences in the clinical course of diabetes, i.e. deteriorated compensation of DM in girls and women in conjunction with menstruation and the menopause. As compared with men, young women have a higher mortality on account of diabetic nephropathy, and at any age they have as higher incidence of hypertension. In DM2 they have also a high incidence of hypertension and risk of compensation of DM during menstruation and later during the menopause. A significantly less frequent complication in women is ischaemia of the lower extremities. From the epidemiological aspect a higher prevalence of DM2 was proved in women after the age of 65 years.

[Diabetes mellitus associated with chronic pancreatitis]

Diabetes mellitus (DM) as part of chronic pancreatitis (ChP) belongs into the group of secondary DM with typical insulin deficiency. The prevalence and incidence of DM in ChP depends on the selected diagnostic criteria, geographical conditions and duration and grade of pancreatitis. Based on our findings during a 15-year investigation of impaired glucose tolerance and insulin secretion in patients with ChP the authors submit some partial (published and unpublished) results. The largest investigated group were 122 patients with ChP diagnosed according to the morphological appearance during ERCP. The authors detected a mutual close relationship between the extent of morphological damage of the efferent system of the pancreas on one hand and impaired glucose metabolism and endogenous insulin secretion on the other hand. It was revealed that values of C-peptide are in patients with ChP and normal glucose tolerance significantly lower as compared with the healthy population, and in patients with ChP and DM they are significantly lower as compared with non-obese type 2 diabetics. With the persistence of ChP the C-peptide levels decline gradually and the incidence of diabetes increases but even when DM persists in ChP C-peptide does not reach zero values as in type 1 DM. For detection of diabetes in ChP assessment of the fasting blood sugar level does not suffice and an oral glucose tolerance test must be made.

[C-peptide as the decisive factor for classification of type 1 diabetes mellitus and type 2 diabetes mellitus]

OBJECTIVE

The main objective was to seek, based on defined groups of diabetics, C-peptide levels on fasting and after stimulation which would help to differentiate diabetes mellitus type 1 from diabetes mellitus type 2 in patients with manifestation of diabetes in adult age. GROUPS: Group A comprised 65 non-obese diabetics type 2 with failure of PAD treatment. Group B included 304 newly manifested diabetics type 1 and 2 aged 31-65 years. Group C was formed by 424 patients with diabetes mellitus type 1 and type 2 with different duration of diabetes.

RESULTS

Group A: mean C-peptide levels on fasting 0.32 and after stimulation with a standard breakfast 0.59 pmol/ml suggest absolute insulin deficiency in type 2 diabetics with failure of PAD treatment. Group B: 29.2% diabetics type 1 had already during manifestation of diabetes C-peptide levels on fasting < 0.43 pmol/ml and 47.9% C-peptide of < 0.6 after a meal. There were 1.9 and 4.9% subjects among type 2 diabetics with such low C-peptide levels. After a six-year follow up the mean C-peptide levels on fasting declined in type 1 diabetics from 0.49 to 0.16 pmol/ml and in patients originally with type 2 diabetes reclassified to type 1 the levels dropped from 0.56 to 0.26 pmol/ml. Group C served as the basic group for statistically (linear regression method) detected discrimination values of C-peptide differentiating diabetes mellitus type 1 and diabetes mellitus type 2--the liminal value being 0.59 pmol/ml on fasting and 1.0 pmol/ml after a meal.

CONCLUSION

In clinical practice it is not possible to assess reliably slowly manifesting diabetes type 1 (LADA by age, BMI and compensation of diabetes. Positivity of antiGAD antibodies does not rule out diabetes mellitus type 1. In unequivocal cases the decisive factor is therefore the C-peptide level on fasting and after a meal.

