Advances in cystic fibrosis-related diabetes: Current status and future directions

AIMS

The aim of this review is to give an update of the recent advances in the pathophysiology, prognosis, diagnosis and treatments of cystic fibrosis-related diabetes (CFRD).

METHODS

The literature survey focuses on original and review articles dealing with CFRD between 2006 and 2023, and in particular with: pathophysiology, risk and predictive factors, screening, chronic complications of CFRD, management and the effects of CFTR channel modulator therapies on glucose homeostasis, using PubMed®.

RESULTS

The rising prevalence of CFRD is due to prolonged life survival among patients with cystic fibrosis (CF). Advances in the understanding of the pathophysiology highlight the singularity of CFRD. Adherence to diagnostic guidelines remains challenging. Besides the classical OGTT, alternative diagnostic tests are being considered: HbA1c measurement, continuous glucose monitoring (CGM), intermediate measurements of alternative glucose tolerance stages through OGTT and homeostatic model assessment (HOMA). Early treatment of (pre)diabetes in CF patients is mandatory. The advent of CFTR channel modulator therapies have created a paradigm shift in the management of CF: they seem to improve glucose homeostasis, but the mechanism remains unclear.

CONCLUSION

CFRD management is an ongoing concern. Optimal care has reduced the negative impact of CFRD on lung function, nutrition, and survival. Increasing prevalence of CFRD and prolonged lifespan lead to more microvascular complications. New screening tools (Hba1c, CGM, HOMA) show potential for better classification of patients. The effect of CFTR modulators on glucose metabolism warrants further research.

1-h post-load plasma glucose for detecting early stages of prediabetes

Prediabetes is a very prevalent condition associated with an increased risk of developing diabetes and/or other chronic complications, in particular cardiovascular disorders. Early detection is therefore mandatory since therapeutic interventions may limit the development of these complications. Diagnosis of prediabetes is currently based on glycemic criteria (fasting plasma glucose (PG), and/or glycemia at 120 min during a 75 g oral glucose tolerance test (OGTT) and/or glycated hemoglobin (HbA1c). Accumulating longitudinal evidence suggests that a 1-hour PG ≥155 mg/dl (8.6 mmol/l) during the OGTT is an earlier marker of prediabetes than fasting PG, 2-h post-load PG, or HbA1c. There is substantial evidence demonstrating that the 1-h post-load PG is a more sensitive predictor of type 2 diabetes, cardiovascular disease, microangiopathy and mortality compared with conventional glucose criteria. The aim of this review is to highlight the paramount importance of detecting prediabetes early in its pathophysiological course. Accordingly, as recommended by an international panel in a recent petition, 1-h post-load PG could replace current criteria for diagnosing early stages of "prediabetes" before prediabetes evolves as conventionally defined.

Current status of insulin degludec in type 1 and type 2 diabetes based on randomized and observational trials

Insulin degludec is a new ultra-long-action basal insulin. Using treat-to-target protocols, controlled trials have shown comparable HbA_1c reductions with insulin degludec and comparators in both type 1 and type 2 diabetes. Most studies identify, however, better control of fasting plasma glucose with insulin degludec vs. either insulin glargine U100 or detemir, and all have consistently demonstrated clinically relevant decreases in (nocturnal) hypoglycaemic episodes. These characteristics have provided added therapeutic value for insulin degludec in clinical practice. Thus, the aim of this review is to discuss, within the context of randomized and observational studies, the clinical effects of insulin degludec use in type 1 and type 2 diabetes.

Impact of flash glucose monitoring on glycaemic control and quality of life in patients with type 1 diabetes: A 18-month follow-up in real life

We conducted a prospective observational study to evaluate the medium-term impact of the flash glucose monitoring system (FGM) in a type 1 diabetic population. We included 248 patients, switched from conventional blood glucose monitoring (BGM) to FGM. We evaluated glycaemic control at 2-4 (T1) and 5-11 (T2) months after initiation and at the last available visit (T3, 18 ± 4 months). We asked patients to fill in, at T0 and T2, two questionnaires based on the Diabetes Treatment Satisfaction Questionnaire; and on the Hypoglycaemia Fear Survey. Glycaemic control improved, from 8.1 ± 1.3% at T0 to 7.8 ± 1.2% at T1 (p < 0.001) and remained unchanged after. Average number of controls increased from 3.2 ± 1.2 BGM to 7.7 ± 3.9 at T1 (p < 0.001). We observed a modest decrease in daily insulin doses. We evidenced an increase in mild hypoglycaemic events, especially in well-controlled subjects, but no increase of severe events. Satisfaction score improved from 30.5 ± 7.7 points to 38.3 ± 5.1 points (p = 0.018), was correlated with the reduction in and was higher in less controlled patients at inclusion. "Behaviour" score regarding hypoglycaemias decrease from 5.7 ± 4.1 to 4.4 ± 3.6 points (p < 0.001). In conclusion, this 18-months study trial indicates that using the FGM technology in patients with T1D may improve glycaemic control, in real-life conditions, especially in less controlled patients. FGM was associated with an increase of patients' satisfaction regarding treatment. Hypoglycaemic events, however, were not reduced in frequency. Therefore, the need for an educational team and a structure program in the management of this new technology remains mandatory.

Long-term effects of GLP-1 receptor agonists in type 2 diabetic patients: A retrospective real-life study in 131 patients

AIM

We evaluate retrospectively long-term effects of GLP-1 receptor agonists in type 2 diabetic patients treated between 2008 and 2016.

METHODS

131 patients treated by GLP-1 receptor agonists (GLP-1RAs) were included. The objective was to evaluate the evolution of glycated hemoglobin (HbA_1c) during a period up to 4 years. The secondary objectives consisted of analysing the long-term effects of treatment on body mass index (BMI), blood pressure and lipids; reporting the proportion of patients who reached HbA_1c objectives; estimating the time before treatment failure and determining predictive factors of failure. We also compared twice-daily exenatide to once-daily liraglutide on the major parameters.

RESULTS

HbA_1c improved significantly, mostly during the first year of treatment (-1.2%), and this effect was maintained after 4 years (-1.4% vs. baseline). At 1 year, 26% and 47% of subjects achieved HbA_1c levels <7.0% and 7.5%, respectively. Treatment failure was observed in 51% of patients after a mean duration of GLP-1RA treatment of 50 months. Half of patients had failed after 42 months. Baseline HbA_1c greater than 9.0% and male gender were predictive factors of treatment failure. BMI also decreased: -0.9 kg/m² the first year, -1.9 kg/m² after 4 years. No significant difference was found between patients treated with exenatide and liragutide over time.

