Introduction Of Insulin Therapy Research Articles

Effects of periodontal management for patients with type 2 diabetes on healthcare expenditure, hospitalization and worsening of diabetes: an observational study using medical, dental and pharmacy claims data in Japan

To investigate the effects of regular periodontal management for people with type 2 diabetes on total healthcare expenditure, hospitalization and the introduction of insulin. We collected data of individuals who were prescribed diabetes medications during the fiscal year 2015 from the claims database of a prefecture in Japan. We fitted generalized linear models that had sex, age, comorbidities and the status of periodontal management during the previous two years as predictors. A total of 16,583 individuals were enrolled. The annual healthcare expenditure in the third year was 4% less (adjusted multiplier 0.96, 95% confidence interval [CI] 0.92-1.00) in the group receiving periodontal management every year. The adjusted odds ratio (aOR) for all-cause hospitalization was 0.90 (95% CI: 0.82-0.98). The aOR of introducing insulin in the third year for those who had not been prescribed insulin during the previous two years (n=13,222) was 0.77 (95% CI: 0.64-0.92) in the group receiving periodontal management every year. Regular periodontal management for diabetic people was associated with reduced healthcare expenditure, all-cause hospitalization and the introduction of insulin therapy.

Nurse management of glycemia in cardiac intensive care

Abstract Introduction Scientific studies have shown that hypoglycaemia is an important risk factor for adverse events in cardiac intensive care. Nursing management of blood glucose, via protocol, is an important tool to avoid cases of hypoglycaemia. Objective We evaluate the efficacy and safety of a glycemia control protocol based on nursing management in diabetic patients in Intensive Care Unit. Material and methods We conducted a retrospective analysis on 500 patients hospitalized for acute coronary syndrome or heart failure, with an average age of 75±12 years, clinically stable. The protocol used provides, on medical indication, the suspension of home therapy (both oral hypoglycemic agents and insulin) and the introduction of insulin therapy according to the scheme 0.2/0.5 IU/kg/day. The dosage lower than 0.2 IU/kg/day is used for patients in home therapy with oral hypoglycemic agents and basal blood sugar <150 mg/dl and the dose greater than 0.5 IU/kg/day for patients already on home insulin therapy and basal blood sugar> at 200 mg/dl. The intermediate dosage. 3–0.4 IU/kg/day is instead used in patients with glycaemia between 150 and 200 mg/dl regardless of home therapy. On the basis of the dosage schedule, the daily insulin requirement is obtained which is then administered at 50% as a slow analogue at 10 pm and at 50% as a rapid analogue, further divided into three doses with each main meal. Once the initial therapy has been set, the nurse acts autonomously according to a correction algorithm (based on the calculation of the correction factor (FC) according to the formula FC = 3000/body weight in kg or FC = 1700/total daily dose of insulin > FC = reduction in blood glucose in mg/dl determined by 1 IU of insulin) which provides for the modification of insulin therapy based on the patient's weight and the blood glucose values measured with sticks at 8, 12, 18 and 22. If during hospitalization and/or discharge, inadequately controlled glycemic values persist, the patient is sent to diabetes advice and the current home therapy is resumed upon discharge or according to diabetes advice. Results We observed an excellent pre and post prandial glucose control with extremely reduced incidence of hypoglycaemia which occurred in only 3 cases, one of which with severe hypoglycaemia (glucose detected <40 mg/dl, resolved with the administration of glucose 33 20ml% followed by infusion of 10% glucose solution and glycemic stick after 15') for administration error and two with moderate hypoglycaemia (glucose detected between 40–70 mg/dl resolved with the reduction of 2 IU of rapid analogue and repeated stick post prandial). Conclusions A nursing management protocol for blood glucose values in patients with diabetes mellitus hospitalized for acute coronary syndrome or heart failure is safe and allows good control of blood glucose values. Funding Acknowledgement Type of funding source: None