[Detection programme for diabetes mellitus type 2 in the Czech Republic--initial results]

Detection programmes and screening activities with the objective to reveal risk groups with asymptomatic diabetes mellitus or impaired glucose tolerance are an important tool for reducing the morbidity and mortality of type 2 diabetics from cardiovascular diseases. The detection programme in the Czech Republic was focused on the risk group of the population above 45 years of age. During the screening in which 120 general practitioners and 20 diabetolgists participated a total of 30672 subjects were examined and the results were evaluated statistically in 26577 subjects (86.52%). Diabetes mellitus was detected in 2.43% of the examined subjects and impaired glucose tolerance in 1.28 % of the investigated group. The most frequently present risk factor in newly detected diabetics was hypertension and obesity. As compared with non-diabetics, whose ratio in the group above 60 years was 47.9%, 56.7% were newly detected diabetics in this age group.

[Prevalence of dyslipidaemia, hypertension and vascular complications in newly diagnosed diabetics (prospective study: part 2)]

In a 10-year prospective study of a group of 314 newly manifested diabetics (1988-1991) aged 20-65 years the authors follow up the development of diabetic complications and therapeutic methods used in diabetes. 85 patients were classified on detection of diabetes as diabetes mellitus (DM) type 1, 228 as DM type 2. At the age under 30 years there were 10 subjects (group M), the remainder (304) formed group A. In this second part of the initial results the authors provide information on biochemical changes, prevalence of hypertension and vascular complications already during manifestation of DM. Hypercholesterolaemia was detected in 29% of the group,triacylglycerylaemia was recorded in 31%. The mean cholesterol levels were in the subgroup of patients above 50 years of age significantly higher in women (6.51 mmol/l) as compared with men of similar age (5.66 mmol/l), while mean triacylglycerol levels did not differ in men and women above 50 years of age. Pathologically elevated levels of microalbuminuria were recorded in 13.7%. Hypertension was found in 42.7% diabetics type 2 in group A. 8.4% of this group were examined for ischaemic heart disease. 4.8% of the patients had an acute myocardial infarction in the case-history and 1.3% a cerebrovascular attack. Ophthalmological examination revealed in 8 type 2 diabetics (3.5%) diabetic retinopathy.

CONCLUSION

In the investigated group of newly manifested diabetics aged under 65 years the authors detected a high prevalence of hypertension, hyperlipoproteinaemia and macroangiopathic complications, in particular in obese type 2 diabetics.

Haemostasis, cytoadhesive molecules (sE-selectin and sICAM-1) and inflammatory markers in non-insulin dependent diabetes mellitus (NIDDM)

Non-insulin dependent diabetes mellitus (NIDDM) is connected with a higher incidence of macrovascular atherosclerotic disorders. The aim of the study was to detect any difference in levels of "cardiovascular risk factors"--fibrinogen, PAI-1 and inflammation response (documented by an increase of protein of acute phase orosomucoid) and of soluble cytoadhesive molecule sE-selectin and sICAM-1 (as markers of endothelial dysfunction) in blood plasma of 118 patients with NIDDM in comparison to the levels in blood plasma of 59 healthy persons as a control group. We observed higher levels of fibrinogen (fibrinogen level was 3.44 +/- 1.02 g/l in NIDDM pts versus 2.44 +/- 0.55 g/l in control group, p < 0.01) and PAI-1 Ag concentration was 159.7 +/- 110.3 ng/ml in NIDDM pts versus 51.43 +/- 24.64 ng/ml in control group, p < 0.01) together with an increase of acute phase protein orosomucoid as a "inflammatory response marker" (orosomucoid concentration was 0.85 +/- 0.23 g/l in NIDDM pts versus 0.54 +/- 0.18 g/l in control group, p < 0.01) in patients with NIDDM. The increase of these "cardiovascular risk factors" levels will be probably induced by higher activity of inflammatory cytokines IL-1 beta and/or TNF alpha in NIDDM patients, because both are inducers of orosomucoid fibrinogen and PAI-1 synthesis. This hypothesis is also supported by observation of higher levels of soluble cytoadhesive molecules sE-selectin (sE-selectin level was 64.25 +/- 26.8 ng/ml in NIDDM pts versus 46.64 +/- 29.57 ng/ml in control group, p < 0.01) and sICAM-1 (sICAM-1 level was 307.71 +/- 86.2 ng/ml in NIDDM pts versus 255.6 +/- 58.0 ng/ml in control group, p < 0.01) in patients with NIDDM. Both cytoadhesive molecules are produced by endothelial cells which are influenced by IL-1 beta and/or TNF alpha. According to these findings we suppose that an "inflammation" plays an important role in the evolution of atherosclerotic process at NIDDM together with the known influence of glucose and lipid metabolism pathology.