CONCLUSIONS

The beneficial effects of GLP-1RAs on HbA_1c reached a plateau after the first year of treatment and are maintained at 4 years only in one third of patients. Failure occurred predominantly in men with a baseline HbA_1c greater than 9%.

Improvement of psoriasis during glucagon-like peptide-1 analogue therapy in type 2 diabetes is associated with decreasing dermal γδ T-cell number: a prospective case-series study

BACKGROUND

A few case reports suggest that incretin-based therapies could improve psoriasis in patients with type 2 diabetes, the mechanism(s) of which remain unclear.

OBJECTIVES

To determine the effects after 16-20 weeks of treatment with a glucagon-like peptide (GLP)-1 analogue on clinical severity and histopathological aspects of psoriasis in patients with type 2 diabetes, and to examine the presence of γδ T cells and the expression of interleukin (IL)-17 in psoriasis before and after treatment.

METHODS

Seven patients with type 2 diabetes and psoriasis were followed. Psoriasis Area and Severity Index (PASI) was measured at baseline (T0) and after 7 ± 1 (T1) and 18 ± 2 (T2) weeks' treatment with exenatide/liraglutide. The histopathological pattern of psoriasis, and flow cytometry and immunological data (γδ T-cell percentage and IL-17 expression) were obtained from psoriatic and control sites.

RESULTS

The mean PASI decreased from 12·0 ± 5·9 to 9·2 ± 6·4 (P = 0·04). Histological analysis showed a reduction in epidermal thickness after treatment. The dermal γδ T-cell percentage was higher in psoriatic lesions than in control specimens (P = 0·03), as was IL-17 expression (P = 0·018). A reduction of γδ T cells from 6·7 ± 4·5% to 2·7 ± 3·8% (P = 0·05) was demonstrated in the six patients with improved/unchanged PASI. A correlation between PASI and γδ T-cell percentage evolution during therapy (T2-T0) was noted (r = 0·894, P = 0·007). IL-17 was reduced in the four patients with the highest PASI reductions.

CONCLUSIONS

The administration of a GLP-1 analogue improved clinical psoriasis severity in patients with type 2 diabetes. This favourable outcome was associated with a decrease of dermal γδ T-cell number and IL-17 expression. Further studies are needed to establish long-term efficacy in (diabetic) patients with psoriasis.

Diabetes and cancer: a 2013 synopsis

Diabetes, in particular type 2 diabetes, and cancer are two diseases that appear to be associated. Numerous epidemiological studies indicate indeed that diabetes increases the incidence of several tumors. Chronic hyperglycemia and/or insulin resistance with compensatory hyperinsulinemia could account for the association. On the other hand, the interpretation of the link between diabetes and cancer could be influenced by therapeutical interferences. Considering all these data together, cancer should be considered as a "new potential complication" of diabetes and integrated in the follow-up of diabetic subjects.

Predictive factors associated with primary failure to exenatide and non goal attainment in patients with type 2 diabetes

OBJECTIVE

We prospectively analysed HbA1c changes after 12 months of exenatide therapy and determined which baseline clinical and/or biological factors predict response.

RESEARCH DESIGN AND METHODS

Open-label cohort of 41 subjects with type 2 diabetes (56% male) poorly-controlled on maximally-tolerated oral dual therapy. Age (mean ± 1SD) was 60 ± 10 years, and known diabetes duration 11 ± 8 years (mean ± 1SD). Biometric changes in weight, body mass index (BMI), waist circumference (WC), HOMA modeling (Homeostasis Model Assessment) of β-cell function (HOMA-B) and insulin sensitivity (HOMA-S) as well as in HbA1c were assessed at baseline, and after 6 or 12 months exenatide therapy. Patients were divided into three groups: goal-achievers (GA, n = 15), defined as achieving HbA1c ≤ 7.5% (58 mmol/mol) at 12 months; nongoal- achievers (NGA, n = 16; HbA1c > 7.5% (58 mmol/mol) at 12 months); and primary failure to exenatide therapy (early lack of efficacy; PF, n = 9). Non-responders represented the combined NGA plus PF patients.

RESULTS

The addition of exenatide to maximally-tolerated oral dual therapy led to target HbA1c attainment (≤ 7.5% (58 mmol/mol) at 1 year) in 37% of cases, associated with reduction in weight, BMI and waist circumference. GA were older than non-responders (64 ± 9 vs. 57 ± 10 years, p = 0.032). Diabetes duration was comparable. Baseline HbA1c was significantly lower in GA (8.3 ± 0.9 vs. 9.5 ± 0.9% in non-responders; p < 0.001). Baseline HOMA-B and HOMA-S were comparable, while HOMA product (BxS) was higher in GA (17 ± 6 vs. 14 ± 6% in non- responders, p = 0.04). At 12 months, HbA1c reached 7.0 ± 0.6% in GA vs. 9.0 ± 1.3% in non-responders. Weight, BMI and waist circumference decreased in both groups. In GA and non-responders, there was a marked relationship between baseline HbA1c and absolute decrement in HbA1c over the study period. Logistic regression demonstrated that baseline HbA1c was the strongest predictor for target attainment following exenatide therapy (p < 0.001), with age to a lesser degree (p = 0.089).

CONCLUSION

Baseline HbA1c is a major predictor of response to exenatide treatment, defined as target HbA1c (≤ 7.5%, 58 mmol/mol) attainment. The lower the baseline HbA1c, the greater the likelihood of reaching the target HbA1c at 12 months, even though patients with higher baseline HbA1c benefited from the largest absolute reduction in HbA1c levels.

