Uncontrolled Type 2 Diabetes Mellitus Research Articles

Stress and Other Determinants of Diabetes-Specific Quality of Life in Low-Income African Americans with Uncontrolled Type 2 Diabetes Mellitus.

Understanding diabetes-specific quality of life (DSQOL) is important to improving lives of people with type 2 diabetes mellitus (T2DM). Despite the prevalence of T2DM among African Americans, there is scant evidence about DSQOL in this population. This study aims to understand relationships between DSQOL and demographics, clinical markers, psychosocial factors, and stress in African Americans. We hypothesize that: 1) predictors of DSQOL in African Americans will be consistent with predictors identified in prior studies with non-African Americans, and 2) greater stress will independently predict poorer DSQOL. Participants were 211 low-income African Americans with uncontrolled T2DM. The two hypotheses were tested using distinct linear regression models. Significant predictors of poorer DSQOL were: 1) fewer years of school, 2) fewer T2DM-related complications, 3) longer T2DM duration, and 4) more perceived stress. Findings suggest that interventions targeting stress could improve DSQOL in African Americans.

Effects of bromocriptine mesylate on homocysteine and high-sensitivity C-reactive protein levels in patients with type-2 diabetes mellitus.

Introduction: Quick release bromocriptine (BROM-QR), currently approved for glycemic control, reduces the risk of cardiovascular events in adults with type-2 diabetes mellitus (T2DM). This study evaluates the effect of BROM-QR on homocysteine (HOMC) and high sensitive C-reactive protein (hs-CRP), the biochemical markers of coronary atherosclerosis/inflammation, in patients with uncontrolled T2DM. Methods: In this non-randomized, before-and-after clinical trial, patients with uncontrolled T2DM on stable doses of two oral hypoglycemic agents received BROM-QR for 6 months. The change in serum concentrations of HOMC was the primary endpoint. Anthropometric measurements such as body mass index (BMI) and waist circumference were measured at the baseline and at the completion of treatment along with fasting plasma glucose (FPG), HbA1c, total cholesterol, triglyceride, creatinine and hs-CRP. Multivariate regression analysis was performed to identify factors associated with changes in the levels of HOMC. Results: In 64 patients (46 completed 6 months of treatment), age was 55±7 years and the duration of T2DM was 8.0 ± 4.4 years. On enrollment, mean HbA1c, FPG, hs-CRP and HOMC levels were 9.0± 1.3 percent, 184 ± 42 mg/dL, 3.8± 3.4 mg/dl and 10.8 ± 6.2 micromole/L; respectively. Mean decrease of 0.7 ± 1.1 percent for HbA1c (P = 0.001) and 22 ± 44 mg/dL for FPG was observed (P = 0.002). HOMC levels decreased to 8.5 ± 5.2 micromole/L (P = 0.011) while hs-CRP levels remained unchanged at 3.7 ± 2.9 mg/dL (P = 0.835). Conclusion: While HOMC and HbA1c levels decreased significantly after 6 months of treatment with BROM-QR in patients with T2DM, serum levels of hs-CRP, total cholesterol and triglyceride did not significantly change.