The treatment of diabetes with new generation drugs

Introduction: Diabetes is a global problem, affecting nearly 422 million people around the world. Pathogenesis includes a defect in secretion or insulin activity. This results in an increase in the glucose level, which is associated with the development of complications. These include changes in peripheral vessels and nerves that lead to their damage. It is necessary to introduce appropriate treatment in the earliest stages of the disease to prevent these effects.Materials and methods: The aim of this work is to present knowledge about the treatment based on the recommendations of the Polish Diabetes Association, American Diabetes Association, as well as a literature review and analysis of publications published on PubMed and Google Scholar platforms.Results: Over the years, the recommendations and recommendations for treatment change. Recently, a greater role has been given to the latest antidiabetic drugs. This group includes SGLT-2 inhibitors as well as incremental drugs, the main representatives of which are GLP-1 analogues. These drugs affect the level of glycemia, but also have a beneficial effect on weight reduction and reduce the risk of cardiovascular events. Recently, Poland has introduced reimbursement of some new generation antidiabetic drugs such as dapaglyphosin, empaglyphosin and canaglyphosin.Conclusions: Dynamic development of diabetes treatment helps to slow down the course of the disease and postpones the introduction of insulin therapy as the final treatment method. Reimbursement of some antidiabetic drugs enables patients to have better access to drugs that have not been within their reach so far. The changes introduced are, in a way, groundbreaking in the treatment of diabetes.

Is Dipeptidyl Peptidase-4 Inhibitor a Risk Factor to Develop Permanent Hypothyroidism in Subacute Thyroiditis in Patients with Type 2 Diabetes Mellitus?

Abstract Introduction: Permanent hypothyroidism rationale is presented in 5 - 26% of the subacute thyroiditis patients. In the last decade, three cases of Subacute Thyroiditis (SAT) were treated with Dipeptidyl Peptidase-4 Inhibitor (DPP-4i) in patients with Type 2 Diabetes Mellitus (T2DM). Case Presentation: Case 1:52-year-old woman presented with T2DM on tolbutamide and sitagliptin. She was diagnosed with SAT and managed with loxoprofen sodium hydrate while maintaining her antidiabetic agents. Three months later, the thyroid function returned to euthyroid condition. Case 2: 74-year-old man T2DM patient on metformin, glimepiride, and sitagliptin. He was diagnosed with SAT and managed with loxoprofen sodium hydrate while maintaining ongoing antidiabetic management. One month later, his thyroid function deteriorated to hypothyroidism and further nine months later, the thyroid returned to euthyroid function. Case 3: 69-year-old-man T2DM patient on vildagliptin. He was diagnosed with SAT and managed with prednisolone (10mg/ day) with cessation of vildagliptin and introduction of insulin therapy. One month later, the thyroid function returned to euthyroid function. Conclusions: We experienced SAT during the administration of DPP-4i in three T2DM patients. Although one of them experienced transient hypothyroidism, none developed permanent hypothyroidism. DPP-4i may not be a risk factor of permanent hypothyroidism in SAT patients with T2DM. Keywords DPP4 inhibitors; Subacute thyroiditis; Type 2 diabetes mellitus Abbreviations DPP-4i: Dipeptidyl Peptidase-4 Inhibitor; TSH: Thyroid Stimulating Hormone; FT3: Free Triiodothyronine; FT4: Free Thyroxine; Tg: Thyroglobulin; CRP: C-Reactive Protein; Trab: TSH Receptor Antibody; Anti-Tg-Ab: Anti-Thyroglobulin Antibody

Profile pacjentów, u których warto stosować insuliny ludzkie – część II

The paper presents cases of early using of insulin therapy. The use of human insulin at the beginning of therapy of diabetes mellitus is possible when the introduction of insulin therapy was delayed and the HbA1c is significantly above the therapeutic target.

Partial Clinical Remission of Type 1 Diabetes Mellitus in Children: Clinical Applications and Challenges with its Definitions

The honeymoon phase, or partial clinical remission (PCR) phase, of Type 1 diabetes mellitus (T1DM) is a transitory period that is marked by endogenous insulin production by surviving β cells following a diabetes diagnosis and the introduction of insulin therapy. It is a critical window in the course of the disease that has short and long-term implications for the patient, such as a significant reduction in the risk of long-term complications of T1DM. To promote long-term cardiovascular health in children with newly diagnosed T1DM, three key steps are necessary: the generation of a predictive model for non-remission, the adoption of a user-friendly monitoring tool for remission and non-remission, and the establishment of the magnitude of the early-phase cardiovascular disease risk in these children in objective terms through changes in lipid profile. However, only about 50% of children diagnosed with T1DM experience the honeymoon phase. Accurate and prompt detection of the honeymoon phase has been hampered by the lack of an objective and easily applicable predictive model for its detection at the time of T1DM diagnosis, the complex formulas needed to confirm and monitor PCR, and the absence of a straightforward, user-friendly tool for monitoring PCR. This literature review discusses the most up-to-date information in this field by describing an objective predictive model for non-remission, an easy tool for monitoring remission or non-remission, and objective evidence for the cardiovascular protective effect of PCR in the early phase of the disease. The goal is to present non-remission as an independent clinical entity with significantly poorer long-term prognosis than partial remission.

