The fat mass, estimated glomerular filtration rate, and chronic inflammation in type 2 diabetic patients

BACKGROUND

The aim of the study was to analyze the degree of obesity and its associations with age, gender, inflammation, an estimated glomerular filtration rate (eGFR), and liver function in type 2 diabetes mellitus (T2DM) patients.

METHODS

A total of 874 consecutive adult Caucasian T2DM patients from outpatient diabetic clinic were included in the study. The relative fat mass (RFM) and body mass index (BMI) were used as obesity markers. Serum creatinine and cystatin C were used for the GFR estimation. Serum high-sensitive C-reactive protein (hsCRP) was used as the indicator of inflammation.

RESULTS

The median, interquartile range (IQR) of RFM in females was higher than that in males (44.8 (42.3-47.2) % vs 31.3 (28.8-34.1) %, respectively; P < .0001). The median (IQR) of BMI in females was no higher than that in males (30 (27-34) kg/m2 vs 30 (27-34), respectively; P = .5152). The obesity prevalence was 99% in males and 98% in females according to RFM. BMI recognized obesity in 51% males and 53% females. RFM was positively associated with hsCRP in both males (rs  = .296, P < .0001) and females (rs  = .445, P < .0001). ALT was positively correlated with eGFRcys in both males (rs  = .379, P < .0001) and females (rs  = .308, P < .0001).

CONCLUSION

The RFM equation leads to higher obesity prevalence compared to BMI. Women have higher RFM compared to men. The kidney function was positively correlated with ALT serum concentrations.

Cystatin C measurement leads to lower metformin dosage in elderly type 2 diabetic patients

The aim of this study was to provide evidence for the hypothesis that estimated glomerular filtration rate from serum Cystatin C (eGFRcys) is better to be determined for all elderly type 2 diabetes mellitus (T2DM) patients based on eGFRcys upward and downward reclassification rate for hypothetical metformin dose reduction by eGFRcys at the GFR decision point of 45 mL/min/1.73 m². A total of 265 consecutive T2DM elderly patients (age range 65‐91 years) from outpatient diabetic clinic were included in the study. The Kidney Disease Improving Global Outcomes (KDIGO) guidelines for metformin dosing were strictly followed. Estimated glomerular filtration rate from serum creatinine (eGFRcrea) led to results of metformin eligibility. Each of the results of eGFRcrea‐based eligibility was further compared to eGFRcys‐based eligibility. Creatinine was measured by enzymatic method standardized against international reference material SRM 967. Cystatin C was determined by method traceable to DA ERM 471 international standard. eGFRcrea and eGFRcys were calculated according to Chronic Kidney Disease Epidemiology Collaboration (CKD‐EPI) equations. A downward reclassification rate was higher than upward reclassification rate (31 vs 3, respectively; P < 0.0001). The median (IQR) eGFRcrea was higher than eGFRcys (73 (58‐85) vs 63 (50‐75) mL/min/1.73 m², respectively; P < 0.0001). eGFRcys reclassified significant proportion of patients with T2DM from metformin eligible CKD stages to less or non‐eligible stages. The downward reclassification was more frequent in patients older than 80 years (P < 0.01). Cystatin C‐based eGFR selects more complicated patients, where lower doses of metformin are possibly advisable. We recommend calculating both eGFRcrea and eGFRcys for metformin dosing in elderly patients with T2DM.

Effectiveness and safety of lixisenatide for treatment of diabetes in the real world: data from the Monitoring Registry in a Real-Life Cohort in the Czech and Slovak Republic

INTRODUCTION

GLP1 receptor agonist lixisenatide has demonstrated its efficacy in numerous clinical trials, nevertheless its real-life effectiveness data is limited.

AIM

To describe effectiveness and safety of lixisenatide in routine clinical practice in the Czech Republic and the Slovak Republic, as recorded by the Registry-Based Observational Study.