The effect of glycosaminoglycan sulodexide on oxidative stress and fibrinolysis in diabetes mellitus

Glycosaminoglycan sulodexide may influence morphology and functional properties of the basement membranes in microvessels. The aim of this study was to evaluate the effect of sulodexide administration on albuminuria and on different biochemical variables indicating endothelial dysfunction, oxidative stress and fibrinolysis in diabetic patients. Twenty diabetic patients of both types with micro- or macroalbuminuria were selected for sulodexide treatment. Daily dose of 600 U (60 mg) was injected intramuscularly five days a week. Fifteen doses were applied during 3 weeks. The patients were examined before and after treatment as well as 6 months later. No changes of diabetes control were observed during the study and after 6 months of wash-out period. Significant decrease of albuminuria (p < 0.001) was observed during the sulodexide administration with the following increase to pretreated values during the wash-out period. A decrease of serum N-acetyl-beta-glucosaminidase (NAG) activity (p < 0.03) at the end of treatment as compared to pretreated values was found in the whole group of diabetic patients. Slight reduction of oxidative stress expressed by malondialdehyde and superoxide dismutase was apparent after treatment but no simultaneous change in fibrinolysis was observed. Sulodexide may have some protective effects influencing functional properties of the basement membrane as manifested by lowered albuminuria. In addition, it may slightly decrease oxidative stress in diabetic patients and it could stabilize endothelial cells.

[The level of diabetic compensation and endogenous secretion of insulin in newly diagnosed diabetics. Prospective study: Part 1]

In a prospective study of newly detected diabetic patients in 1989-1991 the authors focused their attention on the evaluation of blood sugar levels and HbA1c during manifestation of DM and the amount of insulin secretion in relation to diabetes type 1 and 2 in adult patients. Part 1 of the paper reveals great differences in the fasting blood sugar level during manifestation of DM (26% of the group had a blood sugar level lower than 8.5 mmol/l and 14% above 15 mmol/l) even after 1-4 months treatment (3.8-17.2 mmol/l). Similar differences were found in HbA1c values (4.5-12.9%). High C-peptide levels revealed an incorrectly assessed diagnosis of type 1 diabetes in 16.7% diabetics and low C-peptide values on fasting and postporandial values were at variance with the diagnosis of type 2 diabetes in 6% of the group.

[Plasma leptin levels in patients with kidney diseases of various etiologies]

BACKGROUND

Leptin is a new hormone influencing food intake, energy expenditure and body weight. This protein is produced by adipocytes, exerts its effects on brain, endocrine pancreas and other organs by activating transmembrane receptors and is cleared from plasma mainly by the kidneys. The aim of our study was to compare plasma concentrations of leptin in our nephrological out-patients and controls.

METHODS AND RESULTS

We examined 36 diabetic patients with various stages of nephropathy, 12 males with nephrotic syndrome due to membranous nephropathy, 15 dialysis patients and 11 controls. Leptin was assessed in plasma by ELISA. There was a significant difference between plasma levels of leptin in males and females (7.7 +/- 11.4 vs 17.6 +/- 17.3, p < 0.001) and in dialysis and non-dialysis patients (19.6 +/- 16.5 vs 10.7 +/- 14.5, p < 0.05). There was also a difference between dialysed and non-dialysed men (15.1 +/- 16.2 vs 5.9 +/- 9.2, p < 0.05). We found no difference between men with and without nephrotic syndrome and between BMI or age. There was a positive correlation of leptin with diabetic and non-diabetic women. There was positive correlation of P-leptin with serum creatinine in non-dialysed women (r = 0.68, p < 0.001) and a negative correlation with S-albumin in nephrotic men (r = -0.65, p < 0.05).