Allo- and auto-percutaneous intra-portal pancreatic islet transplantation (PIPIT) for diabetes cure and prevention: the role of imaging and interventional radiology.

Although the life expectancy of patients with type 1 diabetes mellitus (T1DM) has improved since the introduction of insulin therapy, the acute life-threatening and long-term complications from diabetes mellitus are significant causes of both mortality and morbidity. Percutaneous intra-portal pancreatic islet transplantation (PIPIT) is a minimally invasive, repeatable procedure which allows a β-cell replacement therapy through a liver islet engraftment, leading to insulin release and glycaemic control restoration in patients with diabetes. Allo-PIPIT, in which isolated and purified islets from cadaveric donor are used, does not require major surgery, and is potentially less expensive for the recipient. In case of long-term T1DM, islet-after-kidney (IAK) transplantation can simultaneously cure diabetes and chronic renal failure, while islet-transplant-alone (ITA) is performed in brittle, short-term T1DM, based on the infusion of an adequate islet mass and on a steroid-free immunosuppressive regimen according to the Edmonton protocol. Results of the Collaborative Islet Transplant Registry (CITR) demonstrate that allo-PIPIT reduces episodes of hypoglycemia and diabetic complications, and improves quality of life of diabetic patients. Auto-PIPIT, in which the own patient's islets are used, has been investigated as a preventive treatment for pancreatogenic diabetes in patients who undergo extensive pancreatectomy for malignant and non-malignant disease. This Review outlines the role of imaging and interventional radiology in allo- and auto-PIPIT.

Heterogeneity of change in state affect following insulin therapy initiation in type 2 diabetic patients

Abstract The aim of the study was to explore heterogeneity of change in state affect following the introduction of insulin therapy in patients with type 2 diabetes. State affect was assessed twice among 305 patients: just before the introduction of insulin therapy and at 1-month follow-up. Latent class growth modeling showed that negative affect (NA) increased in 78% of the sample, whereas positive affect (PA) improved in only 17% of the participants. On the basis of cross-tabulation of these changes a 4-class model of emotional response to the new treatment was obtained. The largest subgroup of participants (57%) manifested “threat response”, i.e. moderate-stable PA with increase in NA. Participants in the “challenge response” subgroup (11.8%) showed increases in both NA and PA. The third class (10.2%) characterized by “no response”, had low-stable NA and moderate-stable PA. The smallest “stress response” subgroup (9.8%) showed increase in NA and high-stable PA. Gender, age and education level were significant covariates of group membership. Thus, the findings revealed heterogeneous emotional response to the new treatment, which may be of clinical relevance for improving diabetic patients’ adjustment through a more individual, person-centered approach.

Latent Autoimmune Diabetes in Adults Complicated by Persistent Isolated Glucosuria in the Absence of Hyperglycemia

Latent autoimmune diabetes in adults (LADA) is an autoimmune diabetes of adult-onset with the presence of diabetes associated autoantibodies. Familial renal glucosuria (FRG) is an inherited renal tubular disorder that causes persistent isolated glucosuria in the absence of hyperglycemia. We report a novel case of LADA and certain FRG. A 44-year-old man was admitted to our hospital for uncontrolled diabetes. Before admission, he had never suffered from diabetic coma and showed an improvement in HbA1c only with diet therapy. His HbA1c was 11.9% (107 mmol/mol), and anti-glutamic acid decarboxylase antibody was 13.0 U/mL. A glucagon stimulation test showed the decrease of insulin secretion: plasma C-peptide (CPR) 0 min, 0.69 ng/mL; CPR 6 min, 0.90 ng/mL. Analysis of genomic DNA revealed a novel heterozygous mutation in the SGLT2 coding gene, SLC5A2 (c.875G >A, p.Cys292Tyr), which was assessed as probably damaging with a score of 0.998 (sensitivity: 0.27; specificity: 0.99) by an in silico analysis. Therefore, he was diagnosed with LADA and certain FRG. He has not shown any symptoms and his HbA1c improved to 6.4% (46 mmol/mol) three months after the introduction of insulin therapy. Our case clearly implies the clinical effectiveness of SGLT2 inhibition in patients with LADA.

