[Non-alcoholic steatohepatitis (NASH) : a model of metabolic inflammation («metaflammation»)]

Diseases related to fatty liver, independently of alcohol consumption («non-alcoholic fatty liver disease» or NAFLD), are increasing because of the epidemics of obesity and type 2 diabetes. These disorders reflect a continuum that comprises isolated steatosis, steatohepatitis (NASH) and fibrosis, with, at the end, an increased risk of cirrhosis and hepatocarcinoma. It has been recently proposed to replace the term NAFLD by MAFLD, i.e. «Metabolic (dysfunction) Associated Fatty Liver Disease», which better reflects the pathogenesis of the disease. Inflammation plays a crucial role in the aggravation of the disorder and profoundly influences the prognostic evolution. This article illustrates the natural history of this underestimated metabolic disorder, recall the diagnostic criteria used in clinical practice, emphasizes the deleterious role of inflammation and discusses some therapeutic perspectives.

[Inflammation, obesity and type 2 diabetes. Role of the NLRP3 inflammasome and gut microbiota]

Type 2 diabetes is characterized by chronic hyperglycaemia in a context of insulin resistance and ?-cell dysfunction. A chronic low-grade inflammation is observed in obesity and has been associated with the development of metabolic disorders. The molecular mechanisms underlying this inflammation are not fully understood. Production of interleukin-1? by macrophages infiltrating insulin-sensitive tissues and pancreatic islets plays a major role in the pathogenesis of type 2 diabetes. This pro-inflammatory cytokine is produced through the activation of the NLRP3 inflammasome in response to danger signals that accumulate during obesity, including saturated fatty acids. The composition of the intestinal microbiota differs in obese subjects compared with lean individuals, particularly in response to high saturated fat diet. These modifications could trigger a chronic low-grade inflammation and promote the emergence of type 2 diabetes. The microbiota could therefore constitutes a therapeutic target in the prevention and management of metabolic abnormalities associated with obesity.

[Bempedoïc acid, new cholesterol-lowering drug]

Patients at high or very high cardiovascular risk should have a LDL cholesterol level as low as possible, a target that may be difficult to be reached with statin monotherapy, especially when this treatment is not well tolerated. It is generally recommended to use pharmacological combinations to reach more and more strict objectives. Bempedoic acid is a new oral cholesterol-lowering medication that reduces hepatic cholesterol synthesis by inhibiting the enzyme adenosine triphosphate (ATP)-citrate lyase enzyme. Because this medication is a prodrug that is selectively activated in the liver, it is deprived of any muscular adverse effect. This article summarizes the mode of action, pharmacokinetics, efficacy, safety profile, indications and reimbursement conditions of bempedoic acid. This novel cholesterol-lowering drug is indicated in combination with statins (with or without ezetimibe) in patients who do not attain LDL goals despite administration of a statin at the maximum tolerated dose or in case of statin intolerance.

[Gestational diabetes mellitus : prelude of risks not to be misunderstood]

Gestational diabetes mellitus is a common complication in pregnant women. It is diagnosed between the 24th and 28th last menstrual period thanks to an oral glucose tolerance test with 75 g of glucose. Although blood glucose levels usually return to normal after childbirth, it can lead to some medium- and long-term complications, including cardiovascular, metabolic and renal complications. Early detection of various risk factors related to these complications would avoid some negative consequences for women with background of gestational diabetes.

[Oral semaglutide, first oral GLP-1 receptor agonist (Rybelsus®)]

Oral semaglutide (Rybelsus®) is a co-formulation of semaglutide, a glucagon-like peptide-1 (GLP-1 RA) receptor agonist, with an absorption enhancer, sodium N- (8- [2- hydroxybenzoyl] amino) caprylate (SNAC), which facilitates the absorption of semaglutide across the gastric epithelium in a concentration dependent manner. The safety and efficacy of oral semaglutide were assessed in the PIONEER clinical trial programme, which included 9543 patients with type 2 diabetes (T2DM). Across a range of different T2DM patients receiving different background medications, oral semaglutide provides more effective glycaemic control than common oral glucose-lowering therapies, associated with a clinically relevant reduction in body weight, including in patients with more advanced T2DM on insulin treatment. The tolerability profile for oral semaglutide was consistent with the other GLP-1 RAs. Cardiovascular (CV) safety of oral semaglutide was noninferior to placebo in CV high-risk patients. Available in three doses (3, 7 and 14 mg) to be gradually increased, Rybelsus® is currently reimbursed in Belgium after failure of antidiabetic treatment (including metformin; HbA1C superior to 7.5 % or 58 mmol/mol) in T2DM patients with a body mass index ? 30 kg/m².

[Advocacy for an improved training in clinical nutrition during the medical cursus]

The knowledge of physicians regarding nutrition is often far below the expectations of patients, and does not comply with official recommendations. However, poor-quality nutrition and diet represent the first cause of mortality worldwide. As a result of an insufficient training and awareness, many physicians cannot meet patients' expectations. Moreover, nutrition is sometimes felt as a field of low scientific level, thereby opening the area to pseudo-scientific drifts. We advocate an improvement in the training in nutrition during the medical cursus, namely by the transversal integration of nutritional insights into medical courses, and the recognition of post-university training validated by the academic authorities. A clarification of the roles and the recognition of the competency are urgently required to promote the professionalism of nutritional counselling.