CONCLUSIONS

Women have higher plasma leptin concentrations than men and dialysis patients have higher concentrations than non-dialysed patients. Apart from the positive correlation with S-creatinine in non-dialysed women. There was positive correlation with S-albumin in nephrotic men there were no correlations with renal function, BMI, age, S-cholesterol, S-triglycerides and S-albumin.

[Relation between plasma levels of IGF-I, leptin and TNF-alpha in diabetics]

BACKGROUND

TNF-alpha, IGF-I and leptin are agents which influence insulin resistance, they play probably a part in the pathogenesis of diabetic nephropathy and influence mutually their production. The objective of the submitted investigation was to assess whether there exist relations between their concentrations in the plasma of diabetic patients.

METHODS AND RESULTS

The authors examined 37 patients aged 18-67 years from a diabetic clinic, 10 with normal albuminuria and normal renal function, 12 with microalbuminuria and 15 with macroalbuminuria and/or reduced renal function. TNF alpha, IGF-I and leptin were assessed in plasma, using commercial kits, by the ELISA method. IgF-I in plasma correlated inversely with glycated haemoglobin (r = -0.20, p < 0.05). In women a correlation was found between IGF-I and TNF-alpha concentrations (r = 0.65, p < 0.01). No other mutual correlations were found between concentrations of the investigated substances and between cytokine concentrations and serum creatinine, glycated haemoglobin, the blood glucose level and body mass index.

CONCLUSIONS

IGF-I plasma levels correlate inversely with glycated haemoglobin and in women with the TNF-alpha level. No other correlations were found between IGF-I. TNF-alpha and leptin plasma levels. The levels do not correlate with age, renal function and compensation of diabetes.

[The short-acting insulin analog Lispro (Humalog) in the treatment of diabetes--comparison of preprandial and postprandial administration and comparison with treatment using Humulin R]

The results of a clinical trial comprising 162 type 1 and 2 diabetics who took for 12 weeks Humalog in cartridges revealed that administration of this insulin before or 20 minutes after a meal does not affect the blood sugar level in a major way. None of the patients developed after Humalog administration local or general allergic manifestations. Hypoglycaemic episodes grade I and II were not more frequent during treatment with human insulins. The mean compensation of diabetes (HbA1c) remained unchanged. 80% of the diabetics are statistically significantly satisfied with Humalog treatment as compared with Humulinem R administration.

[Type 1 diabetes mellitus in the aged]

Diabetes mellitus type I was till recently considered a disease affecting children and young adults. Research in the past several years provided evidence that this type of diabetes is found in all age groups and that the majority develops after the age of 35 years. Diagnostic possibilities of type I diabetes were markedly extended due to the introduction of radioimmunoassay of antibodies against glutamate decarboxylase. This examination has a 82% sensitivity and 100% specificity in diabetes. Diabetes mellitus in advanced age is manifested much less dramatically than in child age. It is found in non-obese subjects and usually its clinical manifestation is gradual. At first the patients are as a rule treated by diet. After several months usually sulphonylurea derivatives are started and only later insulin. If the diagnosis of diabetes mellitus type I is beyond doubt due to autoimmune disease, assessed preferably by antiGAD antibodies, immediate substitution therúpy with insulin is fully indicated. The latter can protect the residual function of B cells of the islets of Langerhans of the pancreas and contribute thus to the prevention of microvascular complications of diabetes mellitus.

[Pitfalls in treatment with oral antidiabetic agents]

In the treatment of type 2 diabetes (NIDDM) we possess three groups of oral hypoglycaemic drugs: sulfonyl urea derivatives, biguanides (metformin) and alpha-glucosidase (acarbose) inhibitors. Oral treatment of diabetes has a favourable impact on the patients metabolic deviations but it involves also certain dangers and pitfalls. The side-effects of oral antidiabetics can be reduced to a minimum by respecting consequentially contraindications of administration of different preparations, knowledge of their mechanism of action and individual selection of a suitable antidiabetic for every patient.