Factors associated with early beginning of partial remission in young adult patients with newly diagnosed type 1 diabetes

Clinical remission of type 1 diabetes reflects the transient recovery of β-cell function and improvement in insulin sensitivity, occurring after introduction of insulin therapy. The aim of the study was to identify factors associated with early beginning of partial remission phase in patients with newly diagnosed type 1 diabetes. One hundred and sixteen patients (41 women and 75 men), aged 18–34 (mean age 23.8 ± 8.7 years), were included into the study. Mean hospitalization time was 7 ± 2 days. Early remission was defined as reaching total daily insulin dose <0.3 U/kg with correct glycaemia in 24-h (7-point) glycaemic profile before discharge from the hospital, with random serum C-peptide above 0.5 μg/l. In group entering early remission (74 patients), significantly lower HbA1c values (9.6 ± 2.6 vs. 11.5 ± 4.5 %, p < 0.001), higher body mass index (BMI) (21.9 ± 2.9 vs. 20.8 ± 4.2 kg/m2, p < 0.05), less frequent ketonuria (45 vs. 79 %, p < 0.01) and diabetic ketoacidosis (11 vs. 26 %, p = 0.06) were recorded at diagnosis. The results indicate that degree and duration of metabolic disturbances are associated with early beginning of partial remission in young adults with newly diagnosed type 1 diabetes. Early onset of remission is common in this age group.

Mortality in childhood-onset type 1 diabetes: Nationwide population based data from Norway

Type 1 diabetes with onset in childhood (0-14.9 years) represents one of the most frequent chronic diseases in children and young adults. Norway has one of the highest incidences of childhood onset type 1 diabetes in the world. Before introduction of insulin therapy in 1922, few children survived more than one to two years after clinical onset. When insulin came available, a major shift occurred in the distribution of causes of death in type 1 diabetic patients away from diabetic coma, which dominated the pre-insulin era, to renal and cardiac diseases. The disease is related to a significant burden to society and patients because most cases require lifelong treatment with insulin as well as day-to-day monitoring. Type 1 diabetes also confers increased risk of severe late complications such as renal failure, blindness, amputations, heart disease and stroke. Despite advances in diabetes treatment, type 1 diabetes is still associated with considerable premature mortality resulting from acute and chronic complications of diabetes and an increase in mortality at every age. Although the main cause of death in type 1 diabetes is long-term complications, an excess death rate has also been reported in subjects with short duration without signs of long-term complications.

Diabète néonatal permanent par mutation récessive du gène de l’insuline : une observation familiale

Permanent neonatal diabetes mellitus is a rare disorder usually presenting within the first few weeks or months of life and defined by chronic hyperglycemia due to severe nonautoimmune insulin deficiency. Nonsyndromic neonatal diabetes is genetically heterogeneous and several genes have been linked to this disorder. Here, we report on a new homozygous recessive mutation in the INS gene in 2 siblings born to consanguineous parents and diagnosed with permanent neonatal diabetes without extrapancreatic features. Their clinically unaffected parents were heterozygous. Their phenotype was also characterized by severe intrauterine growth retardation, most likely reflecting severe insulin deficiency in prenatal life, hyperglycemia, and moderate dehydration in the first few days of life. Their clinical course was uneventful after introduction of insulin therapy with catch-up growth and acquisition of normal developmental milestones.