[Continuing or stopping metformin in patients with type 2 diabetes exposed to SARS-CoV-2 ?]

Both obesity and type 2 diabetes (T2D) are recognized risk factors for developing a more severe form of COVID-19, with a higher death rate. Metformin is considered as the first-line medication for the treatment of T2D, especially in obese patients. Beyond its glucose-lowering activity, metformin exerts pleiotropic effects, among which an anti-inflammatory effect that could be beneficial. However, metformin is contraindicated in case of severe renal insufficiency, liver failure and/or unstable heart failure, because of a risk of lactic acidosis. Yet, COVID-19, besides the well-known pneumonia that can be responsible for severe hypoxemia, may be associated with multisystemic organ failure, among which kidneys, liver and heart. Thus, the question arises whether metformin, which represents the background therapy in above 80 % of patients with T2D, should be continued in patients exposed to SARS-CoV-2 or instead be stopped. This article summarizes the most important results of observational studies, which all argue for a beneficial effect of metformin therapy that is associated with a significant reduction in mortality among hospitalized patients with T2D due to COVID-19. Finally, some practical advices will be given.

[Ultra-rapid lispro (Lyumjev®)]

Development of new insulins aims to mimic in a better way the natural physiology of this hormone secreted by the pancreas. Rapid insulin analogues have proven a better capacity to reduce postprandial glycaemic peaks after eating. Nevertheless, these molecules are still quite inaccurate to limit glycaemic excursions after the meals. This reality is often described by patients using continuous glucose monitoring systems. So, there is undeniably a place for even more rapid insulins. The ones named «ultra-rapid insulin» tend to better control hyperglycaemia after meals thanks to more favourable profiles regarding pharmacodynamics and pharmacokinetics. Ultra-rapid lispro (URLi) Lyumjev®, is the new ultra-rapid insulin available in Belgium. This review aims to describe its advantages compared to some other rapid insulins thanks to data obtained from trials in type 1 and type 2 diabetes.

[Covid-19 and diabetes]

Diabetes is one of the most important comorbidities linked to the severity of infection caused by severe acute respiratory syndrome coronavirus (SARS-CoV-2). The prevalence of diabetic patients hospitalized in intensive care units for COVID-19 is two-to-threefold higher than that observed in non-diabetic patients and a risk of progressing to critical or fatal disease is increased by a factor of 3 to 4 in patients with diabetes. Multiple mechanisms link diabetes as a risk factor of severe COVID-19, including both diabetes-related (such as hyperglycaemia) and diabetes-associated (such as immune dysfunction, obesity and hypertension) components. Optimising glycaemic control to reduce the risk of severe COVID-19 appears important but challenging and the best choice of antidiabetic treatment remains to be established, even if an early introduction of insulin in type 2 diabetes patients with COVID-19 is encouraged upon admission to the hospital. Future investigations are necessary to improve both the management and the prognosis in these very high risk patients.

[Sport in type 1 diabetic patient : interests and precautions]

Physical activity is a key step in the management of diabetes, both in type 1 and type 2 diabetes. In diabetic subjects, it is recommended to practice 150 minutes of weekly physical activity spread over at least three days, with a maximum of two consecutive days without exercise. However, more than 60 % of type 1 diabetic patients fail to meet this goal. This is largely explained by the fear of potential adverse effects, in particular the occurrence of hypoglycaemia during exercise, which represents a major obstacle to its safe practice. Therefore, specific therapeutic education should be considered in these subjects in order to promote regular physical activity.

[The diagnostic trap of acute pancreatitis with normal pancreatic enzymes]

We report the case of a patient admitted in Emergency Care for abdominal pain and whose biological assessment did not show any increase in pancreatic enzymes. The abdominal CT-scan revealed pancreatitis of grade E according to the Balthazar radiological score. A diagnosis of acute necrotic pancreatitis secondary to hypertriglyceridemia was thus made. In cases of acute pancreatitis, the rate of pancreatic enzymes may rarely be normal for unclear reasons. In the case of an evocative clinical presentation, the diagnosis of acute pancreatitis cannot be ruled out on the basis of this normal dosage. A CT-scan of the pancreas is then indicated to confirm the diagnosis.

[A decade of progress in the management of dyslipidemia]

Over the past 10 years, meta-analyzes of statins, randomized clinical trials using ezetimibe and anti-PCSK9 antibodies, and Mendelian randomization studies have strengthened the central and causal role of LDL-c in the development of cardiovascular disease. The LDL-c target has been gradually lowered and to date there is no LDL-c threshold below which the benefit of the reduction disappears. The decrease in cardiovascular risk is proportional to the absolute reduction in the concentration of LDL-c regardless of the means by which this reduction is obtained. These data led to the formulation of new guidelines for the management of dyslipidemias relating in particular to a lowering of the LDL-c target and to the complementary use of ezetimibe and anti-PCSK9 antibodies after statins.

[A revolution in the management of type 2 diabetes : antidiabetic agents providing a cardiovascular and renal protection independently of glucose control !]