METHODS

Multinational, multicenter, observational, non-interventional, 6-month prospective product registry of patients with type 2 diabetes mellitus aged > 18 years who were initiating therapy with lixisenatide. Patients were enrolled into this registry, provided written informed consent, between 1 May 2013 and 31 December 2015. Evaluations were performed at baseline and after 3 and 6 months of lixisenatide treatment. The primary objective of the study was the absolute change in glycated hemoglobin (HbA1c) from baseline to month 6 after lixisenatide initiation. The study was approved by responsible ethics committees and performed in accordance with the Helsinki Declaration. Informed consent was obtained from all patients before enrolment in the study.

RESULTS

Overall 772 eligible patients (51.4 % males), mean age 56.7 (± 9.3) years, with mean diabetes duration 7.7 (± 5.5) years, mean duration of treatment with oral antidiabetic drugs 6.8 (± 4.9) years, and body mass index 37.6 (± 5.9) kg/m2 were enrolled in the study. Overall, 93.6 % were obese, 86.3 % subject were treated for hypertension, and 76.0 % for dyslipidemia. In total 96.1 % of patients completed the 6 months therapy. Lixisenatide significantly reduced HbA1c (decrease by 9.7 ± 14.4 mmol/mol [3.1 ± 0.2 % DCCT] after 6 months in per protocol population), and body weight (decrease by 3.5 ± 5.4 kg). The best responders to the treatment were younger patients with higher BMI, who had a shorter duration of diabetes. Overall safety profile of lixisenatide was satisfactory in the study. The most frequent adverse events were functional disorders affecting the gastrointestinal system. There was no episode of severe hypoglycemia reported throughout the study.

CONCLUSION

In a real-life practice cohort of patients with type 2 diabetes mellitus 6 months treatment with once-daily GLP1 receptor agonist lixisenatide significantly improved glucose control and decreased body weight without increasing the risk of symptomatic and/or severe hypoglycemia risk.

FUNDING

Sanofi Czech Republic.Key words: GLP1 receptor agonist - glycated hemoglobin - HbA1c - lixisenatide - oral antidiabetic drugs (OAD) - observational study - hypoglycemia - type 2 diabetes mellitus.

[Clinical contribution of new basal analogue insulin]

Chronic long term hyperglycemia plays a key role in the pathogenesis of micro and macrovascular complications. The UKPDS study and its further analysis has proved that reduction of the value of glycated hemoglobin by 1 % leads to a 14 % reduction of the risk of myocardial infarction and a 37 % reduction of the risk of microvascular complications. Effective control of glycaemia, optimal value of pre-prandial, postprandial glycaemia, and low variability from the start of the disease has a long term beneficial impact. The therapy of basal insulin analogues ranks among the recommended procedures for achieving control. The new insulin analogues (insulin glargin 300 U/ml, insulin degludec) have a longer effect, practically a peakless course, lower variability, lower risk of hypoglycemia events and better application technique with greater flexibility of administration. The pharmacokinetic and pharmacodynamics properties provide new quality in the chronic therapy of people with type 1 and 2 diabetes.

KEY WORDS

diabetes mellitus - glycemia control - hypoglycemia - new basal insulin analogues.

[Education of a patient with diabetes - an integral part of complex therapy]

Determination of the diagnosis of diabetes mellitus means a radical life change for a patient. Education of a patient with diabetes means the provision of essential information and practical guidance for linkage of the disease with the life style of the patient for the purpose of providing the required control of the disease, to gain the necessary knowledge for self-care management of the disease in collaboration with the education team. Education is a permanent integral part of the complex therapy of diabetes, adaptation to the phases of the disease, targeting not only the patient but immediate family. The fundamental aim is improvement of the state of health and the ensuring of life quality.Key words: content of education - diabetes mellitus - education - educational phases - education team.

[Clinical importance of basal insulin analogues and insulin Toujeo® 300 units/ml]

Type 2 diabetes mellitus is a heterogeneous disease that requires a personalized approach to treatment with goals tailored to capabilities and abilities of the patient, his other diseases so as to ensure good diabetes control without the risk of hypoglycemic events and the development or progression of late diabetic complications. Recommendations for treatment of diabetes is classified in second-line as a one of the possibilities of treatment of basal insulin immediately after the failure of therapy with metformin and diet. The new generation of basal insulin analogues provides its effect profile and features a completely new quality to the treatment of diabetes. Toujeo® 300 units/ml is a new long-acting basal insulin glargine concentration of 300 units/ ml with a low glycemic variability, which in studies has demonstrated consistent control of diabetes in a significant reduction in the risk of hypoglycemia especially at night compared with insulin glargin of concentration 100 units/ml.