Glycemic control and weight changes in patients with type 2 diabetes intensified to three insulin regimens after therapeutic failure to exenatide

The aim of this multicentre and observational study was to evaluate in a real life setting glycated haemoglobin A1(c), (HbA1c) as well as body weight outcomes in patients with type 2 diabetes in whom insulin was initiated after unsatisfactory response to exenatide, combined with maximal dosages of metformin and a sulfonylurea. We included 81 patients. In 56 patients, data were available after 6-8 and in 42 after 9-12 month's follow-up. Age and duration of diabetes were 57 +/- 11 and 11 +/- 6 years, respectively. Body mass index (BMI) was 32.4 +/- 6.9 kg/m2. Insulin was initiated with a basal insulin injection (22%), premixed insulin injections (48%) or a basal prandial scheme (30%). In the 6-8 and 9-12 month's cohorts, HbA(1c) decreased from 9.3 +/- 1.4 to 8.2 +/- 1.2% and from 9.3 +/- 1.3 to 8 +/- 1.1%, respectively (p < 0.0001). However, only 9 and 12% of subjects reached a target HbA(1c) of less than 7.0%, respectively. About half of the patients had HbA(1c) levels equal or higher than 8.0%. Insulin doses were progressively increased during the follow-up period. Insulin treatment was associated with a significant body weight increase (5-7 kg) (p < 0.0001). In conclusion, a high proportion of patients remained above the HbA(1c) targets after 6-12 month's treatment, despite a progressive increase in insulin dosages. Insulin treatment was associated with a marked weight gain.

[Knowledge of the general population about hypertension and diabetes mellitus in South Kivu, Democratic Republic of Congo]

BACKGROUND

In the Democratic Republic of Congo (DRC), a country in a post-conflict period, high priority cannot be given to non-communicable diseases other than to emergencies. This certainly involves inadequacy in raising awareness for prevention of these diseases.

OBJECTIVE

To evaluate the level of knowledge of the Congolese general population on hypertension and diabetes mellitus.

METHODS

Responses to a questionnaire from 3% of the general population aged 15 and older in the city of Bukavu and two rural areas: Hombo and Walungu (South Kivu, eastern DRC), recruited after stratification by ward in the city of Bukavu and a group of prone villages were expected. The questions focused on identification, testing, causes, complications and treatment of hypertension and diabetes mellitus.

RESULTS

Of the 7770 respondents, screening for hypertension and diabetes mellitus affected only 14.9% and 7.3% of subjects respectively. Knowledge of these two conditions was generally low in the general population, although better in the subgroups of patients and those with higher socioeconomic level (P<0.05). Use of the medias was also associated with better knowledge (P<0.05).

CONCLUSIONS

This study shows that knowledge about hypertension and diabetes mellitus and their testing in South Kivu is low. It is imperative that the Congolese government includes non-communicable diseases in its priorities of the millennium. Similarly, the WHO should actively contribute to screening for them in low-income countries.

Improvement of psoriasis during exenatide treatment in a patient with diabetes

CONTEXT AND AIM

Psoriasis is an immune-mediated skin disorder frequently associated with obesity and type 2 diabetes (T2D). This report is of a clinically significant improvement in psoriasis lesions in a patient with T2D during treatment with a GLP-1 receptor agonist (exenatide).

OBSERVATION

A 61-year-old male patient (BMI: 25.5 kg/m(2)) with T2D treated with metformin and sulphonylureas had also complained, since 1980, of extensive psoriasis that required multiple steroid-based treatments [Psoriasis Area and Sensitivity Index (PASI) score: 11]. In September 2008, his diabetes treatment was intensified with exenatide (Byetta(®)) to improve poor glycaemic control. The patient, as expected, lost weight and reduced HbA(1c) levels from 65 mmol/mol to 56 mmol/mol. However, after just 1 month of treatment with exenatide, the patient also reported a dramatic improvement in psoriatic plaques that was confirmed at the 1-year follow-up (PASI: estimated at 3-4). Withdrawal of exenatide was associated with weight gain, deterioration of glycaemic control and deterioration of psoriasis (PASI:>10). After reinstating exenatide treatment, the patient again reported a prompt improvement in psoriasis (PASI: 3.1).

CONCLUSION

There was a major and rapid improvement in psoriasis in our patient with T2D following treatment with exenatide. A possible mechanism might be through direct modulation of the immune system by GLP-1 receptor agonists.

Hemiballism revealing type 2 diabetes in an elderly: clinical and neuroimaging findings and etiopathogenic links

Hemiballism-hemichorea is characterized by non-patterned and involuntary unilateral movements. It is a rare clinical sign unmasking type 2 diabetes mellitus, mostly in elderly patients. We report the clinical and neuroimaging findings of a patient admitted for hemiballism-hemichorea of the right upper limb, leading to the diagnosis of type 2 diabetes. We hereby describe clinical and neuroimaging findings. After initiation of treatment and restoration of euglycaemia, we note a complete remission of the initial neurological symptoms.

Insulin detemir in routine clinical practice: a 26-week follow-up in type 1 diabetic patients from the Belgian PREDICTIVE Cohort

AIM

PREDICTIVE (Predictable Results and Experience in Diabetes Through Intensification and Control to Target: an International Variability Evaluation) is a multi-national study designed to evaluate the safety and efficacy of insulin detemir (Levemir) in "real world" medical practice. The aim of the study is to report the PREDICTIVE results of the Belgian type 1 diabetic cohort.

METHODS

Two hundred and thirty-two patients treated with a basal-bolus insulin scheme were considered for analysis. Seventy-eight percent of those patients were previously treated with insulin glargine as a basal insulin, while 22% received NPH, before switching to Levemir.

RESULTS

Mean age and duration of diabetes were 45 +/- 15 and 18 +/- 13 years, respectively (means +/- SD). HbA1C was 8.3 +/- 1.2%. We observed (at weeks 12 and 26 after baseline) a significant reduction in all hypoglycaemic events including major hypoglycaemias after switching to detemir (p < 0.0007). There was no change in HbA1C. Fasting blood glucose decreased from 170 +/- 49 to 158 +/- 45 mg/dl at week 26 (p < 0.009), while fasting blood glucose variability was reduced from 69 +/- 35 to 57 +/- 30 mg/dl at week 26 (p < 0.0001). Total insulin doses increased during the trial from 0.74 +/- 0.28 to 0.82 +/- 0.14 U/kg/day (p < 0.0001). No weight gain was observed during the study. Patient's satisfaction increased significantly (from 6.3 +/- 1.5 to 7.2 +/- 1.6 at week 26, p < 0.0007).

CONCLUSION

This report from the Belgian cohort of PREDICTIVE extends the safety and efficacy data of insulin detemir in type 1 diabetic patients treated with a basal-bolus insulin scheme.