Type 2 diabetes is a complex disease with an increasing prevalence and a huge morbidity and premature mortality, essentially due to cardiovascular and renal complications. Classical glucose-lowering agents (metformin, sulphonylureas) exert little protective effects on these complications so that emphasis has been put on a multifactorial management targeting all risk factors. Gliptins offer the advantage of an excellent tolerance profile, with no hypoglycaemia or weight gain, but have not shown any specific cardiovascular or renal protection. Over the last decade, new antidiabetic medications (glucagon-like peptide-1 receptor agonists and gliflozins) have demonstrated a cardiovascular and renal protection, independently of glucose control. These data of evidence-based medicine have revolutionized the therapeutic approach of patients with type 2 diabetes who are at high risk of atherosclerotic cardiovascular disease, heart failure and progressive renal disease. Unexpectedly, the protective effect of gliflozins is currently investigated in patients with heart failure or renal disease, in the absence of diabetes.

[Extended indications for antidiabetic agents with cardio-renal protection in updated international recommendations for themanagement of at risk patients with type2 diabetes]

The strategy for the management of type 2 diabetes (T2D) has been updated late 2019-2020 by a group of experts of the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD). The indications of two pharmacological classes that have demonstrated a cardiovascular and renal protection, i.e. sodium-glucose cotransporter type 2 inhibitors (SGLT2i) and glucagon-like peptide-1 receptor agonists (GLP-1AR), are now extended because of the favourable results of recent clinical trials. In patients with T2D at high cardiovascular risk (even without previous event, but with indicators of atherosclerotic disease), the addition of these antidiabetic agents to metformin background therapy is now recommended independently of the glycated haemo¬globin (HbA1c) level. For SGLT2i, the prescription may be extended to patients with an estimated glomerular filtration rate down to 30 (instead of 60) ml/min/1.73 m², in particular in patients with progressive renal disease and albuminuria and in patients at risk of heart failure, especially if left ventricular ejection fraction is reduced. However, these new proposals could not be applied stricto sensu because of strict reimbursement criteria based upon HbA1c currently applied in our country.

[Which injectable therapy after failure of oral antidiabetic agents in type 2 diabetes ?]

The shift to injection therapy, after failure of oral antidiabetic agents, is often considered as a difficult step by both the patient with type 2 diabetes and the physician, a situation that may lead to clinical inertia. Schematically, two options may be considered, either starting insulin therapy with a preference for basal insulin analogues, or adding a glucagon-like peptide-1 receptor agonist (GLP-1 RA). Each option has its advantages and disadvantages, which opens the road to personalized medicine. Nevertheless, the preference is increasingly given to GLP-1 AR, yet this solution is more limited by reimbursement conditions. A combination of the two approaches is also possible, with the recent commercialisation of fixed-ratio specialities combining a basal insulin analogue and a GLP-1 RA. This clinical case offers the opportunity to discuss all these different therapeutic options in a patient with poorly controlled type 2 diabetes despite a combination of oral antidiabetic agents, taking also into account the current conditions for reimbursement in Belgium.

Clinical Impact of Nutritional Status and Energy Balance in Elderly Hospitalized Patients

OBJECTIVES

This study aimed 1) to assess the nutritional status of patients hospitalized in a geriatric ward using the recent Global Leadership Initiative on Malnutrition (GLIM) criteria, 2) to determine the balance between the energy intake (EI) with an enriched diet and the energy requirement (ER) using indirect calorimetry, and 3) to assess whether undernutrition is associated with 1-year outcome.

DESIGN

This is a prospective cross-sectional study.

SETTING

This study was performed in a geriatric unit.

PARTICIPANTS

Patients of this geriatric unit were eligible for the study if they agreed to participate and if they did not meet the exclusion criteria (presence of malignant tumour, uncontrolled heart or renal failure, thyroidal disease, uncontrolled sepsis, oedema of the lower limbs, wearing of a pacemaker, biological thyroid dysfunction and inability to perform walking tests).

MEASUREMENTS

Rest energy expenditure (REE) was measured by indirect calorimetry within the week of hospitalization. Total energy expenditure (TEE) was obtained by multiplying REE by a physical activity level coefficient and energy expenditure that was related to thermogenesis (i.e., 10% of the total amount of energy ingested over 24 h) was added. Food intake was measured over a 3-day period. Undernutrition was defined using MNA and the criteria of the GLIM leadership. Clinical outcomes included 1-year institutionalisation and mortality.

RESULTS

Seventy-nine patients (84.9 ± 5.3 years) were included. A total of 21 (26.6 %) patients were found undernourished. REE was 1088 ± 181kcal/day (17.8 ± 2.9 kcal/kg/day) and TEE was 1556 ± 258 kcal/day (25.4 ± 4.2 kcal/kg/day). Weight-adjusted REE and TEE were higher in undernourished patients compared to those well-nourished (19.8 ± 3.1 vs. 17.1 ± 2.6 kcal/day and 28.4±4.5 vs. 24.4±3.7 kcal/day) (p<0.05). The lower was the Body Mass Index (BMI), the higher was the energy needs (p<0.01). EI was significantly greater than energy requirements (difference requirements - intake with enriched diet = -354 ± 491 kcal/day; p<0.0001). This difference did not depend on BMI (p=0.82), appendicular skeletal mass index (ASMI) (p=0.63), or the presence of undernutrition (p=0.33). At 1-year follow-up, 15 (19%) patients died and 20 (25.6%) were institutionalized. On multivariable analysis, male gender (OR=5.63; p=0.015) and undernutrition (OR=7.29; p=0.0043) emerged as independently associated with death. On multivariable analysis, only ASMI (OR 0.59 (0.35-0.99), p=0.044) and activities of daily living (ADL) (OR 1.14 (1.00-1.30), p=0.043) were significantly associated with institutionalization.