[The effect of sulodexide, a glycosaminoglycan, on albuminuria in diabetic patients]

The authors administered to type 1 diabetics (n = 15) or type 2 diabetics (n = 20) with microalbuminuria or macroalbuminuria for a period of 15 days i.m. doses of sulodexide (Vessel Due F), 600 i.u. (i.e. 60 mg). The evaluation of the whole group revealed a statistically significant reduction of the original mean value of albuminuria (509 +/- 127 ug/min) already during the first week of sulodexide administration (382 +/- 105). A further decrease was recorded after the second and third week of treatment (326 +/- 89, 319 +/- 85 ug/min). While in diabetics with microalbuminuria < 100 micrograms/min the mean levels of excreted albumin were not affected, in diabetics with macroalbuminuria 200 ug/min a significant reduction of albuminuria persisted (p < 0.001) achieved during sulodexide treatment persisted for three weeks after completed treatment. No differences were found between the results of type 1 and type 2 diabetics.

CONCLUSION

Seventy-seven per cent type 1 and type 2 diabetics responded to parenteral sulodexide administration for 15 days by a statistically significant reduction of albumin.

Glycosaminoglycan sulodexide decreases albuminuria in diabetic patients

Albuminuria is a dominant biochemical feature of developing diabetic nephropathy. A disturbed metabolism of heparan sulphate characterized by an increased loss of anionic charges in the basement membrane has been considered as one of the main factors causing an increased albumin output into urine. All therapeutic approaches inducing a reduction of the albumin excretion rate (AER) have a protective effect on renal function. The effect of glycosaminoglycan sulodexide on albuminuria was studied in a group of 53 diabetic patients (26 Type 1 and 27 Type 2) with micro and macroalbuminuria. Sulodexide (Vessel Due F) was administered intramuscularly in one daily dose (600 lipasemic units) for 3 weeks followed by a 6 week wash-out period. A significant decrease of AER was found in a total cohort of patients following just 1 week of sulodexide treatment (mean 162 micrograms/min, range 10-2708 micrograms/min vs mean 248 micrograms/min, range 20-3160 micrograms/min, P < 0.001). This effect lasted 3-6 weeks after drug withdrawal. Similar results were obtained if Type 1 and Type 2 diabetic patients were evaluated separately but a delay of the AER reduction was observed in the latter group. In all patients the mean AER was reduced to 60-65% of the initial values. A greater effect of sulodexide on albuminuria was observed in patients with AER above 200 micrograms/min than in those with microalbuminuria (a reduction to 47 vs 65% of the initial output). Sulodexide did not significantly reduce albuminuria in 28% of diabetic patients ('non-responders'). In conclusion, glycosaminoglycan sulodexide may reduce AER in patients with micro or macroalbuminuria and it could slow down development of diabetic nephropathy.

[Clinical experience with changing type I diabetics from animal to human insulin administered by the NovoPen 3 applicator]

The objective of the study was to assess the safety of changing ambulatory patients from animal insulin produced in the Czech Republic administered by classical insulin syringes to human insulins of the Danish firm Novo Nordisk, using a NovoPen 3 applicator. Furthermore antibody levels against hog, bovine and human insulin were assessed. Forty-seven patients with diabetes type I stabilized on an intensified insulin regime were after a four-day preparatory period divided at random into two groups. Patients in group A (n = 22) were after randomization changed to human insulin, patients in group B (n = 25) eight weeks later. From the onset of treatment with human insulins up to the end of the study the mean daily dose of insulin in both groups increased (in group A by 1.51 IU/day, in group 1.35 IU/day). This is not statistically or clinically significant. During the same period a statistically significant decline of the mean value of the daily 8-point glycaemic profile was recorded (in group A by 0.85 mmol/l, in group B by 0.51 mmol/l). Glycosylated haemoglobin declined also significantly in the course of the study (in group A by 1.64%, p = 0.00004, in group B by 1.02%, p = 0.0077). The greatest drop occurred during the preparatory period. Despite the increased daily insulin dose and improved compensation the number of hypoglycaemic events declined significantly in both groups (in group A by 0.78%, p = 0.0102, in group B by 0.74%, p = 0.0134). Hypoglycaemic coma was not recorded in either group. A significant drop of insulin antibodies was found in both group after the onset of treatment with human insulins. From the results of the study ensues that metabolically compensated type I diabetics with a mean daily insulin dose of 0.6 IU/kg body weight can be changed without any complications, in the ambulatory department, to human insulins with the same dosage. Concurrently a gradual decline of antibodies can be expected.