Coronary in-stent restenosis in diabetic patients after implantation of sirolimus or paclitaxel drug-eluting coronary stents

It is now emerging that, in patients who are at high risk for cardiovascular complications and, in particular, those with diabetes, the occurrence of late restenosis and thrombosis after treatment of coronary artery disease with drug-eluting stents is higher than earlier reports have suggested. Therefore, the aim of this study was to assess the prevalence of in-stent restenosis in a cohort of consecutive patients with diabetes treated for coronary disease in 2005 with drug-eluting stents [either sirolimus (58%) or paclitaxel (42%)]. The duration of follow-up was 9.0+/-3.4 months [mean+/-1 standard deviation (S.D.)]. A total of 154 patients (type 2 diabetes: 91%) were included in the study (age: 66+/-10 years), and the total number of implanted stents was 184. Two subjects died from cardiac causes, while myocardial infarction and (un)stable angina were observed in 3 (2%) and 39 (25%) patients, respectively. In-stent restenosis, appraised by angiography, was observed in 17 individuals (11%) after a mean follow-up of five months. Mean HbA(1c) in patients with restenosis was 7.6+/-1.8%. There was no difference in the rate of restenosis with sirolimus-(n=8) compared with paclitaxel-(n=9) eluting stents. Male gender, oral therapy for diabetes and stent diameter were predictors of in-stent restenosis. In conclusion, even over a medium-term period, in-stent restenosis remains a potential risk for coronary diabetic patients treated with drug-eluting devices.

Relationship between osteopontin and vascular calcifications in type 2 diabetic patients

AIM

To measure circulating osteopontin levels in a cohort of type 2 diabetic patients and to determine whether osteopontin could be associated with lower limb arteries calcifications, either intimal (atherosclerotic) or medial (mediacalcinosis).

METHODS

Osteopontin was measured in 60 patients with type 2 diabetes who were subdivided in three groups: group 1 (n=19) was characterized by the absence of peripheral vascular calcifications on plain soft tissue radiograms; group 2 (n=18) presented intimal calcifications without mediacalcinosis; in group 3 (n=23), mediacalcinosis was the dominant pattern.

RESULTS

Osteopontin levels were significantly higher in patients with mediacalcinosis (558 ng/ml [140-2289], median [range]) than in subjects without vascular calcifications (337 [134-841], P = 0.024) or in individuals with intimal lesions (340 [140-1154], P = 0.05). No correlation was observed between osteopontin, glycaemic control or HOMA test results. Osteopontin was correlated with creatinine clearance (P = 0.037).

CONCLUSION

In type 2 diabetic patients, circulating levels of osteopontin were higher in the presence of medial calcifications than in subjects without vascular lesions or in individuals with calcifications limited to the intimal

Bone density and markers of bone remodeling in type 1 male diabetic patients

AIMS

To assess the prevalence and severity of bone disease in type 1 diabetic patients and to determine serum markers of bone remodeling as well as their relationship with bone mineral density (BMD).

METHODS

BMD [by dual energy x-ray absorptiometry (DXA)] and serum markers of bone remodeling [osteocalcin, c-terminal telopeptide of type I collagen (CTX)], leptin and osteoprotegerin (OPG) were measured in 42 adult males with type 1 diabetes. Twenty-four non-diabetic subjects served as controls.

RESULTS

In 40% of the patients, osteopenia at the lumbar spine (L1-L4) and/or at the left hip was found, and 7% met criteria for osteoporosis. L1-L4 BMD z-score was correlated with age (r=0.365, P=0.018) and a similar trend was observed at left hip. L1-L4 BMD z-score was negatively correlated with CTX and osteocalcin (r=-0.343, P=0.028; r=-0.376, P=0.024, respectively). A significant correlation was evidenced between BMD z-score at both lumbar spine and left hip and leptin values (r=0.343, P=0.03; r=0.395, P=0.012, respectively) but after adjustment for weight this correlation was no longer significant. Osteocalcin, CTX and leptin concentrations were comparable between patients and controls, while OPG concentrations tend to be higher in diabetic subjects (P=0.08). CTX was negatively correlated with age (r=-0.390, P=0.012) and positively correlated with osteocalcin (r=0.696, P<0.001). OPG was positively correlated with age (r=0.507, P=0.001).

CONCLUSION

Our results suggest that in diabetic subjects osteopenia is a relatively frequent complication but bone loss is attenuated with age progression. Whether this is also mediated by OPG and/or leptin remains to be confirmed.

The role of alexithymia factors in glucose control of persons with type 1 diabetes: a pilot study

OBJECTIVE

To clarify the respective contribution of demographic characteristics, health conditions and three psychological variables (depression, anxiety, alexithymia) for glycaemic control measured by glycated hemoglobin (HbA1c).

MATERIALS AND METHODS

Sixty-four persons diagnosed with type 1 diabetes completed psychological measures and demographic information at admission (T1) to the hospital and in a follow-up (+8 weeks) (T2). Additional information about their health conditions was also considered.

RESULTS

At T1, the alexithymia factor "difficulties describing feelings" (DDF) predicted HbA1c over and above the predictive power of demographic information, health conditions, anxiety, and depression. Additionally, higher decrease in HbA1c from T1 to T2 was predicted by higher scores on the alexithymia factor DDF at admission over and above the other predictors.

CONCLUSION

DDF is an important predictor of glucose control. Scoring higher on this factor is related to poorer glycaemic control at admission. Additionally, people with higher scores on this factor seem to benefit highly from the treatment administered at the hospital.

Variability in erythrocyte fructosamine 3-kinase activity in humans correlates with polymorphisms in the FN3K gene and impacts on haemoglobin glycation at specific sites

BACKGROUND

Part of the fructosamines that are bound to intracellular proteins are repaired by fructosamine 3-kinase (FN3K). Because subject-to-subject variations in erythrocyte FN3K activity could affect the level of glycated haemoglobin independently of differences in blood glucose level, we explored if such variability existed, if it was genetically determined by the FN3K locus on 17q25 and if the FN3K activity correlated inversely with the level of glycated haemoglobin.

RESULTS

The mean erythrocyte FN3K activity did not differ between normoglycaemic subjects (n = 26) and type 1 diabetic patients (n = 31), but there was a wide interindividual variability in both groups (from about 1 to 4 mU/g haemoglobin). This variability was stable with time and associated (P < 0.0001) with two single nucleotide polymorphisms in the promoter region and exon 6 of the FN3K gene. There was no significant correlation between FN3K activity and the levels of HbA1c, total glycated haemoglobin (GHb) and haemoglobin fructoselysine residues, either in the normoglycaemic or diabetic group. However, detailed analysis of the glycation level at various sites in haemoglobin indicated that the glycation level of Lys-B-144 was about twice as high in normoglycaemic subjects with the lowest FN3K activities as compared to those with the highest FN3K activities.

