Case report Liraglutid and insuline resistance

Abstract

Weight reduction in patients with cardiovascular (CV) diseases and concurrent overweight or obesity brings a fundamental improvement in health and prognosis of such diseases, a proven reduction in mortality and morbidity, and is associated with a reduction in pharmacotherapy and the number of hospitalizations, therefore, it is also economically effective. With the current growing trend in population, obesity also becomes a population risk factor that is more significant than smoking, and a leading cause of preventable diseases. From this point of view, the availability of a new effective anti-obesity medication is very welcome, in particular, liraglutide elegantly interferes with the physiological mechanisms regulating food intake. In addition, it reduces the risk of developing diabetes and has anti- atherogenic effects. At the obese diabetic 2 type patients on insulin treatment often resistance develops and in spite of high insuline dosage inadequate control of glucose and HbA1c levels are obvious. We present the extreme case on this topic down: May 2013: first examination dated in our database of cardiology care dept. for out patients, 65 years old man, weight 144 kg, height 178 cm, waist circumferrence 143cm. His history: arterial hypertension since 1993, diabetes 2 type since 2008 on peroral treatment, paroxysmal atrial fibrilation since March 2013, diameter of the left atrium 50mm on ECHO, invasive coronarography negat. Therapy: telmisartan, metoprolol, nitrendipin, warfarin, propafenon, digoxin, spironolacton, statin. November 2013: effect of therapeutic lifestyle changes: regular sinus rhythm, weight 133kg, waist circumferrence 134cm, spironolacton substituted by eplerenon (asymetric gynecomastia), digoxin ex May 2014: weight 126kg, September 2014: atrial fibrilation, propafenon substituted by flekainid, then atrial flutter, switch from flekainid to amiodaron and digoxin, warfarin substituted by apixaban February 2015: sinus rhythm , weight 129kg December 2015: weight 140kg, BP 170/90 mmHg, atrial flutter with a-v blockage 4:1, ankle oedema on both sides, Hb 115g/l, urinary acid 499umol/l, creatinin 119 umol/l, added allopurinol, urapidil, furosemid May 2017: intensification of the diabetes treatment, added insulin application, dosage escalation during the next years, on ECHO: left atriium diameter 52mm, left ventricle diameter 62mm, systolic function of the left ventricle preserved, moderate mitral and tricuspidal regurgitation December 2017: sinus bradycardia 46/min, amiodaron and digoxin ex, sick sinus syndrom brady-tachycardia form, hepatomegaly July 2018: bariatric procedure contraindicated by surgeon because of age and health status December 2018: creatinin 169umol/l, urinary acid 652umol/l October 2019: weight 158 kg, hospitalisation for heart failúre, confirmed by increased NT- BNP level, therapeutic changes from sartan to ARNI, from warfarin to apixaban, increased furosemid dosage. February 2021: weight 159kg, O2 peripheral saturation 93%, start of partial fasting (8:16) May 2021: signifficant dyspnoe, NYHA III, ECHO: left atrium diameter 56mm, left ventricle diameter 70mm, EF of the left ventricle 0,50, E/A 0,7 March 2022: attempt to implantate permanent cardiostimulation device unsuccesfull because of anatomic venous abnormalities. Brain MRI: postischemic frontal area defect right side Creatinin 220 umol/l, kalium 5,4 mmol/l, Hb 121 g/l, diabetic nephropathy. Weight 160kg. Added iron supplement. In spite of high insulin dosage (Humalog 3x20 units and basal 2x50 units) 160 units per day the glucose level were around 20mmol/l July 2022: weight 161 kg, starting of liraglutid daily application of 0,6mg s.c., dosage escalation every week to 1,2, 2,4, 3,0 mg. October 2022: hunger feeling was signifficantly reduced, eating of smaller portions, without craving between main time schedule of eating. Weight reduced to 151kg during first 3 months of liraglutid application (cca minus 100g per day), insulin dosage was reduced to 60 units daily (Humalog ex, basal insulin reduced to 60 units) what was accompanied by signifficant glucose level reduction to around 8 mmol/l. Creatinin level was 166 umol/l, acidum uricum level was 323 umol/l. January 2023: weight 157kg, fat content 50%, water content 40%. ECHO: left ventricle diameter 60mm, EF 0,5, left atrium diameter 54mm, tricuspidal regurgitation not detected, E/A 0,7. creatinin 128 umol/l , kalium 4,5 mmol/l.