[The effect of metformin on lactate levels in type II diabetes]

The authors investigated the lactic acid levels in the blood of 57 type 2 diabetics treated with metformin. The mean lactate level before onset of metformin treatment was in the whole group 2.01 +/- 0.36 mmol/l and after 6 months of metformin administration it remained unchanged 2.00 +/- 0.42 mmol/l. Compensation of diabetes evaluated by HbAlc improved significantly (9.74 +/- 1.62% before treatment, and 8.52 +/- 1.36% after 6 months of treatment). The mean cholesterol levels declined significantly and the mean triacylglycerol levels were after two months of metformin administration significantly lower. Metformin treatment did not lead to an increase of the patients body weight.

[Non-insulin-dependent diabetes mellitus--strategies and problems in genetic research]

Non-insulin dependent diabetes mellitus (NIDDM) is at present one of the most serious and widespread diseases with a mass incidence and its treatment is very costly. In the genesis and development of the disease genetic factors participate along with environmental factors. Genetic research of NIDDM is difficult, as ensues from the very essence of this heterogeneous disease. Research concentrates on the identification of specific genetic determinants which influence the predisposition of the individual to glucose intolerance which, if revealed, would make more effective prevention and treatment possible. Intensive research is focused on different candidate genes. Although some "minority" genes were identified, the primary diabetogen was not revealed so far and partial positive results must be confirmed on a larger population sample. The article reviews the contemporary state of genetic research of the disease.

[Personal experience with the Mono type of insulin--clinical study]

A multicentric study was conducted in March to September 1995 to test the effectiveness and tolerance of a new insulin series. A total of 281 diabetics above 15 years of age were followed up, 144 men and 137 women, mean age 63 years with a duration of diabetes from 0.5 to 51 years, without serious organ complications and capable to recognise symptoms of hypoglycaemia. During the investigation a total of five examinations of the investigated parameters were made. The authors revealed a statistically insignificant decline of body weight, blood sugar level on fasting and HbA1c and a significant drop of the postprandial blood sugar level. The BP reading and urinary findings were unaltered. The authors found a significant drop of the daily insulin dose in MONO N, D and ID and an insignificant rise of the daily dose in MONO SD. The investigation provided evidence of a satisfactory effectiveness and tolerance of the new insulin series. In MONO N, D and ID there was also a decline in the total consumption.

[Levels of tissue-type plasminogen activator (T-PA), its inhibitor (PAI-1) and fibrinogen in the blood of patients with type 1 and 2 diabetes mellitus]

BACKGROUND

Fibrinogen (Fgb), the tissue activator of plasminogen (t-PA) and its inhibitor (PAI-1) are described as so-called cardiovascular risk factors. The objective of the present investigation was to assess the occurrence of the mentioned risk factors (Fbg, t-PA and PAI-1) in diabetes mellitus (DM) type 1 and 2, compare them with findings in a healthy control group and the two types of diabetes mutually.