CONCLUSION

Interindividual variability of FN3K activity is substantial and impacts on the glycation level at specific sites of haemoglobin, but does not detectably affect the level of HbA1c or GHb. As FN3K opposes one of the chemical effects of hyperglycaemia, it would be of interest to test whether hypoactivity of this enzyme favours the development of diabetic complications.

Metabolic (glycaemic, lipidic) and blood pressure control in 101 type 2 diabetic patients on first admission to diabetes centres

The aim of our study was to analyse the quality of metabolic and blood pressure control in a cohort of 101 patients with type 2 diabetes (54 males; 47 females), previously followed in primary care settings and admitted for the first time to the diabetes centres of Saint-Luc (n=66) or Mont-Godinne (n=35) University Hospitals. Age and (known) duration of diabetes were 64 +/-12 and 6 +/- 7 years (mean +/- SD), respectively. Body mass index was 31 +/- 7 kg/m2. Systolic and diastolic blood pressures were 140 +/-12 and 81 +/-11 mmHg. Homeostasis model assessment (HOMA) showed insulin sensitivity at 63 +/-32% and P-cell function at 49 +/- 44% (n=34). Forty-seven percent of patients received either diet alone or combined with an oral antidiabetic monotherapy. Seven-teen percent of all patients were on insulin monotherapy or associated with oral drugs. HbAlc was 9.0 +/- 2.3%, with 22% of patients within HbAlc targets of < or = 7%. Only a subset of patients reached international targets of care in terms of blood pressure and lipidic profile, despite antihypertensive and lipid-lowering agents in 62% and 36% of patients, respectively. Forty-five percent of individuals had at least one diabetes-related long-term complication. In view of this unsatisfactory control, our results suggest that "anti-diabetic" treatment should be intensified earlier in primary care settings.

The MTHFR CT polymorphism confers a high risk for stroke in both homozygous and heterozygous T allele carriers with Type 2 diabetes

OBJECTIVE

Individuals with Type 2 diabetes are at increased risk of stroke. Plasma homocysteine (tHcy) is an independent risk factor for cardiovascular (CV) disease. The methylene-tetrahydrofolate reductase (MTHFR) gene polymorphism (thermolabile variant C(677)T) is associated with CV risk, partly as a result of increased Hcy, especially in homozygous subjects.

AIM

To relate the occurrence of the MTHFR polymorphism with stroke prevalence by examining allelic frequency and genotype distribution in 165 subjects with Type 2 diabetes studied for the presence of thermolabile C(677)T MTHFR mutation.

RESULTS

Mean age was 67.7 years, and tHcy 18.2 micromol/l. T allele frequency was 38.5%. MTHFR genotypes were: normal (CC) 40%; heterozygous (CT) 43%; homozygous (TT) 17%. Serum levels of folic acid and B12 vitamin were within normal limits. Stroke prevalence was 14%. Sixty-four per cent of stroke-free subjects had the normal C allele vs. 46% in stroke subjects. The frequencies of genotypes (CC-CT-TT) were (%): 44-41-15 in stroke-free vs. 17-57-26 in stroke patients. Coronary (CAD) and peripheral artery disease (PAD) were common in all groups, with no differences according to genotypes. Stroke prevalence was markedly higher in genotypes CT and TT (18 and 21%) compared with CC (6%). Mean tHcy levels were higher in TT subjects.

CONCLUSION

The allelic frequency of C(677)T MTHFR mutation in Type 2 diabetes subjects with stroke is markedly different from that of subjects without stroke. Genotypic characteristics suggest that C(677)T MTHFR mutation confers a higher risk for stroke to both homozygous and heterozygous T allele carriers that cannot be ascribed solely to raised tHcy and/or lower folate status in CT subjects, nor to phenotypic expression of conventional risk factors for stroke. The impact of the MTHFR polymorphism on stroke may result from T allele-linked deleterious effects, or C allele-linked protection. Confirmatory studies are warranted, as this cohort was not randomly selected, and a type 1 error cannot be ruled out.

Pancreas Transplantation for Treatment of Generalized Allergy to Human Insulin in Type 1 Diabetes

We report the case of a 29-year-old man with a 14-year history of type 1 diabetes, normal renal function, and mild diabetic retinopathy. The patient progressively developed a generalized allergic reaction to two insulin excipients--protamine and metacresol--with systemic manifestations of tremor, tachycardia, vertigo, shortness of breath, and short episodes of unconsciousness causing him to be out of work. In June 2003, he received a vascularized cadaveric pancreas transplant using induction with polyclonal antibodies along with tacrolimus and sirolimus but without steroids. A hyperglycemic episode following corticosteroid therapy for rejection treatment required reintroduction of insulin therapy with prompt reappearance of allergic manifestations. Now, the patient is euglycemic without insulin or allergic manifestations and a glycated hemoglobin of 6.4%.

Prospective screening for biopsy proven coeliac disease, autoimmunity and malabsorption markers in Belgian subjects with Type 1 diabetes

AIMS

To determine prospectively the prevalence of biopsy proven coeliac disease (CD) in an adult Type 1 diabetic population from Belgium with regards to associated auto-immunity and malabsorption.

METHODS AND RESULTS

Determination in 400 Type 1 diabetic patients of serum anti-endomysial and/or anti-transglutaminase auto-antibodies. All subjects with abnormal serology underwent an intestinal biopsy. Ten patients (2.5%) had positive antibodies. Diagnosis of CD was confirmed by an intestinal biopsy. Eight patients were symptom-free, although laboratory findings suggesting malabsorption were prominent in the presence of CD [microcytic anaemia, iron and folate deficiencies, low levels of 25(OH)vitamin D3, calcium and cholesterol]. Other auto-immune conditions, especially vitiligo, were found in patients with CD.

CONCLUSIONS

Asymptomatic coeliac disease occurs frequently in adult Type 1 diabetic patients, and is often associated with subclinical malabsorption. Screening should be part of routine evaluation, to implement life-long dietary gluten avoidance.