Investigation of the introduction of three times daily injections of Insulin Lispro Mixture‐50 on an outpatient basis: Therapeutic effects of 12 months’ treatment with and without concomitant sulfonylurea

There is no definitive evidence as to whether oral hypoglycemic agents (OHA) should be continued or withdrawn prior to the introduction of insulin therapy on an outpatient basis. Insulin Lispro Mixture-50 (LM-50), which supplements basal insulin secretion because of the presence of the intermediate-acting component contained in it, may enable more stable glucose control and allow discontinuation of prolonged OHA therapy, such as with sulfonylureas (SU). To determine whether the introduction of three times daily (t.i.d.) injections of LM-50 on an outpatient basis was effective in yielding adequate glucose control in patients with type 2 diabetes (T2D) who had poor glucose control despite treatment with OHA, patients were divided into two groups: those in whom the use of all OHA except SU was suspended [the SU(+) group; n = 10] and those in whom all OHA, including SU, were discontinued [the SU(−) group; n = 12]. Twenty-two patients with T2D undergoing treatment at Saiseikai Niigata Second Hospital were included in the study. Patients had been treated with maximum doses of OHA, but had failed to show adequate glucose control (HbA1c ≥7%). All patients refused inpatient therapy, but agreed to receive LM-50 injections t.i.d. on an outpatient basis. All patients provided informed consent for inclusion in the present study, which was an open-label, randomized, active-controlled, parallel-group, comparative study. For patients in the SU(+) group, SU was continued at the same dose and LM-50 injections were started at a dose of 0.1 units/kg, t.i.d. Patients in the SU(−) group were started on the same dose of LM-50, but all OHAs were discontinued. The primary efficacy endpoint was the change in HbA1c level. After 1–2 months of LM-50 injections, patients began to get used to the self-monitoring of blood glucose levels and the dose of LM-50 injected was adjusted with the aim of reducing preprandial blood glucose levels to ≤130 mg/dL. Changes in HbA1c levels for patients in both the SU(+) and SU(−) groups are shown in Fig. 1. For the 10 patients in the SU(+) group, significant decreases in HbAlc started to be seen after 1 months treatment with LM-50. Similarly, patients in the SU(−) group exhibited significant decreases after 1 months treatment with LM-50. At the end of 12 months, significant improvements were observed in both the SU(+) and SU(−) groups, with the effects of LM-50 t.i.d. almost the same, regardless of whether SU was continued or discontinued. In the SU(+) group, the percentage of patients in whom HbA1c fell to <7.0% or <6.5% was 50% and 20%, respectively, compared with 66.7% and 41.7%, respectively, in the SU(−) group. There was no significant difference in the percentage change in HbA1c or the percentage of patients in whom HbA1c fell to <7.0% and <6.5% between the two groups. Figure 1 Mean HbA1c levels in patients in whom the use of all oral hypoglycemic agents (OHA), except sulfonylureas (SU), was suspended [SU(+) group; n = 10; ◆] and those in whom all OHA, including SU, were discontinued [SU(−) group; n = 12; ]. ... The body mass index (BMI) and insulin dose administered increased significantly in both the SU(+) and SU(−) groups over the 12-month treatment period (Table 1). There were no significant differences in terms of the percentage change in BMI or the insulin dose between the two groups (Table 1). Table 1 Baseline characteristics and the outcomes and changes from baseline after 12 months treatment of patients in whom the use of all oral hypoglycemic agents (OHA), except sulfonylureas (SU), was suspended [SU(+) group] and those in whom all OHA, ... Furthermore, although the incidence of slight hypoglycemia was the same in the SU(+) and SU(−) groups, serious hypoglycemia did not occur in any of the patients in either group during the 12-month observation period. In general, it is believed that when insulin therapy is introduced on an outpatient basis, complete discontinuation of SU treatment often results in a decrease in the amount of insulin that enters the portal vein, thereby exacerbating hyperglycemia. However, this scenario was not observed in the present study, probably because the LM-50 used in the present study contained both an ultraquick-acting component and an intermediate-acting component (in a ratio of 1:1) and the intermediate-acting component acted in lieu of the basal secretory component induced by SU treatment. Because the LM-50 used in the present study contains bolus insulin and basal insulin at a ratio of 1:1, it is believed that this provides insulin in a pattern that approximates physiological secretion in humans.1,2 In conclusion, LM-50 injections administered three times daily produced almost the same effects in patients with initially poor glycemic control on OAH, regardless of whether SU was continued.