THE ROLE OF METABOLIC SURGERY FOR PATIENTS WITH OBESITY GRADE I ANDCLINICALLY UNCONTROLLED TYPE 2 DIABETES

ABSTRACT Introduction : Even considering the advance of the medical treatment in the last 20 years with new and more effective drugs, the outcomes are still disappointing as the control of obesity and type 2 Diabetes Mellitus (T2DM) with a large number of patients under the medical treatment still not reaching the desired outcomes. Objective : To present a Metabolic Risk Score to better guide the surgical indication for T2DM patients with body mass index (BMI) where surgery for obesity is still controversial. Method : Research was conducted in PubMed, Medline, PubMed Central, Scielo and Lilacs between 2003-2015 correlating headings: metabolic surgery, obesity and type 2 diabetesmellitus. In addition, representatives of the societiesinvolved, as an expert panel, issued opinions. Results : Forty-five related articles were analyzed by evidence-based medicine criteria. Grouped opinions sought to answer the following questions: Why metabolic and not bariatric surgery?; Mechanisms involved in glycemic control; BMI as a single criterion for surgical indication for uncontrolled T2DM; Results of metabolic surgery studies in BMI<35 kg/m2; Safety of metabolic surgery in patients with BMI<35 kg/m2; Long-term effects of surgery in patients with baseline BMI<35 kg/m2 and Proposal for a Metabolic Risk Score. Conclusion : Metabolic surgery has well-defined mechanisms of action both in experimental and human studies. Gastrointestinal interventions in T2DM patients with IMC≤35 kg/m2 has similar safety and efficacy when compared to groups with greater BMIs, leading to the improvement of diabetes in a superior manner than clinical treatment and lifestyle changes, in part through weight loss independent mechanisms . There is no correlation between baseline BMI and weight loss in the long term with the success rate after any surgical treatment. Gastrointestinal surgery treatment may be an option for patients with T2DM without adequate clinical control, with a BMI between 30 and 35, after thorough evaluation following the parameters detailed in Metabolic Risk Score defined by the surgical societies. Roux-en-Y gastric bypass (RYGB), because of its well known safety and efficacy and longer follow-up studies, is the main surgical technique indicated for patients eligible for surgery through the Metabolic Risk Score. The vertical sleeve gastrectomy may be considered if there is an absolute contraindication for the RYGB. T2DM patients should be evaluated by the multiprofessional team that will assess surgical eligibility, preoperative work up, follow up and long term monitoring for micro and macrovascular complications.

THE ROLE OF METABOLIC SURGERY FOR PATIENTS WITH OBESITY GRADE I AND TYPE 2 DIABETES NOT CONTROLLED CLINICALLY.

ABSTRACTIntroductionEven considering the advance of the medical treatment in the last 20 years with new and more effective drugs, the outcomes are still disappointing as the control of obesity and type 2 Diabetes Mellitus (T2DM) with a large number of patients under the medical treatment still not reaching the desired outcomes.Objective: To present a Metabolic Risk Score to better guide the surgical indication for T2DM patients with body mass index (BMI) where surgery for obesity is still controversial.Method: Research was conducted in Pubmed, Medline, Pubmed Central, Scielo and Lilacs between 2003-2015 correlating headings: metabolic surgery, obesity and type 2 diabetes mellitus. In addition, representatives of the societies involved, as an expert panel, issued opinions.Results: Forty-five related articles were analyzed by evidence-based medicine criteria. Grouped opinions sought to answer the following questions: Why metabolic and not bariatric surgery?; Mechanisms involved in glycemic control; BMI as a single criterion for surgical indication for uncontrolled T2DM; Results of metabolic surgery studies in BMI<35 kg/m2; Safety of metabolic surgery in patients with BMI<35 kg/m2; Long-term effects of surgery in patients with baseline BMI<35 kg/m2 and Proposal for a Metabolic Risk Score.Conclusion: Metabolic surgery has well-defined mechanisms of action both in experimental and human studies. Gastrointestinal interventions in T2DM patients with IMC≤35 kg/m2 has similar safety and efficacy when compared to groups with greater BMIs, leading to the improvement of diabetes in a superior manner than clinical treatment and lifestyle changes, in part through weight loss independent mechanisms . There is no correlation between baseline BMI and weight loss in the long term with the success rate after any surgical treatment. Gastrointestinal surgery treatment may be an option for patients with T2DM without adequate clinical control, with a BMI between 30 and 35, after thorough evaluation following the parameters detailed in Metabolic Risk Score defined by the surgical societies. Roux-en-Y gastric bypass (RYGB), because of its well known safety and efficacy and longer follow-up studies, is the main surgical technique indicated for patients eligible for surgery through the Metabolic Risk Score. The vertical sleeve gastrectomy may be considered if there is an absolute contraindication for the RYGB. T2DM patients should be evaluated by the multiprofessional team that will assess surgical eligibility, preoperative work up, follow up and long term monitoring for micro and macrovascular complications.