The treat-to-target paradigm: a cross-sectional survey of current therapies and achieved metabolic control in 800 type 2 diabetic patients

The aim of this cross-sectional study is to analyse the current treatment schemes as well as the quality of control (metabolic; blood pressure) in a cohort of 800 type 2 diabetic patients recruited in a University Center and not by generalist practionners, in scope with current international recommendations. Insulin therapy was administered, alone or combined with oral antihyperglycaemic drugs, to 48% of subjects. HbA1c was 7.7% (6.7-8.7 (median; percentiles 25-75)). Antidyslipidaemic drugs were used in 45% of individuals. However, only 27% of the cohort had LDL levels lower than 100 mg/dl while 58% of males and 48% of females attained HDL targets. Systolic and diastolic blood pressure levels were 144 +/- 21 and 81 +/- 12 mmHg (mean +/- SD), despite one or more antihypertensive agent(s) prescribed to 68% of subjects. In conclusion, in a Belgian adult type 2 diabetic population attending a tertiary centre for follow-up, overall metabolic and blood pressure controls remain unsatisfactory according to targets defined by international guidelines. This audit makes a multi-faceted intervention aimed at intensifying current therapies all the more necessary.

C677T methylene-tetrahydrofolate reductase mutation in type 2 diabetic patients with and without hyperhomocysteinaemia

OBJECTIVE

The aim of the study was to determine the prevalence of the C677T mutation in a cohort of type 2 diabetic patients with and without elevated total plasma homocysteine (tHcy).

METHODS

80 type 2 diabetic patients with hyperhomocysteinaemia (group 1, tHcy: 21.3 +/- 6.7 micromol/L) and 50 subjects with normal levels (group 2, tHcy 11.2 +/- 2.3 micromol/L) were studied. C677T mutation was assessed by polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP).

RESULTS

Homozygosity was present in 23% of patients in group 1 and 8% in group 2 (P<0.02). No significant difference in heterozygosity frequency was observed between patients with and without hyperhomocysteinaemia. T allele frequency was 0.43 in group 1 and 0.35 in group 2.

CONCLUSION

C677T mutation is frequent in diabetic patients with hyperhomocysteinaemia and could contribute, besides non genetic factors, to increased levels of tHcy.

Predictive factors of thyroid carcinoma in non-toxic multinodular goitre

The management of nontoxic multinodular goitre (NMNG) remains controversial. The challenge for the clinician is to identify the small proportion of NMNG patients with associated thyroid carcinoma who would thus benefit from surgery. We studied retrospectively the medical records of 80 patients with NMNG and coexisting thyroid carcinoma who underwent total thyroidectomy. Eighty total thyroidectomy patients with NMNG whose histology was benign were then randomnly chosen as controls. In univariate analysis, the following parameters were significantly more frequent in the carcinoma group: rapid growth of the goitre (p = 0.002), presence of microcalcifications (p = 0.01), hypoechogenicity (p = 0.02), firm consistency of a nodule (p = 0.03), and presence of a dominant cold nodule on scintigraphy (p = 0.03). In the multiple regression analysis, the variables significantly associated with carcinoma were rapid growth (Odds ratio (OR) = 4.13, 95% confidence interval(CI): 1.72-9.89), hypo-echogenicity (OR = 3.11, 95% CI: 1.13-8.51) and the presence of a dominant nodule (OR = 2.26, 95% CI: 1.06-4.79)). In the cancer group, tumour size was positively correlated with compression signs (p = 0.01), age (p = 0.02), the presence of a dominant nodule on scintigraphy (p = 0.02), and with rapid growth (p = 0.04). Concerning nodule size estimated on US (ultrasound), the majority (65%) of patients without carcinoma had nodules < 3 cm, whereas 73% of patients with clinical thyroid carcinoma (> or = 1 cm on histology) had nodules with a diameter of > or = 3 cm on US (p = 0.02). In conclusion, our study suggests that surgical treatment of NMNG should be proposed in the presence of rapid nodular growth, compression signs, dominant nodule on scintigraphy, nodule size > or 3 cm and hypo-echogenicity.

Non-pharmacological management of type 2 diabetes

Major studies have demonstrated an association between poor glycaemic control and the development of micro - and macrovascular complications in type 2 diabetes. Optimized metabolic control, including treatment of hyperglycaemia and other risk factors, reduces the risk of complications. Current strategies aiming at achieving the best possible control include a non-pharmacological approach consisting of lifestyle intervention using physical exercise and modification of nutrition intakes in the early stage of type 2 diabetes, or in later stages, combined with pharmacotherapy. Such an approach is also efficient in preventing type 2 diabetes in patients with impaired glucose tolerance. The purpose of this review is to analyse, in a clinical practice perspective, the current recommendations with respect to lifestyle modifications.

Comparative performance of serum cystatin-c versus serum creatinine in diabetic subjects

OBJECTIVE

Serum cystatin-C, a protein with constant production rate, undergoes glomerular filtration. Cystatin-C is a candidate surrogate marker, allegedly superior to serum creatinine, for estimating glomerular filtration rate, due to its high correlation with absolute measurement of the latter. The aim of this study was to assess from intra- and inter-subject variability the performance of cystatin-C in a cohort of diabetic patients spanning a wide range of kidney function and to compare it to that of serum creatinine.

RESEARCH DESIGN AND METHODS

98 consecutive diabetic in-patients (45 type 1 and 53 type 2) were included. Mean age was 53 +/- 15 years (1SD). Creatinine clearance was 98 ml/min (median; range: 16-244). We used the discriminant ratio (DR) methodology to compare the performance of serum cystatin-C vs. that of creatinine to segregate subjects according to their glomerular filtration rate.

RESULTS

Serum creatinine values on day 1 and 2 were 1.10 +/- 0.76 and 1.07 +/- 0.89 mg/dl and concentrations of cystatin-C were 1.10 +/- 0.60 and 1.06 +/- 0.63 mg/L. A close linear relationship was observed between means of duplicates for creatinine and cystatin-C (Pearson product-moment correlation 0.92). DR was obtained from the ratio of the underlying between-subject to the within-subject standard deviations. DR values were 5.23 for creatinine and 8.82 for cystatin-C (P<0.0001), implying superior discriminating ability for cystatin-C. Once adjusted for attenuation, measured Pearson product-moment correlation rose from 0.92 to 0.97. The DR methodology allowed for deriving an unbiased linear regression equation between methods, with slope and intercept at 0.79 and 0.23, respectively.

CONCLUSIONS

Serum cystatin-C better discriminates among a population of type 1 and 2 diabetic patients with regard to their estimated glomerular filtration rate when compared with conventional serum creatinine measurement.