CONCLUSIONS

Undernutrition as assessed by the GLIM criteria remains common in elderly patients hospitalized in a geriatric unit and is associated with increased 1-year mortality but not with institutionalization. Energy requirements are higher in undernourished patients and in patients with a low BMI. Enriched energy intakes could sufficiently cover the energy needs of this population.

[The metabolism of alcohol]

Ethanol is rapidly and almost completely absorbed by the digestive tract, mainly in the small intestine. Alcohol is then metabolized mainly in the liver where it is converted into acetaldehyde. Two systems contribute to this metabolization, the predominant alcohol dehydrogenase pathway, and the pathway controlled by the microsomal ethanol oxidizing system (MEOS), which is inducible and is also involved in the metabolism of other drugs. Acetaldehyde is then metabolized to acetate, which largely leaves the liver to be converted into acetyl-CoA in other tissues. Alcohol is oxidized preferentially to other energetic substrates, leading, in turn, to a decrease in oxidation of lipids which are stored in adipose tissue.

[Metabolic complications and nutritional deficiencies related to excessive alcohol consumption]

Metabolic disturbances associated with chronic alcohol consumption, among which those affecting glucose regulation, lipid profile, uric acid and nutritional status, are described. In fact, alcohol abuse can lead to overweight and obesity, but also to protein-caloric malnutrition. Finally, we will discuss concerns about vitamin and mineral deficiencies that may be observed in alcoholic people and can contribute to aggravate somatic complications.

[Management of hypertriglyceridaemia]

Hypertriglyceridaemia is a common finding in medical practice. The reduction of triglyceride levels may contribute to reduce the cardiovascular risk (at least in patients with low HDL cholesterol) and to avoid the occurrence of acute pancreatitis (in case of severe hypertriglyceridaemia). The discovery of causes of hypertriglyceridaemia (comorbidities, medications) may lead to specific measures. Otherwise, the focus should be put on dietary advises first (reduced caloric intake to promote weight loss, less alcohol, less sucrose), which, if well conducted, may result in spectacular results. If they fail, some pharmacological approaches may be considered, but with generally a limited success rate. Among them, fenofibrate is the best studied and has been shown to be useful for cardiovascular prevention, especially if low HDL cholesterol is associated with hypertriglyceridaemia in patients with type 2 diabetes.

[Management of hyperglycaemia of type 2 diabetes. Paradigm change according to the ADA-EASD consensus report 2018]

The strategy for the management of hyperglycaemia in type 2 diabetes was updated in October 2018 by a group of experts of the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD). They are triggered by the results of cardiovascular outcome trials published since 2015, which demonstrated a cardiovascular (and renal) protection with two classes of medications, SGLT2 inhibitors (gliflozins) and some GLP-1 receptor agonists (mainly liraglutide) in patients with established cardiovascular disease. Thus, after failure of lifestyle and metformin, the addition of one of these agents is recommended in presence of atherosclerotic cardiovascular disease. In case of heart failure or renal disease, the preference is given to a SGLT2 inhibitor, provided that estimated glomerular filtration rate is adequate (superior to 45-60 ml/min/1.73 m²). In all other patients, the choice is guided by the main objective, in concertation with the patient : to reduce the risk of hypoglycaemia (gliptin, gliflozin, pioglitazone or GLP1 receptor agonist), body weight excess (SGLT2 inhibitor or GLP-1 receptor) or medication cost (sulphonylurea, pioglitazone). If oral treatment is insufficient, the preference is now given to a GLP-1 receptor agonist rather than basal insulin. Thus, instead of a glucocentric and metabolic viewpoint predominant in the previous position statement, a paradigm change is proposed, focusing on cardiovascular and renal protection, within a patient-centred approach.

[Reappraisal of metformin : less restrictions and more potential indications]

While commercialized since over 60 years, metformin is still the first-line drug recommended for the management of type 2 diabetes and is thus today the first glucose-lowering agent used worldwide. Despite this long experience, metformin retains its mysteries, especially regarding the underlying mechanisms responsible for its antidiabetic activity and other potential beneficial effects. During the last years, some contra-indications of metformin use have been at least partially withdrawn while new indications have been recognized. Furthermore, interesting prospects have been reported in important, although unexpected, medical areas such as cancer and neurodegenerative diseases. However, promising results in animal studies and observational human studies have now to be confirmed in well conducted randomized controlled trials.