Clinical Perspectives on Motivational Interviewing in Diabetes Care

During the past two decades, prolific development has occurred in the areas of medication and self-management technology options for people with diabetes. No other time period since the introduction of insulin therapy in the 1920s has seen such significant improvements in diabetes care. However, despite these improvements, there are still sizable gaps in quality outcomes for people with diabetes. These gaps in care are manifested in research reflecting that overwhelming numbers of people with diabetes do not meet guidelines for glycemic control, blood pressure, and lipid levels.1,2 These care gaps are also accompanied by challenges clinicians experience in facilitating behavior change across the entire spectrum of diabetes care: physical activity, diet, weight loss, regular use of medications, and the use of well-established algorithms linking self-monitoring of blood glucose to medication and lifestyle self-management. We, as clinicians, experience pain and frustration when our patients with diabetes develop complications that could have been delayed or prevented by enhanced self-management. But few of us received training to prepare us for the seemingly daunting tasks of working with the ambivalence, resistance, depression, and burnout that many experience living with diabetes. Few illnesses affect as many aspects of life as diabetes.3 For decades, I practiced in primary care with a special interest in diabetes. After pursuing additional training, I transitioned my practice several years ago to working exclusively in diabetes care with a special interest in the behavioral aspects of self-management. My practice now is populated by referrals from other clinicians to see people who are struggling with or completely neglecting their diabetes self-management. In this article and a second one that will be published in the next issue of Diabetes Spectrum , I will share perspectives on motivational interviewing (MI). This collaborative approach to diabetes care offers clinicians who are …

Autoimmune Diabetes in HIV-Infected Patients on Highly Active Antiretroviral Therapy

Various autoimmune diseases, especially autoimmune thyroid disease, are known to occur in HIV-infected patients on highly active antiretroviral therapy (HAART). However, no reports have described the development of autoimmune diabetes during HAART. Our objective was to investigate the clinical course of the development of autoantibodies and diabetes during HAART. Based on their high antiislet autoantibody titers and requirement for insulin therapy, we diagnosed three HIV-infected patients with autoimmune diabetes. To clarify the relationship between the development of an autoimmune reaction against pancreatic beta-cells and recovery of CD4+ T lymphocyte (CD4) counts, we retrospectively assayed stored samples of the patients' plasma for antiglutamic acid decarboxylase antibody (GAD-Ab). No GAD-Ab was detected in the plasma samples of any of the three patients prior to HAART, and their CD4 counts were below 20 cells/microl at their nadir. The GAD-Ab tests became positive from 6 to 38 months after the start of HAART, and their conversion to positive followed a dramatic increase in the patients' CD4 count. Two patients developed diabetes after testing positive for GAD-Ab. Although one patient had mild diabetes prior to testing positive for GAD-Ab, the rapid worsening of glycemic control and introduction of insulin therapy almost coincided with the detection of GAD-Ab. The high magnitude of the CD4 increase during HAART and the timing of the detection of autoantibody were similar to the magnitude and timing reported in HAART-associated autoimmune thyroid disease. Autoimmune diabetes develops in some HIV-infected patients after immune restoration during HAART.

Insulin detemir: a better basal insulin for the management of diabetes?

The prevalence of diabetes mellitus continues to grow. The current number of people in the USA diagnosed with diabetes has reached 17.5 million and, in 2007, the cost of the disease reached US$174 billion. The common feature of diabetes is the relative lack of insulin. This defect appears to worsen over the lifetime of the individual, necessitating the introduction of insulin therapy in most affected individuals. Of the various choices, basal insulin is commonly initiated as the first insulin. There are three choices for basal insulin; two insulin analogs (insulin glargine and insulin detemir) and neutral protamine Hagedorn (NPH) insulin. Although NPH is inexpensive, its use is fraught with unpredictability and, in some cases, an insufficient duration of action. Both insulin analogs have an advantage over NPH by possessing a longer duration and fewer complications of hypoglycemia. Compared with insulin glargine, detemir may have a greater advantage owing to lower within-patient variability of action, incidence of hypoglycemia and weight gain.