METHODS AND RESULTS

Fifty patients with type 1 DM were examined (mean BMI 23.8), 59 patients with type 2 DM (mean BMI 28) and 33 healthy subjects as controls (mean BMI 24.6). Both groups of diabetics were compensated. To assess the t-PA and PAI-1 concentration the ELISA test was used, Fbg was assessed by Clauss' method. The euglobulin fibrinolysis time (ECLT) was also examined. In both groups of patients with DM higher concentration of t-PA were found (DM type 7.06 +/- 2.4 ng/ml, p < 0.05, DM type 2 15.15 +/- 6.07 ng/mg, control 4.67 +/- 2.87 ng/ml, p < 0.05). In patients with DM type 1 a higher concentration of t-PA was found in patients with retinopathy (8.2 +/- 1.7 ng/ml than in patients with DM type 1 without retinopathy (6.9 +/- 1.3 ng/ml), p < 0.05). The PA-1 concentration was, as compared with controls, raised only in type 2 diabetics (DM type 2 124.57 +/- 47.22 ng/ml, control 88.57 +/- 15.7 ng/ml p < 0.05). Between the two groups also a difference in the PAI-1 level was found (DM type 179.25 +/- 17.95 ng/ml, vs. DM type 2, p < 0.05). With these findings corresponded the ECLT activation in DM type 1 (203.4 +/- 76.8 min. vs. ECLT in the control group 276.08 +/- 84.87 min., p < 0.05) and conversely a reduction of the euglobulin fibrinolysis in type 2 DM (448 +/- 117 min.), as compared with the controls (p < 0.05), as well as compared with DM type 1 (p < 0.05). The fibrinogen level was also elevated only in DM type 2 (3.619 +/- 0.69 g/l) as compared with the control group (2.42 +/- 0.42 g/l, p < 0.05) as well as compared with DM type 1 (2.53 +/- 0.47 g/l, p < 0.05). No difference was found in the fibrinogen level between DM type 1 and the control group.

CONCLUSIONS

In both groups of patients with diabetes mellitus type 1 and 2 among the mentioned cardiovascular risk factors only a raised t-PA concentration was recorded. Concurrent elevation of PAI-1 and fibrinogen was found only in diabetes mellitus type 2.

[Levels of lactic acid in type II diabetics treated with buformin]

The objective of the work was to assess the blood lactate levels in type 2 diabetics selected at random, treated for prolonged periods with buformin. 77% of the investigated group of diabetics (N = 70) had elevated blood lactate levels and 16% of them had hyperlactataemia (more than 5.0 mmol/l). In 33% patients with an originally elevated lactataemia after 12 weeks of discontinued buformin treatment the lactic acid blood levels reached normal values. The lactate levels declined significantly (by more than 25% of the original value) after 6 weeks without buformin treatment in another 45% of the diabetic patients. In 18% of the investigated patients, who had high lactate levels even after discontinuation of treatment, in two-thirds neither impaired function of the kidneys and liver nor cardiac disease or alcoholism were detected.

[The Prague Diabetes Registry. 3. Retinopathies, nephropathies and neuropathies in type 1 diabetics. The Prague Diabetes Collective]

In the Prague register of all adult diabetics by April 1, 1992 data on 1443 patients above 18 years with type 1 DM were recorded. In 42.2% of diabetics diabetic retinopathy was observed which is manifested most frequently after 11 to 15 years' persistence of diabetes. Proteinuria, the first sign of diabetic nephropathy, was found in 13.8% of the group, 5.4% of the diabetics are in the stage of renal insufficiency. Nephropathy is 3 to 4 times more frequent in diabetics with retinopathy. Peripheral neuropathy is found in 32.8% type 1 diabetics.

[The Prague Diabetes Registry--computer utilization. 2. Body mass index, family history, manifestation of diabetes mellitus]

Eighty percent of all diabetic patients in Prague, incl. those with IGT, are overweight. There are 4.6 times as many obese female diabetics, as compared with normal weight type 2 diabetics. Among type 2 male diabetics there are 1.9 times more obese ones. A familial incidence of diabetes is reported by 42% type 1 diabetics and 36% type 2 diabetics. In 64.7% of type 2 diabetics diabetes was detected accidentally. In the group of type 1 diabetics in 92.1% diabetes was detected from clinical manifestations incl. coma.