[Possibilities of therapy GLP1 RA for diabetics with nephropathy]

The incretin hormone GLP1 (glucagon-like peptide 1) has also systemic effects besides its effects on the pancreas. The renal expression for the receptors GLP1 and DPP4 has been described in a whole line of experimental stu-dies. Activation of the receptors for GLP1 in the kidneys has diuretic and natriuretic effects apparently through the renal tubular cells and sodium transporters. Pre-clinical incretin therapy decreased albuminuria, affected glomerulosclerosis, oxidative stress and fibrosis in the kidneys. Diabetic nephropathy is the major cause of kidney failure. In the course of renal insufficiency the functional possibilities and simultaneous safe compensation of diabetes are limited. The treatment GLP1 RA of patients with type 2 diabetes and nephropathy appear to be effective from the aspect of effectiveness and safety.

[Insulin analogues of patients with diabetes and renal impairment]

The main cause of renal failure is diabetic nephropathy which affects 20-40 % of diabetic patients. Diabetics with altered renal function have restricted therapeutic options due to the risk of accumulation of oral antidiabetic drugs and of their metabolites at a reduced glomerular filtration rate. Good metabolic control is very important during the early phases of nephropathy for reducing the risk of progression and in the stage of renal failure reduces the risk of progression of atherosclerosis and improves life prognosis. Metabolism of insulin is changed during renal failure, clearance of insulin is prolonged, the risk of hypoglycemia increases. Short-acting insulin analogues have faster absorption and long-acting analogues have a lower risk of hypoglycemia. Thus they can positively affect glycemic control of patients with diabetes and impaired renal function.

[Long-term acting insulin analogues and the risks of hypoglycemic incidence]

As recommendation for treatment of type 2 diabetes mellitus, incorporating individualization of therapeutic targets for patients with co-morbidities, for whom hypoglycemia increases the risk of complications. The sufficient target value is 60 mmol/mol of HbA1c under the guidelines of Czech Diabetesl Society. Insulin therapy becomes essential for a whole line of patients, including those of advanced age, in relation to duration of diabetes and progression of the disease. The Diabetes and Aging Study observed patients of 60 years age with diabetes, in which hypoglycemia ranked among the most frequent side effects of therapy and where incidence increased with age. It is necessary to select simple insulin regimens which are in accordance with the associated diseases and the age of the person. A therapy of basal insulin analogues, linked to a low risk rate of hypoglycemic incidence, enables combination with oral antidiabetic drugs and GLP-1 receptor agonists.Key words: basal insulin analogues - hypoglycemia - type 2 diabetes mellitus.

[Up to day trends in insulin therapy]

Patients with type 2 diabetes mellitus have a double risk of development of cardiovascular diseases than patients without diabetes. Two thirds of patients with type 2 diabetes mellitus can die from heart attack or a cerebrovascular accident if it is not possible to influence these risks by procedures such as decreasing the blood pressure, cholesterol level, glycemia and to stop smoking. The recommendations of ADA/ EASD for therapy of type 2 diabetes mellitus emphasizes that the therapy should be conducted in such a manner as to decrease the risk of cardiovascular complications and undesirable effects, primarily hypoglycemic events. A whole line of clinical studies, e. g. DCCT EDIC, UKPDS have documented the importance of intensive insulin therapy for achievement of normoglycemia, decreasing risk of microangiopathic complications and in followup observation, also decreasing of cardiovascular risk. An ORIGIN study with insulin glargine documented the safety of therapy of longacting insulin analog and also reduction of development of new diabetes from prediabetes. Insulin therapy with respect to the positive outcomes of study with insulin analogs moved up to the second line in algorithm therapy, immediately after metformin therapy and change of life style.