[Contribution of FreeStyle Libre® in the care of diabetic patients : experience at the CHU of Liege]

Since July 2016, diabetic patients included in the INAMI glycemic self-monitoring system in category A in Belgium can benefit from a new system for measuring the concentration of subcutaneous glucose : FreeStyle Libre® (FSL) from Abbott company. The main advantage of this technology is that it is less invasive as it does not require finger blood sampling and allows patients to obtain, in addition to the instantaneous value of glucose concentration, retrospective kinetic data, but also prospective trend of its kinetics. In this study, we mainly evaluated the contribution of FSL on the overall equilibration of diabetes and on the time spent in hypoglycaemia. We also asked patients how satisfied they were with this system. Data from 838 diabetic patients (type 1 or total insulin deficiency) were collected between May 2016 and October 2017, 645 patients with FSL system and 193 preferring to continue self-monitoring of capillary blood glucose (SBG). In the FSL group, compared to the SBG group, there was a slight decrease in HbA1c estimated at 0.15 ± 0.073 % after 15 months. This decrease appears mainly when the starting level is high (HbA1c superior to 7.5 %). Patients perform an average of 8.8 checks per day : the more patients perform daily scans, the greater the number of data comprised within the target, that is, the better the overall glucose control. A higher number of scans is also associated with a decrease in the average duration of hypoglycaemia. Finally, the satisfaction survey shows a high degree of patient satisfaction with the use of FSL.

[Assessment of a digestive malabsorption syndrome]

Malabsorption syndrome is a complex clinical entity that needs to be carefully explored. Patients present frequently chronic diarrhoea associated with weight loss. These symptoms affect patient's quality of life. The assessment of this syndrome requires a detailed anamnesis, a careful clinical exam, the use of biological measurements in both blood and faeces, and, if necessary, other more complex investigations including radionuclide tests. It is important to find the right pathogenesis in order to start effective treatments if possible. First, there are classical bowel pathologies like celiac disease and rarely Crohn disease. Second, biliopancreatic pathologies may also result in a malabsorption syndrome. Of note, this syndrome is very common after abdominal surgery like intestinal resection following mesenteric ischemia, biliopancreatic and gastric surgery. We will use a clinical case of malabsorption after an abdominal surgery to illustrate how to explore these patients who are suffering from malabsorption.

[Faster aspart insulin (FIASP®)]

Fast-acting insulin aspart (faster aspart), commercialized under the trade name of Fiasp®, is insulin aspart in a new formulation aiming to mimic the physiologic prandial insulin release more closely than currently available rapid-acting insulin products. Fiasp® is insulin aspart (NovoRapid®) in which two excipients (L-arginine and niacinamide) have been added, L-arginine serving as a stabilising agent, while niacinamide being responsible for accelerated initial absorption after subcutaneous administration. The pharmacokinetic characteristics of insulin faster aspart have the potential to better reproduce the fast endogenous prandial insulin secretion and thereby to improve postprandial glucose control compared with insulin aspart. The onset phase 3 programme compares head-to-head insulin faster aspart to insulin aspart. Studies showed significant reductions in postprandial glucose increment (in type 1 and type 2 diabetic patients), and glycated haemoglobin (HbA1C, in type 1 diabetes), without markedly increasing the risk of hypoglycaemia. A post hoc analysis of pooled data from six clinical trials conducted in patients with type 1 diabetes confirmed the beneficial pharmacokinetic and pharmacodynamic profiles of insulin faster aspart (earlier plasma insulin appearance, early insulin exposure two times greater and earlier offset of exposure of insulin faster aspart versus insulin aspart).

[SGLT2 inhibitor or GLP-1 receptor agonist in a patient with type 2 diabetes and cardiovascular disease ?]

Two classes of antidiabetic agents have shown a cardiovascular and renal protection in patients with type 2 diabetes and high cardiovascular risk. Empagliflozin, a sodium-glucose cotransporter type 2 (SGLT2) inhibitor, and liraglutide, a glucagon-like peptide-1 (GLP-1) receptor agonist, were granted a reduction of major cardiovascular events and mortality after the positive results of EMPA-REG OUTCOME and LEADER outcome trials, respectively. Protection mechanisms most probably differ between the two pharmacological classes and are perhaps complementary. The question that may arise in clinical practice is to know which drug should be selected between these two options in a patient with type 2 and established cardiovascular disease, before considering a potential combination. The aim of this article is to discuss about the best therapeutic choice according to the patient individual profile and the specificities of each molecule.

[Use of oral glucose-lowering agents in patients with renal impairment]

Patients with type 2 diabetes (T2D) and chronic kidney disease (CKD) are increasingly numerous, especially in the elderly population. Surprisingly, this situation is often under-recognized or even neglected in clinical practice. Yet, most oral antidiabetic (OAD) agents have limitations in case of renal impairment, either because they require a dose reduction, or are contra-indicated mainly for safety reasons. This clinical case gives the opportunity to discuss the modalities of prescription and cautions to be taken when using most commonly prescribed OAD, metformin, insulin secretagogues (sulfonylureas, repaglinide), DPP-4 inhibitors (gliptins) and SGLT2 inhibitors, in a patient with T2D and CKD.

[Diabetes and Ramadan : consequences of fasting and practical aspects of management]

A lot of diabetic Muslims choose to fast during Ramadan, despite recommendations that advise some patients to abstain according to established risk factors. Fasting exposes the diabetic subject to acute major complications, including diabetic ketoacidosis and severe hypoglycaemia. Patients with diabetes, therefore, had to benefit from individualized care already before Ramadan, including a risk assessment, a specific education integrating in particular the adaptation of the pharmacological treatment in order to limit the occurrence of these acute complications.