Observational Study of Patients in Morocco With Uncontrolled Type 2 Diabetes Treated With Metformin and/or Sulfonylurea With or Without Insulin

Background: Several types of oral antidiabetic drugs (OADs), with or without insulin, may be used to achieve glycemic control in patients with type 2 diabetes mellitus (T2DM). However, real-life studies assessing diabetes treatments in Morocco are rare. Our aim was to assess the efficacy of various antidiabetic treatment regimens to achieve glycemic control in patients with uncontrolled T2DM, to determine the factors associated with a lack of glycemic control and to compare the clinical outcome after 26 weeks of treatment in a real-life setting. Methods: This prospective, observational study was carried out on 1,377 patients with uncontrolled T2DM in 139 Moroccan centers. Three groups of patients were defined according to the type of treatment: group 1: metformin and/or sulfonylurea only; group 2: metformin and/or sulfonylurea + insulin prior to inclusion; and group 3: metformin and/or sulfonylurea + started on insulin at or after inclusion. Clinical data including glycated hemoglobin (HbA1c), fasting blood glucose (FBG), blood pressure and weight were recorded at inclusion and after 3 and 6 months of treatment. Results: Mean HbA1c decreased from 9.7±1.8% at baseline to 7.5±1.2% at week-26 follow-up (P < 0.001) and the proportion of patients with controlled glycemia (HbA1c < 7%) increased from 10.8% at 12 weeks to 32.4% after 26 weeks of treatment (P < 0.001). Mean decreases in HbA1c at 26 weeks were: -1.8% in group 1 (P < 0.001), -2.7% in group 2 (P < 0.001) and -2.1% in group 3 (P < 0.001). Lack of glycemic control was related to non-observance of lifestyle recommendations, lack of treatment efficacy, poor treatment compliance and absence of diabetes education. Uncontrolled glycemia was significantly associated with obesity, hypertension, dyslipidemia, use of one OAD only and no insulin therapy. Mean weight of all patients decreased over the 26-week period, irrespective of treatment regimen. Conclusion: In a Moroccan primary care setting, observed treatment of T2DM with lifestyle recommendation, metformin, sulfolylurea and insulin was associated with improvement of glycemic control without weight gain. J Endocrinol Metab. 2015;5(6):321-327 doi: http://dx.doi.org/10.14740/jem314w

A 21-Year-Old Woman with Hepatomegaly

We report the case of a 21-year old woman with uncontrolled diabetes mellitus type 1 presenting with tender hepatomegaly and mildy elevated liver enzymes, with negative investigations for common causes. She was diagnosed by liver biopsy with glycogenic hepatopathy, an uncommon and likely under-recognized complication of poor glycemic control. The disease is typically reversible after weeks to months of appropriate insulin therapy and is unlikely to lead to permanent liver disease. Our patient was treated with a new insulin regimen and analgesics and discharged home. Unfortunately, on follow-up imaging in our patient 10 months later, her hepatomegaly persists. Her glycemic control remains unchanged and she has since been admitted to hospital twice for episodes of diabetic ketoacidosis.