[Follow-up of newly diagnosed patients with diabetes in the Prague population. II. Changes in the group of new diabetics after a 2-year follow-up]

From the total number of 1551 new diabetics and patients with PGT 85 subjects died in the course of two years. Treatment was changed 118 times, failure of PAD treatment was recorded in 11 type 2 diabetics. Three patients originally classified as type 1 were later included in type 2. In three diabetics (of 14) who had sings of diabetic retinopathy already during manifestation of DM marked deterioration of the finding on the fundus occurred. The incidence of macroangiopathic complications did not change.

[Follow-up of newly diagnosed patients with diabetes in the Prague population. I. Incidence of diabetes and disorders of glucose tolerance, methods of detection, complications]

The authors followed up the incidence of new cases of diabetes in nine Prague diabetological clinics, the way of manifestation of diabetes and its detection, age dependence, seasonal character and incidence of complications. The incidence of type 2 diabetes was 269, of type 1 2.3 and impaired glucose tolerance 27 per 100,000 population. In 76% diabetes was detected accidentally, most frequently by the health community doctor or factory medical officer; 65% of the diabetes were older than 60 years. 51% suffered from hypertension and in 0.9% of type 2 diabetics retinopathy was found.

[The effect of Sinecal fiber on compensation in type 2 diabetics]

The authors investigated in 28 type 2 diabetics the effect of addition of 21 g Sinecal fibre to the normal diet on the glucose and lipid metabolism. The value of C,peptide was significantly influenced after breakfast and a single dose of Sinecal. The other investigated parameters (blood sugar on fasting and after a meal, glycosuria, glycosylated proteins, C-peptide on fasting and after a meal, triacylglycerol and cholesterol) were not influenced by a single nor by long-term intake of Sinecal. Further development of fibre preparations with better tolerance and a greater effect on the glucose metabolism is desirable.

N-acetyl-beta-glucosaminidase and albuminuria in normal and diabetic pregnancies

Fourteen diabetic women without signs of nephropathy were examined during pregnancy. Serum fructosamine concentration indicating short-term metabolic control of diabetes was normalized at the beginning of the second trimester and was within the normal limits till the delivery. A gradual increase of N-acetyl-beta-glucosaminidase activity in serum and urine has been found during pregnancy in diabetic and healthy women. No significant differences of N-acetyl-beta-glucosaminidase activities were observed between the above groups. A successive increase of albuminuria during pregnancy was present in diabetic and healthy women with about 10-times higher values at delivery. A significant positive correlation was observed between albuminuria and urinary NAG activity in both groups of pregnant women (r = 0.77). We did not find any deterioration in N-acetyl-beta-glucosaminidase activities and albuminuria in seven diabetic women one year after delivery.

[Fiber in the diabetic diet]

An increased dietary fibre intake can improve in diabetic patients the compensation of diabetes. The effect of fibre depends on its composition, mode of administration, daily intake and the carbohydrate content of the diet. The reduction of the blood sugar level depends also on the patient's body weight and the degree of compensation of diabetes.

Comparison of N-acetyl-beta-glucosaminidase and albuminuria with clinical finding of microangiopathy in type I diabetes mellitus

N-acetyl-beta-Glucosaminidase activity in serum and urine and microalbuminuria were measured in 70 type-I diabetics and compared with glycated serum protein as well as with the finding of diabetic retinopathy. A significantly increased N-acetyl-beta-glucosaminidase activity in serum correlated positively with glycated protein but not with the development of retinopathy. Urinary N-acetyl-beta-glucosaminidase activity and albuminuria were significantly increased in diabetics with (p less than 0.001) or without (p less than 0.01) retinopathy as compared to healthy controls. A significant positive correlation was observed between urinary N-acetyl-beta-glucosaminidase activity and albuminuria (r = 0.73, p less than 0.01) as well as between blood pressure and albuminuria (r = 0.51, p less than 0.05).