[Which antidiabetic agent in a patient with type 2 diabetes and heart failure ?]

Heart failure is raising an increasing interest in patients with type 2 diabetes. Indeed, they combine different risk factors for this complication and they have time to develop it because they survive longer due to a better prevention of atherothrombotic cardiovascular events. Beyond the classical therapy of heart failure, management should select the most suited glucose-lowering agents. Indeed, all do not have the same impact as some of them have proven their ability to reduce the risk of hospitalisation for heart failure whereas others are associated with an increased risk, either well proven or at least suspected. The aim of this clinical case is to discuss the use of glucose-lowering drugs in a patient with type 2 diabetes with or at risk to develop heart failure.

[Asthma and obesity]

Asthma and obesity are both common diseases in western world. According to the data from our asthma clinic 20 % of our patients are obese and this rate increases up to 25 % in severe asthmatics included in the Belgian Severe Asthma national Registry. Alteration of thoracic mechanics contributes to greater symptom burden and poor asthma control in obese asthmatics. In particular the response to inhaled corticoids is attenuated. Weight loss results in a dramatic improvement in asthma control and should be a major goal in the asthma management of these patients.

[Optimizing basal insulin therapy in type 2 diabetes]

Because of the natural history of type 2 diabetes and the increasing life expectancy, more and more patients are treated with insulin after failure of oral therapy. International guidelines give the preference to basal insulin, most often while maintaining metformin. If this treatment does not allow to reach the glycaemic objectives, optimizing therapy is mandatory. This clinical case offers the opportunity of discussing both advantages and disadvantages of three therapeutic options : the shift from basal insulin to a basal-plus or a basal-bolus insulin regimen, the addition of another oral glucose-lowering agent, either a dipeptidyl peptidase-4 inhibitor (gliptin) or an inhibitor of cotransporters sodium-glucose type 2 cotransporters (gliflozin), or the combination of basal insulin and a glucagon-like peptide-1 receptor agonist.

Energy and Nutrient Content of Food Served and Consumed by Nursing Home Residents

OBJECTIVE

The aim of this study was to compare energy and protein content of the served food with the actual intake from the food consumed by nursing home residents. This study also aimed to compare food intake and dietary allowances.

DESIGN

This is a cross sectional study.

SETTING

This study was performed in nursing homes.

PARTICIPANTS

Residents of these 2 nursing homes were eligible for the study if they agreed to participate and if they meet the selection criteria (to be older than 65 years and have a regular texture diet).

MEASUREMENT

Nutrient content of the served food and real food consumption was calculated for all meals during a 5-day period by precise weighting method. Difference between consumed and served dietary content was evaluated by the Chi² test.

RESULTS

Seventy-four Belgian nursing home residents (75% of women, 85.8 ± 7.04 years on average) were included in this study. These subjects had a mean body mass index of 24.9 ± 4.83 kg/m². The mean energy content of the served food was 1783.3 ± 125.7 kcal per day. However, residents did not eat the whole of the meals and the actual energy content of the consumed food was significantly less (1552.4 ± 342.1 kcal per day; p<.001). The average protein content of the food served was equal to 0.96 ± 0.20 g/kg/day and the average consumption of protein by the residents was 0.88 ± 0.25 g/kg/day. The difference between protein served and consumed was also significant (p=.04). Moreover, people considered as well nourished, eating significantly more energy than the others (p=.04).

CONCLUSION

Meals served in nursing homes are not entirely consumed by their residents. As expected, the energy consumed are lower in subjects considered as malnourished or at risk of malnutrition.

[About the choice between a DPP-4 inhibitor and a SGLT 2 inhibitor tor treating type 2 diabetes]

Two new classes of oral antidiabetic agents play an increasing role in the management of type 2 diabetes, dipeptidyl peptidase-4 (DPP-4) inhibitors (gliptins) and sodiumglucose cotransporters type 2 (SGLT2) inhibitors (gliflozins). After failure of a monotherapy with metformin (first pharmacological choice in type 2 diabetes), both may offer an alternative to the add-on of a sulphonylurea, especially in patients at risk of hypoglycaemia. However, the choice between a DPP-4 inhibitor and a SGLT2 inhibitor is not easy and should be oriented based upon the individual patient characteristics. The arguments in favour of one or another pharmacological class are discussed, considering a clinical case of a patient with coronary heart disease and type 2 diabetes not well controlled with metformin.

[Clinical approach of a suspicion of hypoglycaemic malaise in a nondiabetic adult]

Malaises are often attributed to hypoglycaemia in nondiabetic people who don't have any other serious medical problem. However, such a diagnosis is often overused, because not really demonstrated in most instances. The diagnosis of hypoglycaemia should be structured, based upon the Whipple triad. First, the anamnesis must search for adrenergic and neuroglucopenic symptoms that suggest hypoglycaemia. Afterwards, hypoglycaemia must be authentified by a measurement of a low glucose level at the time of a malaise. Finally, if the malaise is due to a hypoglycaemia, it should resume rapidly after the administration of sugar. When the diagnosis is made based upon this triad, the medical interview should precise the severity of the symptoms and focus on the chronology of the malaises, after meal or in the fasting state, which is crucial to differentiate functional reactice hypoglycaemia from hypoglycaemia due to an insulinoma. Finally, additional medical examinations may be performed, first based upon clinical biology followed, if necessary, by medical imaging. They will not only confirm the diagnosis of hypoglycaemia, but also contribute to find the cause of hypoglycaemia, which will help in choosing the therapeutic strategy.