Glycogenosis: A Rare Etiology of Transaminitis

Hepatic glycogenosis is a rare etiology of elevated hepatic transaminases reported in the literature. Glycogenosis is associated with uncontrolled diabetes and can be confused with other forms of acute liver injury. This disease can be diagnosed via liver biopsy and reversed by ensuring tight glycemic control. Given this diagnosis is unrecognized but curable, we highlight a case of hepatic glycogenosis in a patient treated at our institution. Patient is a 24 year-old female with past medical history of depression and uncontrolled Diabetes Mellitus Type 1 with recurrent hospital admissions for Diabetic Ketoacidosis (DKA). She presented to the hospital with one day of nausea and vomiting; she was subsequently diagnosed with DKA, and admitted to the intensive care unit for further clinical care. The patient was initiated on fluids and insulin drip for DKA treatment and continued on her home regimen of duloxetine for depression management. Several days into her admission, the patient developed increases in aspartate transaminase (AST) and alanine transaminase (ALT), with initially normal then elevated alkaline phosphatase. Bilirubin and INR remained with normal limits. Over 10 days, lab values peaked with AST of 535, AST of 465, and alkaline phosphatase of 194. Initial serology including HBs Ag, HBc Ab, HCV Ab, CMV, EBV, HIV, ANA, AMA, antiSMA, and ferritin were negative. Given that there was no history of herbal intake or new hepatotoxic medications initiated, suspicion for drug induced liver injury was low, albeit remained on the differential. There were no episodes of hypotension or active infection throughout the admission. A right-upperquadrant ultrasound was performed with unremarkable findings. During previous admissions for DKA, there were similar acute instances of elevated liver-associated enzymes (Figure 1). Given concern of this recurrent transaminitis, a liver biopsy was pursued. Hematoxylin & eosin (H&E) staining revealed glycogen deposits with no hepatitis or fibrosis, convincing for a diagnosis of hepatic glycogenosis (Figure 2).Figure 1Figure 2Hepatic glycogenosis should be suspected in the appropriate clinical situation after other etiologies are ruled out. It is easily treatable with strict glycemic control. Given the reversibility of liver injury in these patients, raising awareness about an underreported and unrecognized disease is undoubtedly clinically significant in medical practice.

A 21-Year-Old Woman with Hepatomegaly

We report the case of a 21-year old woman with uncontrolled diabetes mellitus type 1 presenting with tender hepatomegaly and mildy elevated liver enzymes, with negative investigations for common causes. She was diagnosed by liver biopsy with glycogenic hepatopathy, an uncommon and likely under-recognized complication of poor glycemic control. The disease is typically reversible after weeks to months of appropriate insulin therapy and is unlikely to lead to permanent liver disease. Our patient was treated with a new insulin regimen and analgesics and discharged home. Unfortunately, on follow-up imaging in our patient 10 months later, her hepatomegaly persists. Her glycemic control remains unchanged and she has since been admitted to hospital twice for episodes of diabetic ketoacidosis.

Latent Autoimmune Diabetes of Adult Masquerading as Type 2 Diabetes Mellitus

Latent autoimmune diabetes of adults (LADA) is a slowly progressing subtype of type 1 diabetes mellitus (DM) that shares features of both type 1 and type 2 diabetes mellitus (T2DM), leading to its misdiagnosis and mismanagement. We present a case of a 30-year-old man who was diagnosed and managed as T2DM but later confirmed as a case of LADA. He was sent to the endocrinology clinic by his primary care physician for management of “uncontrolled T2DM”. He had been placed on glipizide and metformin, but was noted to have suboptimal blood glucose control and unintentional weight loss of about 20 - 30 lbs over a 3-month period. A diagnosis of LADA was confirmed by the presence of autoantibody to glutamic acid decarboxylase 65 (anti-GAD-65 antibody). His oral medications were discontinued and he was started on basal and mealtime insulin. It is important to identify LADA in adult patients thought to have T2DM, as these patients respond poorly to oral hypoglycemic drug therapy, require insulin and are at increased risk for developing ketoacidosis. Clinical presentation of LADA is often similar to T2DM, with diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS) being uncommon complications. J Med Cases. 2015;6(7):327-329 doi: https://doi.org/10.14740/jmc2183w

Region-specific cerebral metabolic alterations in streptozotocin-induced type 1 diabetic rats: an in vivo proton magnetic resonance spectroscopy study.

Clinical and experimental in vivo (1)H-magnetic resonance spectroscopy ((1)H-MRS) studies have demonstrated that type 1 diabetes mellitus (T1DM) is associated with cerebral metabolic abnormalities. However, less is known whether T1DM induces different metabolic disturbances in different brain regions. In this study, in vivo (1)H-MRS was used to measure metabolic alterations in the visual cortex, striatum, and hippocampus of streptozotocin (STZ)-induced uncontrolled T1DM rats at 4 days and 4 weeks after induction. It was observed that altered neuronal metabolism occurred in STZ-treated rats as early as 4 days after induction. At 4 weeks, T1DM-related metabolic disturbances were clearly region specific. The diabetic visual cortex had more or less normal-appearing metabolic profile; while the striatum and hippocampus showed similar abnormalities in neuronal metabolism involving N-acetyl aspartate and glutamate; but only the hippocampus exhibited significant changes in glial markers such as taurine and myo-inositol. It is concluded that cerebral metabolic perturbations in STZ-induced T1DM rats are region specific at 4 weeks after induction, perhaps as a manifestation of varied vulnerability among the brain regions to sustained hyperglycemia.