Effect of insulin treatment on plasma oxidized LDL/LDL-cholesterol ratio in type 2 diabetic patients

In type 2 diabetes mellitus, oxidized LDL/LDL-Cholesterol ratio, an accurate estimation of in vivo LDL oxidation, has been reported elevated and associated with macrovascular disease. Because insulin therapy induces significant modification of lipid metabolism, in type 2 diabetes, we evaluated the effect of insulin treatment on oxidized LDL/LDL-C ratio in type 2 diabetic patients and analyzed the results in comparison with the modifications induced by insulin on glycaemia, plasma lipids and LDL receptors. Plasma oxidized LDL concentrations were measured by sandwich ELISA in 21 type 2 diabetic patients before and 3 months after the introduction of insulin therapy, and in 27 age-matched controls. Type 2 diabetic patients had, compared to controls, significantly increased oxidized LDL/LDL-C ratio (P<0.0001). Three months after insulin treatment, oxidized LDL/LDL-C ratio was significantly reduced (21.1+/-4.7 vs. 24.0+/-5.8 U/mmol, P<0.01). This reduction was strongly associated, in multivariate analysis, with reduction of LDL(TG/cholesterol ratio) (P=0.008), and to a lesser extent with the decrease of LDL fructosamine (P=0.034), but not with the increase of the number of LDL receptors. In the present study we demonstrate for the first time a lowering effect of insulin therapy on oxidized LDL/LDL-C ratio in type 2 diabetic patients. This decrease is mainly associated with the reduction of LDL TG-enrichment, and to a lesser extent with the decrease of LDL glycation, but not with the insulin-induced increase in number of LDL receptors.

Insulin‐induced oedema in children and adolescents

Oedema is an uncommon complication of insulin therapy, which has only rarely been reported in childhood. We describe a case of a 12-year-old girl with newly diagnosed type 1 diabetes, who presented with oedema of the lower extremities and periorbitally, one day after the initiation of insulin treatment. Other causes of oedema were excluded. Following administration of frusemide, oedema resolved within ten days. An extended review of the literature revealed only nine cases of insulin-induced oedema in children and adolescents aged </=16 years. In conclusion, insulin-induced oedema should be considered during the introduction of insulin therapy in children and adolescents with newly diagnosed type 1 diabetes. Loop diuretics and ephedrine may be beneficial when spontaneous resolution does not occur.

Growth, growth factors and diabetes

Type 1 diabetes mellitus (T1DM) and other chronic diseases in children are well known to adversely affect linear growth and pubertal development. In the years immediately following the introduction of insulin therapy, short stature was consistently reported in children with T1DM. However, over the past 50 years significant improvement in the prognosis for growth and final height in children with diabetes has been achieved. Although pre-pubertal and post-pubertal growth are important phases in growth, puberty and its related hormonal changes represent a critical phase for growth gain and final height particularly in patients with T1DM. Growth impairment reported in diabetic patients is dependent on abnormalities in physiological bone growth and corresponds to abnormalities of the growth hormone-insulin-like growth-I (GH-IGF-I) axis. These alterations seem to be related to appropriate insulin levels and thereby to glycaemic control as judged by haemoglobin levels. Modern diabetes care, particularly intensified insulin regimens, might improve metabolic control in patients with T1DM, therefore preventing abnormalities of the GH-IGF-I axis and leading to normal growth and final height similar to that of their unaffected peers.

Redefining insulin therapy in type 2 diabetes mellitus.

Type 2 diabetes mellitus is a progressive disease characterized by persistent insulin resistance and a relentless decline in insulin secretion that is accelerated by chronic hyperglycemia. Mounting evidence indicates that earlier introduction of insulin therapy may mitigate the deleterious effects of glucotoxicity in patients with early type 2 diabetes, presumably by reducing strain on pancreatic beta-cells and enhancing insulin secretion and also by improving peripheral insulin action. At present, the available data can only be considered hypothesis-generating, but support the notion that beginning basal insulin supplementation immediately after combination oral agents fail to attain glycemic targets has the potential to preserve beta-cell integrity or delay beta-cell loss, leading to more sustained glycemic control. Long-term controlled studies are clearly warranted to confirm this treatment paradigm. In the meantime, the tools for translating this concept to clinical practice can be extrapolated from the Treat-to-Target Trial, which showed that the addition of once-daily basal insulin glargine to oral agents, using a structured titration algorithm based on fasting plasma glucose monitoring, can achieve stringent glycemic control with less risk of nocturnal hypoglycemia than NPH insulin.