[Cardiovascular and renal protection of patients with type 2 diabetes : focus after EMPA-REG OUTCOME and LEADER]

Type 2 diabetes (T2D), often associated with arterial hypertension, represents a high risk of cardiovascular disease and nephropathy. Two clinical trials demonstrate the superiority versus a placebo of two antidiabetic drugs in patients with T2D and high cardiovascular risk : empagliflozin, an inhibitor of sodium-glucose type 2 (SGLT2) cotransporters, in EMPA-REG OUTCOME and liraglutide, an agonist of glucagon-like peptide-1 (GLP-1) receptors, in LEADER. Both medications showed a significant reduction in major cardiovascular events (-14 and -13 %, respectively), cardiovascular mortality (-38 and -22%), all-cause mortality (-32 and -15 %) and renal events (-39 et -22 %). The underlying protective mechanisms remain controverted. Ongoing studies should allow to decide whether the benefits are specific to each molecule or may be attributed to a class effect.

[TECOS: confirmation of the cardiovascular safety of sitaliptin]

The cardiovascular safety of sitagliptin has been evaluated in TECOS ("Trial Evaluating Cardiovascular Outcomes with Sitagliptin"). TECOS recruited patients with type 2 diabetes and a history of cardiovascular disease who received, as add-on to their usual therapy, either sitagliptin (n = 7.257) or placebo (n = 7.266), with a median follow-up of 3 years. The primary cardiovascular outcome was a composite of cardiovascular death, nonfatal myocardial infarction, nonfatal stroke, or hospitalization for unstable angina. Sitagliptin was noninferior to placebo for the primary composite cardiovascular outcome (hazard ratio, 0.98; 95% confidence interval, 0.88 to 1.09; P<0.001). Rates of hospitalization for heart failure did not differ between the two groups (hazard ratio, 1.00; 95% CI, 0.83 to 1.20; P=0.98). The cardiovascular safety of sitagliptin, which was already shown in meta-analyses of phase II-III randomised controlled trials and in observational cohort studies in real life, is now confirmed in the landmark prospective cardiovascular outcome study TECOS.

[2015 updated position statement of the management of hyperglycaemia in type 2 diabetes]

The strategy for the management ot type 2 diabetes, summarized by a group of European and American experts, has been updated early 2015. A patient-centered approach is recommended and the first drug choice is metformin combined with lifestyle improvement. After failure of metformin monotherapy, the selection of a second drug should be based on the efficacy, safety and cost of each pharmacological class. When compared to the position statement of 2012, the most important changes are the possible addition of a gliptin to a dual oral therapy or even to insulin, the commercialization of sodium-glucose cotransporters type 2 (SGLT2) inhibitors (gliflozins, to be used in dual or triple therapy, even in combination with insulin) and the possible combination of a glucagon-like peptide-I receptor agonist together with a basal insulin.

Inhibiting or antagonizing glucagon: making progress in diabetes care

Absolute or relative hyperglucagonaemia has been recognized for years in all experimental or clinical forms of diabetes. It has been suggested that excess secretion of glucagon by the islet α cells is a direct consequence of intra-islet insulin secretory defects. Recent studies have shown that knockout of the glucagon receptor or administration of a monoclonal specific glucagon receptor antibody make insulin-deficient type 1 diabetic rodents thrive without insulin. These observations suggest that glucagon plays an essential role in the pathophysiology of diabetes and that targeting the α cell and glucagon are innovative approaches in the management of diabetes. Despite active research and identification of promising compounds, no one selective glucagon antagonist is presently used in the treatment of diabetes. Interestingly, besides insulin, several drugs used today in the management of diabetes appear to exert their effects, in part, by inhibiting glucagon secretion (glucagon-like peptide-1 receptor agonists, dipeptidyl peptidase-4 inhibitors, α-glucosidase inhibitors and, possibly, sulphonylureas) or glucagon action (metformin). The potential risks associated with total glucagon suppression include α-cell hyperplasia, increased mass of the pancreas, increased susceptibility to hepatosteatosis and hepatocellular injury and increased risk of hypoglycaemia, and these should be considered in the search and development of new compounds reducing glucagon receptor signalling. More than 40 years after its initial description, hyperglucagonaemia in diabetes can no longer be ignored or minimized, and its correction represents an attractive way to improve diabetes management.