Serum adipocyte fatty acid binding protein levels in patients with type 2 diabetes mellitus and obesity: the influence of fenofibrate treatment

Recent studies have demonstrated that adipocyte fatty acid binding proteins (FABP) may play a role in the etiopathogenesis of insulin resistance. The aim of our study was to assess serum FABP levels in obese patients with type 2 diabetes mellitus (T2DM) before and after 3 months of treatment with PPAR-alpha agonist fenofibrate (F) and to explore the relationship of FABP to biochemical parameters and measures of insulin sensitivity assessed by hyperinsulinemic-isoglycemic clamp. We measured biochemical parameters by standard laboratory methods, insulin sensitivity by hyperinsulinemic-isoglycemic clamp and serum concentrations of FABP by commercial ELISA kit in 11 obese females with T2DM before and after three months of treatment with PPAR-alpha agonist fenofibrate and in 10 lean healthy control women (C). Serum FABP levels were 2.5-fold higher in T2DM group relative to C and were not affected by fenofibrate treatment (C: 20.6+/-2.1 microg/l, T2DM before F: 55.6+/-5.7 microg/l, T2DM after F: 54.2+/-5.4 microg/l, p 0.0001 for C vs. T2DM before F). Hyperinsulinemia during the clamp significantly suppressed FABP levels in both C and T2DM group. FABP levels positively correlated with BMI, triglyceride levels, blood glucose, glycated hemoglobin, atherogenic index and insulin levels. An inverse relationship was found between FABP and HDL levels, metabolic clearance rate of glucose, M/I and MCR(glc)/I sensitivity indexes. We conclude that FABP levels are closely related to BMI, parameters of insulin sensitivity, HDL levels and measures of diabetes compensation. This combination makes FABP a valuable marker of metabolic disturbances in patients with type 2 diabetes mellitus.

[The carotid drainage system--a "window" into the atherosclerosis process in diabetics?]

Macrovascular complications present from the viewpoint of morbidity and mortality the biggest risk in type 2 diabetics. An aim of this work is to show ways of detecting clinical and preclinical phases of atherosclerosis with special regard to carotid system. In our paper we have been presenting a sample of 239 patients with cardiovascular incidents and findings on their extracranial carotid systems detected by duplex sonography. 88 patients (36.8%) in the sample had type 2 diabetes, their average age was 68.2 +/- 8.5. 35 were on a diet, 34 were treated with peroral antidiabetics, and 19 with insulin. Findings on extracranial carotid systems were normal in 27.3% of diabetics, in stenoses up to 50% was lumen in 50%, in stenoses 51-70% was lumen in 15.9%, and in stenoses 71-95% was lumen in 6.8% (compared to 3.9 in nondiabetics). Intimomedial thickness (IMT) in a group with positive microalbuminuria was 0.9 +/- 0.3 mm and in a group with negative microalbuminuria 0.87 +/- 0.18 mm. Intimomedial thickness (IMT) and microalbuminuria (MAU) are the markers of risk for atherosclerosis and enable to detect preclinical stages of atherosclerosis. Another enzyme indicated in the process of atherosclerosis is PAPP-A, an indicator of plaque instability. Early detection and early intervention of the atherosclerotic process can prevent growth of atherosclerosis, especially during epidemic increase of type 2 diabetes.

[Problems in the diagnosis of gestational diabetes]

The standard of care of mother and child is in the foreground of interest of the lay public. Gestational diabetes is associated with an increased mortality and morbidity of the foetus, unless diagnosed in time and adequately treated. The screening test for detection of gestational diabetes (according to O'Sullivan) is made in all pregnant women of the Zlín district since 1985. Within 4 months (September-December 2000) it was made in more than 700 women. Of these 58 positive screenings were referred to our out-patient department. Supplemented by oGTT (75 g, WHO). 19 patients with gestational diabetes were detected, 6 with impaired glucose tolerance and 18 with renal glycosuria. During the investigation no patient was detected with negative screening and subsequently confirmed gestational diabetes. In three instances of gestational diabetes insulin treatment was administered, in three cases of renal glyosuria based on the blood sugar level the condition was re-evaluated as gestational diabetes. Gestational diabetes is associated with obesity of the mother. With regard to the increasing incidence of obesity in the population the risk of a higher incidence of diabetes is increasing. Women in fertile age should be tested for hyperglycaemia not only during pregnancy but already before conception.