Prevalence of thyroid cancer in Graves' disease: a retrospective study of a cohort of 103 patients treated surgically

BACKGROUND: Thyroid nodules in patients with Graves' disease (GD) are common, and the incidence of coexisting thyroid carcinoma is a much debated subject, which is addressed in this study. METHODS: In order to determine the incidence rate of coexisting malignancy, a retrospective study was conducted on 103 patients who underwent surgery for GD between 1990 and 2000 at the Cliniques Universitaires Saint-Luc in Brussels, Belgium. The patients were classified into groups. Those in group I had a solitary palpable nodule (4.9%), those in group II multiple palpable nodules (12.6%), group IIIa had nodule(s) revealed by imaging techniques (incidentalomas: 17.5%), and group IIIb had diffuse non-nodular goiter (65%). RESULTS: Patients with nodules (groups I, II, and IIIa) were found to have significantly more thyroid carcinomas than those with diffuse non-nodular goiters (P=0.02), and the rate of malignancy was significantly increased when the nodules were palpable (groups I and II; P=0.03). Eight patients (7.8%) were diagnosed as having coexisting carcinomas, all but one being microcarcinomas. CONCLUSIONS: Well-differentiated papillary carcinomas are found to coexist with GD surgically treated (7.8%) and occur most frequently in GD with palpable nodular lesions (35%). Even though the majority (88%) of coexisting carcinomas are microcarcinomas, the presence of palpable nodules justifies further evaluation and follow-up.

Coeliac disease in patients with type 1 diabetes mellitus and auto-immune thyroid disorders

The paper aims to review the prevalence and natural history of coeliac disease in patients with type 1A diabetes mellitus and autoimmune thyroid disorders. These diseases share a similar genetic background. In diabetic children and adults, the prevalence of (mostly asymptomatic) coeliac disease varies form 0.97 to 6.4%. Diabetes is usually diagnosed first. Screening in relatives may also be positive. Recurrent hypoglycaemia in diabetic subjects (indirectly) suggest the development of coeliac sprue. Thyroid disorders (thyroiditis and Graves' disease) are also usual in coeliac disease. A common etiopathogenic mechanism for the association CD/diabetes/thyroid disorders, with gluten as the driving antigen, was postulated. Thus, screening program for coeliac disease are recommended in individuals with type 1A diabetes and/or auto-immune thyroid conditions, as well as in their first-degree relatives.

[Hurthle cell thyroid carcinoma: report of 13 cases]

The aim of this study was to report the clinical characteristics of 13 patients with Hürthle carcinoma. In the vast majority of them, disease was suspected by a palpable thyroid nodule. The results of preoperative examination (scintigraphy, ultrasonography, thyroglobulin) are also discussed as well as the pathological aspects and follow-up characteristics after total thyroidectomy.

Clinical, biophysical and biochemical variables from African-heritage subjects with type 2 diabetes

We compared the metabolic profile of two ethnic populations with type 2 diabetes, one from Bantu (n = 23; Ban) and the other from Belgian (n = 314) extraction followed at St Luc Hospital. Further comparison with a Belgian sub-cohort (n = 64; Be) matched for age (52 yrs) and sex distribution (M/F: 61/39%) showed no significant difference between Belgian and Bantu subjects with regards to diabetes duration (9 and 11 yrs; Ban and Be respectively), age at diabetes diagnosis (43 and 42 yrs), HbA1c (8.1 +/- 1.9 vs. 8.5 +/- 1.9%; NS), and achieved education level. BMI was lower in Ban (29 +/- 4 vs. 32 +/- 7 in Be; p < 0.02), as were body fat (33 +/- 12 vs. 37 +/- 11 kg; NS) and waist diameter (99 +/- 9 vs. 106 +/- 16 cm; p < 0.02). Forty-eight and 72% of Ban and Be were on metformin (p < 0.05), while insulin was given to 39 and 34%. Daily insulin dose was lower in Ban (0.31 +/- 0.20 vs. 0.47 +/- 0.18 IU.kg-1.24 h-1; p < 0.001). There was no difference in beta-cell function (% beta; normal: 100%) or insulin sensitivity (%S; normal: 100%) as determined with HOMA between groups. % beta (median [perc 25-75]) was 51 [23-119] and 67 [45-84] in Ban and Be, while %S was 32 [29-37] and 37 [27-45]. Smoking (past & current) prevalence was 5 and 47% in Ban and Be (p < 0.0001). Prevalence of micro- and macroangiopathy did not differ between groups, although Ban had more macroalbuminuria (29 vs. 9%; p < 0.05), and were more often treated with Ca(2+)-channel- and beta-blockers than Be subjects (36 and 39% vs. 16 and 8%; p = 0.07 and < 0.05, respectively). Fasting (F) and interprandial (IP) triglycerides (TG) were lower in Ban: 115 [81-149] vs. 189 [155-325] mg.dL-1 for F-TG and 127 [81-160] vs. 170 [128-305] mg.dL-1 for IP-TG (p < 0.0001), as was total cholesterol (201 +/- 53 vs. 223 +/- 40 mg.dL-1 (p < 0.05), despite lower use of hypolipidaemic drug (13 vs. 44%; p < 0.01). African-heritage subjects with type 2 diabetes have similar degree of diabetes control and complications, in the presence of leaner biophysical status, minimal tobacco exposure and lower fasting and interprandial triglycerides.

Clinical expression and insulin sensitivity in type 2 diabetic patients with heterozygous mutations for haemochromatosis

BACKGROUND

Elevated iron metabolism indices as well as liver enzymes abnormalities have been reported in type 2 diabetic patients. The aim of this study was to determine the clinical and biological characteristics of overweight or obese type 2 diabetic subjects, with and without heterozygosity for HFE gene mutation (C282Y or H63D). We also assessed their insulin sensitivity and B cell function.

METHODS

90 patients (age and diabetes duration: 61 +/- 11 and 12 +/- 8 years [mean +/- 1 SD]) were included. BMI was 32 +/- 6 kg/m(2). HbA(1c) was 8.9 +/- 1.8%. HFE genotyping was performed by PCR and restriction enzyme cleavage. Insulin sensitivity and B cell function were measured by the Homeostasis Model Assessment (HOMA).