Metabolic effects of SGLT-2 inhibitors beyond increased glucosuria: A review of the clinical evidence

Sodium-glucose cotransporter type 2 (SGLT-2) inhibitors (canagliflozin, dapagliflozin, empagliflozin) are new glucose-lowering agents that exert their therapeutic activity independently of insulin by facilitating glucose excretion through the kidneys. However, this simple renal mechanism that results in sustained glucose urinary loss leads to more complex indirect metabolic effects. First, by reduction of chronic hyperglycaemia and attenuation of glucose toxicity, SGLT-2 inhibitors can improve both insulin secretion by beta cells and peripheraltissue insulin sensitivity. In the case of canagliflozin, because of low-potency SGLT1 inhibition, a non-renal (intestinal) effect may also be considered, which may contribute to better control of postprandial hyperglycaemia, although this contribution remains to be better analyzed in humans. Second, chronic glucose loss most probably leads to compensatory mechanisms. One of them, although not well evidenced in humans, might involve an increase in energy intake, an effect that may limit weight loss in the long run. Another could be an increase in endogenous glucose production, most probably driven by increased glucagon secretion, which may somewhat attenuate the glucoselowering effect. Nevertheless, despite these compensatory mechanisms and most probably because of the positive effects of the reduction in glucotoxicity, SGLT-2 inhibitors exert clinically relevant glucose-lowering activity while promoting weight loss, a unique dual effect among oral antidiabetic agents. Furthermore, the combination of SGLT-2 inhibitors with other drugs that either have anorectic effects (such as incretin-based therapies) or reduce hepatic glucose output (like metformin) and, thus, may dampen these two compensatory mechanisms appears appealing for the management of type 2 diabetes mellitus.

Inflammatory markers and cardiometabolic diseases

OBJECTIVES

A growing body of evidence emerges that obesity, metabolic syndrome, type 2 diabetes and cardiovascular disease are intimately related to chronic inflammation.

METHODS

A narrative review summarizing the most recent data of the literature describing the pathological implications of inflammation in obese patients with cardiometabolic disorders.

RESULTS

Besides high-sensitive C-reactive protein, various circulating or in situ inflammatory markers have been identified, presumably reflecting the presence of inflammation in various key-organs (visceral adipose tissue, skeletal muscle, pancreatic islets, liver, intestine, arterial wall). Available data support the concept that targeting inflammation, not only reduces systemic inflammatory markers, but also improves insulin sensitivity and ameliorates glucose control in insulin-resistant patients, thus potentially reducing the risk of cardiovascular complications.

CONCLUSION

These observations confirm the role of inflammation in cardiometabolic diseases and support the development of pharmacological strategies that aim at reducing inflammation, especially in patients with type 2 diabetes.

[FROM EVIDENCE-BASED MEDICINE TO PERSONALIZED MEDICINE: THE EXEMPLE OF TYPE 2 DIABETES]

Type 2 diabetes represents a major medical and public health problem due to its huge heterogeneity, the alarming rise of its incidence worldwide and its associated vascular complications, which impair quality of life and reduce life expectancy. At the present time, a patient-centered approach is recommended for the management of type 2 diabetes patients. However, these recommendations are not easy to implement because we only have little objective evidences to establish individualized strategies. Following the recent introduction of new drug classes, a large number of combinations is offered to clinicians, but we do not have high quality interventional studies comparing these different therapeutic possibilities. Moreover, the response to pharmacological treatment can vary greatly from one subject to the other. Pharmacogenetics might be a useful tool to better characterize the patient. However, despite some progress, the evidence we now have is very preliminary and should not allow to improve significantly the individual management of type 2 diabetes in the near future.

[Diabetes mellitus in the elderly: from the epidemiological challenge to a personalized approach]

Diabetes mellitus is a common chronic disease in the elderly, being either a known disease with a long history (type 1 or even more often type 2 diabetes) and then frequently associated with various diabetic complications, or a recently diagnosed diabetes that may, however, have been ignored for a rather long time. In this latter case, diabetes may present as the occurrence or aggravation of one or several geriatric syndromes that overall result in a loss of autonomy. The global geriatric assessment, the estimation of life expectancy and the justification of glucose-lowering treatments should be performed at regular intervals in elderly diabetic people as they determine the right choice of glucose target levels and the best selection of glucose-lowering agents. Medications that can induce hypoglycaemia should ideally be avoided, especially in the frailty older population. The benefit-risk ratio of the proposed therapies should be analyzed first, and then regularly reassessed because of a potentially rapidly progressing condition. The recommended approach is a tailored management of diabetes that should integrate the clinical, functional and psycho-social aspects of elderly individuals.

[Nutrition in the elderly]

Ageing of the body predisposes to a high incidence of undernutrition in the elderly person wherever he or she is living, but the prevalence of malnutrition is particularly high in hospitalized or instutionalized patients. Early detection of malnutrition is important because malnutrition may have significant consequences and evaluation of nutritional status has to be a routine screening in the elderly. There is no single parameter which supplies a full assessment of the patient's nutritional status. It is then necessary to use screening tools for the identification of patients at nutritional risk, based on anamnestic, antropometric and biological data. The MNA (Mini Nutritional Assessment) test is a simple, non invasive, well-validated screening tool for malnutrition in the elderly and is recommended for early detection of risks of malnutrition. Numerous conditions in relationship with physiological ageing, comorbidity, polymedication and the way of life of the individual predispose to undernutrition. Healthy nutrition in older patients should respect the guidelines for protein and energy requirements, excepted in severely ill patients and/or in case of malnutrition in which case the protein-energy intake should be increased.