Glycogenic Hepatopathy With Persistent Hepatomegaly in a Patient With Uncontrolled Type 1 Diabetes

Even though glycogen overloading of the liver was first described as a component of Mauriac syndrome in 1930, glycogenic hepatopathy (GH) is still an under-recognized complication of type 1 diabetes mellitus (T1DM). GH diagnosis is challenging as it is clinically difficult to distinguish GH from steatohepatitis or glycogen storage disease, and liver biopsy is essential for confirmatory diagnosis. GH is usually a transient condition with unknown long-term complications. We present a case of GH with persistent marked hepatomegaly over 5 years despite normalization of liver enzymes in a patient with uncontrolled T1DM. J Endocrinol Metab. 2015;5(1-2):189-191 doi: http://dx.doi.org/10.14740/jem276w

Observational Study of Patients in Morocco With Uncontrolled Type 2 Diabetes Treated With Metformin and/or Sulfonylurea With or Without Insulin

Background: Several types of oral antidiabetic drugs (OADs), with or without insulin, may be used to achieve glycemic control in patients with type 2 diabetes mellitus (T2DM). However, real-life studies assessing diabetes treatments in Morocco are rare. Our aim was to assess the efficacy of various antidiabetic treatment regimens to achieve glycemic control in patients with uncontrolled T2DM, to determine the factors associated with a lack of glycemic control and to compare the clinical outcome after 26 weeks of treatment in a real-life setting. Methods: This prospective, observational study was carried out on 1,377 patients with uncontrolled T2DM in 139 Moroccan centers. Three groups of patients were defined according to the type of treatment: group 1: metformin and/or sulfonylurea only; group 2: metformin and/or sulfonylurea + insulin prior to inclusion; and group 3: metformin and/or sulfonylurea + started on insulin at or after inclusion. Clinical data including glycated hemoglobin (HbA1c), fasting blood glucose (FBG), blood pressure and weight were recorded at inclusion and after 3 and 6 months of treatment. Results: Mean HbA1c decreased from 9.7±1.8% at baseline to 7.5±1.2% at week-26 follow-up (P &lt; 0.001) and the proportion of patients with controlled glycemia (HbA1c &lt; 7%) increased from 10.8% at 12 weeks to 32.4% after 26 weeks of treatment (P &lt; 0.001). Mean decreases in HbA1c at 26 weeks were: -1.8% in group 1 (P &lt; 0.001), -2.7% in group 2 (P &lt; 0.001) and -2.1% in group 3 (P &lt; 0.001). Lack of glycemic control was related to non-observance of lifestyle recommendations, lack of treatment efficacy, poor treatment compliance and absence of diabetes education. Uncontrolled glycemia was significantly associated with obesity, hypertension, dyslipidemia, use of one OAD only and no insulin therapy. Mean weight of all patients decreased over the 26-week period, irrespective of treatment regimen. Conclusion: In a Moroccan primary care setting, observed treatment of T2DM with lifestyle recommendation, metformin, sulfolylurea and insulin was associated with improvement of glycemic control without weight gain. J Endocrinol Metab. 2015;5(6):321-327 doi: http://dx.doi.org/10.14740/jem314w