[Clinical features and therapy of giant cell temporal arteritis]

Giant-cell temporal arteritis is an urgent condition in ophthalmology as successful treatment depends on early diagnosis and effective therapy before the development of ophthalmological symptoms. The authors investigated on a long-term basis five patients. In the first one complete regression of general and ocular symptoms occurred and vision was preserved. The second patient was admitted already with loss of vision of one eye and despite intensive treatment it did not prove possible to save vision of the second eye. The third patient developed, after clinical recovery, a relapse which was again brought under control. In another patient of relatively younger age it proved possible to arrest the progress of the disease without loss of vision. In the last patient visual acuity improved after treatment.

[Prevention of venous thrombosis and pulmonary embolism. Scoring system of the risk of TEN development]

The authors summarize hitherto used patterns of thromboprophylaxis. They attempted to quantify the risk of development of thromboembolism by means of a "Scoring system of the risk of development of TEN" which facilitates the decision on the intensity of prophylaxis of thromboembolic disease.

[Physical training in type 1 diabetics]

The objective of the investigation was to follow the response of type 1 diabetics to a load and subsequently elaborate simple recommendations which can be used in out-patient practice and to provide thus the diabetologist in the field and his patient with practical recommendations for physical exercise.

[Treatment of insulin-dependent diabetics during delivery]

The authors discuss the care of an insulin-dependent diabetic woman during delivery. Due to the introduction of modern procedures in diabetology, obstetrics and neonatology the perinatal mortality in diabetic pregnancies is close to that in healthy women. In the Zlín region there was in 1997 a total of 2301 deliveries, incl. 8 IDDM patients (0.34%) and 32 patients with gestational diabetes (0.72%). The perinatal mortality in diabetic pregnancies was 0 pro mille and in non-diabetic ones 5.14 pro mille.

[New aspects of pharmacologic and general prophylactic care of the diabetic foot]

Ischaemia, neuropathies and infections are predisposing factors for the development of ulceration of the diabetic foot. Diabetics have evidently a disposition for affections of the peripheral circulation and impaired regulation of the microcirculation as a result of autonomic neuropathy. The lower the driving pressure (in critical ischaemia), the more important are rheological factors and drugs which can influence them. These preparations include e.g. Trental (pentoxiphilline), Prostavasin (prostaglandin E1), Vessel due F (sulodexide). In advanced stages of ischaemic extremities oedema is a very adverse factor. Non-cardiac oedema can be very effectively handled by manual lymphatic drainage combined with intermittent one-segment pneumatic compression which was successfully used by the authors in ulcerations of the diabetic foot. One of the main general protective measures is adequate care of the foot and protective footwear for diabetics. After 3.5 years' use of protective footwear the authors recorded, consistent with data in the literature, a 50% reduction of relapses of ulcerations (and amputations). By examination on an EMED II apparatus abnormally high local pressures on the sole of risk patients can be detected and at the some time the protective effect of materials used for protective insoles can be tested. Active pharmacological and generally protective care of diabetic foot leads to a reduced number of amputations, in particular supracondylar ones by 50 or more per cent.

[Protective special shoes for diabetics. Personal experience with a group of high risk diabetics during a 2 and 1/2 year period]