RESULTS

Heterozygosity for C282Y (wt/C282Y) or H63D (wt/H63D) allele was found in 11 and 12 subjects respectively. There were no major differences in clinical status and iron parameters according to the single allelic presence of C282Y or H63D. However, systolic blood pressure [BP] was lower when such mutation was present. Insulin sensitivity and B cell function (HOMA) were comparable. When the cohort was divided according to gender, we found higher serum iron in females with than in those without HFE mutation (91 +/- 27 vs 73 +/- 25 microgram/dl;P=0.049), while a transferrin saturation index above 45% was observed in 36% of females with a mutation (vs 7% in wt/wt;P=0.06). When analysis was performed according to the presence of each particular mutation, we observed a transferrin saturation index higher than 45% in 60% of wt/C282Y patients vs 21% in the wt/wt group (P=0.008). A significantly lower BP was also identified in wt/C282Y patients. Cholesterol-HDL was 38 +/- 11 vs 46 +/- 12 mg/dl in wt/C282Y and wt/wt subjects, respectively (P=0.045). There were no differences in iron status, BP or lipids between wt/wt and wt/H63D subjects.

CONCLUSION

Type 2 diabetic patients, in particular females, with mono-allelic C282Y mutation, had slightly increased iron parameters. Systolic BP and cholesterol-HDL were also lower in wt/C282Y subjects. No difference in insulin sensitivity or B cell function was observed in the presence of mono-allelic HFE mutations.

Micro- and macrovascular complications and hyperhomocysteinaemia in type 1 diabetic patients

OBJECTIVE

To determine the range of plasma homocysteine values in a cohort of type 1 diabetic subjects and to analyse the relationship between homocysteine levels and chronic degenerative complications.

MATERIAL AND METHODS

71 type 1 diabetic inpatients admitted for poor glycaemic control and/or treatment of complications, especially macroangiopathic, were included in this study. Chronic diabetic complications, smoking prevalence, as well as current use of drugs were recorded, alongside fasting plasma homocysteine.

RESULTS

Age and diabetes duration were 51 (34-63) and 23 (13-32) years respectively (median [percentile 25-75]). HbA(1)c was 9.3% (8.2-10.5). Homocysteine was 9.2 (7.1-13.6) micromol/l, and 17% of patients had elevated homocysteinaemia on the basis of a laboratory cutoff value of 15 micromol/l. Folic acid and vitamin B(12) levels were within the normal range. Univariate statistical analysis showed a significant positive association between homocysteine and age (P<0.001), diabetes duration (P<0.001), systolic blood pressure (P<0.001), plasma creatinine (P<0.001), cholesterol/HDL-C (P=0.021) as well as with retinopathy (P=0.016) and all complications (P<0.001), and a negative correlation with folic acid (P=0.004) and creatinine clearance (P<0.001). Using a multiple regression analysis taking into account major variables, we confirmed an independent association of homocysteine with age (P=0.003), creatinine (P<0.001) and folic acid (P=0.014), but not with vascular complications.

CONCLUSIONS

Increased homocysteine is present in 17% of a limited group of poorly controlled type 1 diabetic patients, and is associated with age, creatinine and folic acid levels. In this type 1 population, there was no independent correlation of homocysteine with vascular complications, in particular macroangiopathy.

Therapy, glycaemic control and complications in type 1 diabetic patients: results from a single centre cohort of 465 subjects

We analysed the clinical characteristics, the degree of glycaemic control and the prevalence of complications in 465 type 1 diabetic adult patients (232 males), in view of current recommendations for metabolic and blood pressure control. Age and diabetes duration were 45 +/- 17 and 20 +/- 13 years respectively (mean +/- 1 SD). Daily insulin dose was 0.65 +/- 0.24 U/kg b.w. 73% of patients received > or = 3 injections/day, while 11% had continuous subcutaneous insulin infusion. All were practicing home blood glucose monitoring. Current HbA1c was 8.5% [7.7-9.3%] (median [percentiles 25-75]). There was no difference in HbA1c according to number of injections or CSII use. When patients were divided according to HbA1c quintiles, significantly lower prevalences of retinopathy and neuropathy were found in quintile 1 individuals. A mean of 53 severe hypoglycaemic episodes was reported per 100 patients/year, and they were more frequent in subjects exhibiting better glycaemic control. High blood pressure levels were found in 27% of subjects according to JNC-VI criteria. Fasting cholesterol (C), LDL-C, HDL-C and triglycerides were within normal range. However, according to current guidelines emphasizing on lower target thresholds, up to 27% of patients exhibited some degree of dyslipidaemia, in particular LDL-C higher than 3.3 mmol/l. In conclusion, in this large cohort of type 1 diabetic patients regularly attending a University Centre, overall glycaemic control remains above the satisfactory levels inferred from optimization studies. Although mean blood pressure and blood lipids were up to recently deemed adequate, a (too) high proportion of diabetic patients exhibited either hypertension and/or dyslipidaemia according to revised therapeutic goals cut-offs.

Erectile dysfunction and lower androgenicity in type 1 diabetic patients

OBJECTIVE

To analyse the clinical characteristics and relevant hormonal profile in type 1 diabetic patients with and without ED.

MATERIAL AND METHODS

Fifty one type 1 diabetic patients were studied. ED was assessed by direct interview. Chronic diabetic complications, smoking and alcohol status as well as current use of medications were recorded. Hormonal profile consisted of plasma LH, FSH, prolactin, androstenedione (Delta(4)), dehydroepiandrosterone (DHEA), DHEA-sulfate (DHEA-S), free testosterone (FT), estradiol (E(2)), sex hormone binding globulin (SHBG), dihydrotestosterone (DHT), cortisol, TSH and free thyroxine (FT(4)).

RESULTS

ED was present in 24 patients (47%) (group 1), who were older (P<0.001), had a longer diabetes duration (P<0.001) and a higher systolic blood pressure (P=0.017) when compared to the subjects who did not complain (group 2). ED was positively correlated to all diabetes-related complications (P<0.02). Antidepressive drug(s) were more frequent in group 1 (P=0.007), as well as prokinetics (P=0.043) and ACE-inhibitors (P=0.010). HbA(1)c was comparable. Patients with ED had lower levels of Delta(4) (P=0.003), DHEA (P<0.001), DHEA-S (P=0.002), FT (P=0.08) while SHBG (P=0.010) and LH (P=0.022) were higher compared to group 2. Multiple logistic regression analysis showed an independent association of ED with Delta(4) (P=0.016), DHEA-S (P=0.037), SHBG (P=0.001) and insulin dose (P=0.025). There was no significant difference for all other measured hormones.

CONCLUSION

ED is impressively prevalent in type 1 diabetes and is associated with age, diabetes duration, chronic complications and decreased androgens.