Latent Autoimmune Diabetes of Adult Masquerading as Type 2 Diabetes Mellitus

Latent autoimmune diabetes of adults (LADA) is a slowly progressing subtype of type 1 diabetes mellitus (DM) that shares features of both type 1 and type 2 diabetes mellitus (T2DM), leading to its misdiagnosis and mismanagement. We present a case of a 30-year-old man who was diagnosed and managed as T2DM but later confirmed as a case of LADA. He was sent to the endocrinology clinic by his primary care physician for management of “uncontrolled T2DM”. He had been placed on glipizide and metformin, but was noted to have suboptimal blood glucose control and unintentional weight loss of about 20 - 30 lbs over a 3-month period. A diagnosis of LADA was confirmed by the presence of autoantibody to glutamic acid decarboxylase 65 (anti-GAD-65 antibody). His oral medications were discontinued and he was started on basal and mealtime insulin. It is important to identify LADA in adult patients thought to have T2DM, as these patients respond poorly to oral hypoglycemic drug therapy, require insulin and are at increased risk for developing ketoacidosis. Clinical presentation of LADA is often similar to T2DM, with diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS) being uncommon complications. J Med Cases. 2015;6(7):327-329 doi: https://doi.org/10.14740/jmc2183w

Inadequate control of diabetes and metabolic indices among diabetic patients: A population based study from the Kerman Coronary Artery Disease Risk Study (KERCADRS).

The goal of diabetes control should be feasible in order to minimize the risk of its adverse events and to reduce its burden and cost on patients. The current study aimed to assess the status of glycemic control in male and female patients with Type 2 Diabetes Mellitus (T2DM) in Kerman, Iran. In the present study, 500 T2DM (300 women and 200 men) from the Kerman Coronary Artery Disease Risk Study (KERCADRS), a population-based study from 2009 to 2011, were selected. Patients were >18 years old, had Fasting Blood Sugar (FBS) higher than 126 mg/dl, and had been through treatment for their diagnosed disease. All participants underwent Glycosylated Hemoglobin (HbA1c) analysis. HbA1c less than 7% was considered as good glucose control. Other metabolic indices based on American Diabetes Association (ADA) target recommendations were considered. The mean level of HbA1c in total subjects was 8.56 ± 4.72% that only 31.66% of men and 26.00% of women had controlled level of HbA1c. Total cholesterol less than 200 mg/dl was reported in 64.50% of men and 44.00% of women, High Density Lipoprotein (HDL) more than 40 mg/dl was revealed in 20.50% of men and 34.67% of women, and Low Density Lipoprotein (LDL) less than 100 mg/dl was reported in 41.50% of men and 25.33% of women. In multivariate logistic regression model, longer duration of disease and higher Waist Circumference (WC) were positively associated with uncontrolled diabetes status. The findings of the present study revealed that diabetes control in T2DM was inadequate. Changing the policy of treatment in individual patient and establishing better diabetes clinic to decrease the frequency of uncontrolled T2DM are crucial. Paying attention to other affecting metabolic components such as WC in the process of T2DM management is important.

Physical Growth and Body Composition of Controlled Versus Uncontrolled Type 1 Egyptian Diabetic Children

BACKGROUND: Type 1 Diabetes Mellitus (T1DM) is one of the most common chronic endocrine disorders of childhood. Data on growth parameters of diabetic children is scarce. AIM: To assess growth and body composition in a group of diabetic children. SUBJECTS AND METHODS: 427 T1DM children (age 2-10 years) were recruited from Diabetic Paediatric Unit, outpatients' clinic of Abou El-Rish Hospital. Anthropometric and body composition parameters were taken and HbA1c was measured for all subjects. RESULTS: Highly significant difference was detected between controlled and uncontrolled groups as regard to weight/age z-score, height/age z-score, BMI z-score, triceps skin fold thickness, subscapular skin fold thickness, midupper arm circumference, fat mass, fat %, lean mass, and body water (p < 0.001). All values are higher in the controlled group than in the uncontrolled group. Uncontrolled subjects were significantly more at risk of being underweight and short, with odds ratio of 15.131 and 16.877 and 95% confidence interval 1.972-116.130 and 3.973-71.694 respectively. However, controlled subjects were significantly more at risk of being obese than the uncontrolled with an odds ratio 0.116 and 95% confidence interval 0.045-0.302. CONCLUSION: Growth was compromised in uncontrolled T1DM children. This is of utmost importance since most of the clinical features are reversible with better glycemic control and appropriate insulin management.