A group of 60 type II diabetics with the risk of development of ulceration of the feet was provided with protective specialized footwear. In the course of 2.5 years in 45 patients who could be evaluated the frequency of relapses of previous ulcerations, the development of first ulcerations and the effect on indicators of immediate high risk of a defect (formation of decubital ulcers, blisters) was investigated, as well as the general biomechanical comfort. In 10 patients with relapsing defects relapses developed twice (20%), no primary ulceration developed. As compared with common footwear, the protective footwear had a favourable effect on the formation of sores and blisters 25 patients (55.5%/ 45/100%) reported improvement of the general comfort when walking. 28 (62.2%) patients make use of the favourable experience with the specialized footwear when selecting shoes or when modifiying standard footwear. A surprising finding was delayed fatigue when walking reported by 35 (77.8%) patients, mitigation of dysaesthesias by 23 (51%), pain in the joints by 14 (31.1%), improved stability by 35 (77.8%) of the patients. With regard of the improvement of some subjective complaints the use of protective footwear can be considered a symptomatic-therapeutic element. According to clinical results specialized footwear has a favourable and protective effect on already damaged feet with a reduced tolerance for combined (mechanical, ischaemic, neurotrophic, infectious) insults. Consistent with data of authors from abroad after a 2-5-year follow-up there was a cca 50% reduction in the number of relapses of ulcerations and amputations as compared with common not modified footwear.

[Angiologic findings in type 1 diabetics who have had diabetes longer than 25 years]

The authors present a group of type 1 diabetics with duration of IDDM longer than 25 years (15 men and 10 women), mean age 53.8 years, mean duration from diagnosis of IDDM 35.0 years. The authors performed angiologic examination by using noninvasive methods with focus on affections of extracranial carotid arteries and peripheral arteries by using ultrasonographic methods and by measuring skin perfusion pressure by the photocell of the plethysmograph on the fingers of lower extremities. The authors investigated the subsequent risk factors--obesity, smoking, hypertension, hyperlipoproteinaemias, ischaemic heart disease, strokes. Macroangiopathy of lower extremities was detected in 28.5%, hemodynamically nonsevere stenosis of the extracranial carotid arteries in 20% of patients. As a result, the authors emphasize the need for regular control of arterial changes in diabetics of type 1.

[Incidence and developmental interdependence of peripheral nerve disorders in type 1 diabetics]

In 1987-1988 the authors subjected to comprehensive neurological examination 79 type I diabetics. The group comprised subjects under 60 years and patients with other possible neurotoxic influences were eliminated. After a detailed clinical examination in 75.9% diabetics clinical signs of affection of the peripheral nervous system were revealed, incl. 45.6% clinical diabetic neuropathies were detected. In all instances it was symmetrical distal sensory or sensomotor polyneuropathy and in four instances moreover the carpal tunnel syndrome was detected. The most frequent neurological disorder was panhypaesthesia on the acra of the lower extremities. The most frequent subjective complaint were paraesthesias of the feet and subsequent cramps. The authors investigated moreover parameters of the long-term compensation of diabetes, the duration of diabetes and the biological age of diabetics. They assessed the statistical significance of these parameters for the development of diabetic neuropathy which was proved only for the parameter of the duration of the disease and the biological age of type I diabetics (p less than 0.05).

[Incidence and developmental interdependence of peripheral nerve disorders in type 2 diabetics]

In 1987-1988 160 type 2 diabetics, dispensarized in diabetological out-patient departments of the medical clinic of the Institute for Postgraduate training were subjected to neurological examinations. The selection of the group was governed by an effort to reduce to a minimum the association of other neurotoxic influences. The group therefore comprised subjects under 60 years of age; diabetics with other diseases with a possible neurotoxic action, drug abuse, alcohol abuse, etc. were eliminated. After a detailed neurological examination signs of affection of the peripheral nervous system were detected in 87.5%, clinically manifest diabetic neuropathy was found in 78 diabetics (48.75%); 12 had moreover mononeuropathy of the median nerve. The clinical picture was uniform: impaired perception of vibrations on the acra of the lower extremities with ascendent propagation, reduction to disappearance tendinous-muscular reflexes on the lower extremities. Subjectively more frequently cramps of the feet than paraesthesias were reported. The authors revealed that long-term compensation of diabetes, the duration of diabetes and the biological age of the diabetics were statistically significant for the manifestation of diabetic neuropathy. This significance was proved for the factor of biological age (p less than 0.05); there was also a significant correlation between the long-term state of compensation of type 2 diabetes and the manifestation of neuropathy (p = 0.06).