Physical Growth and Body Composition of Controlled Versus Uncontrolled Type 1 Egyptian Diabetic Children

BACKGROUND: Type 1 Diabetes Mellitus (T1DM) is one of the most common chronic endocrine disorders of childhood. Data on growth parameters of diabetic children is scarce.AIM: To assess growth and body composition in a group of diabetic children.SUBJECTS AND METHODS: 427 T1DM children (age 2-10 years) were recruited from Diabetic Paediatric Unit, outpatients' clinic of Abou El-Rish Hospital. Anthropometric and body composition parameters were taken and HbA1c was measured for all subjects.RESULTS:Â Highly significant difference was detected between controlled and uncontrolled groups as regard to weight/age z-score, height/age z-score, BMI z-score, triceps skin fold thickness, subscapular skin fold thickness, midupper arm circumference, fat mass, fat %, lean mass, and body water (p &lt; 0.001). All values are higher in the controlled group than in the uncontrolled group. Uncontrolled subjects were significantly more at risk of being underweight and short, with odds ratio of 15.131 and 16.877 and 95% confidence interval 1.972-116.130 and 3.973-71.694 respectively. However, controlled subjects were significantly more at risk of being obese than the uncontrolled with an odds ratio 0.116 and 95% confidence interval 0.045-0.302.CONCLUSION: Growth was compromised in uncontrolled T1DM children. This is of utmost importance since most of the clinical features are reversible with better glycemic control and appropriate insulin management.

Laparoscopic Roux-en-Y Gastric Bypass for Type 2 Diabetes Mellitus in Nonobese Chinese Patients

Although bariatric surgery performed for morbid obesity has been shown to significantly improve type 2 diabetes mellitus (T2DM), data on its effectiveness to improve T2DM in nonobese patients are scarce. The present pilot study evaluated the clinical effects of laparoscopic Roux-en-Y gastric bypass surgery (LRYGB) in Chinese T2DM patients with body mass index (BMI) ≤27.5 kg/m. A total of 68 consecutive patients with uncontrolled T2DM underwent LRYGB from May 2010 to March 2012. All patients were subjected to follow-up controls with anthropometric and metabolic indices at 1, 3, 6, and 12 months after surgery. Glycemic control was evaluated. One year after the surgery, LRYGB resulted in 69.4%±52.2% excess weight loss percentage (%EWL), remission of T2DM in 80.9% of all the patients. In the group of T2DM patients with BMI≤27.5 kg/m (n=28), 9 (32.1%) cases showed T2DM remission, 10 (35.7%) showed glycemic control, 7 (25%) showed improvement, and 2 (7.1%) were unchanged. The change in BMI, waist circumference, and the plasma levels of FPG, HbA1C, triglycerides, HDL-C, and insulin were statistically significance at 1 year (P<0. 05). There was no perioperative mortality, but 6 (8.8%) patients experienced complications. LRYGB resulted in significant weight loss and remission of T2DM in Chinese patients. Despite a lower response rate of surgery treatment compared with obese patients, T2DM patients with BMI≤27.5 kg/m still exhibited improvement and remission of T2DM. Diabetic patients should consider bariatric surgery, especially if traditional pharmacotherapy has not been effective. Longer follow-up is required for better evaluation.

Outcomes and treatment patterns of adding a third agent to 2 OADs in patients with type 2 diabetes.

Patients with uncontrolled type 2 diabetes mellitus (T2DM), despite therapy with 2 oral antidiabetic drugs (OADs), may add a third OAD or a glucagon-like peptide-1 receptor agonist (GLP-1) or initiate insulin therapy. The transition to insulin has been shown to be delayed in current practice, potentially through clinical inertia--the failure of health care providers to initiate or advance therapy when indicated. Patients and physicians may be resistant to insulin therapy because of beliefs about side effects and limitations to patients' lifestyle, while patients may consider that starting injectable therapy signifies a considerable worsening of their disease and may feel they have "failed" to manage it effectively. To describe current treatment patterns and outcomes among adult patients with T2DM in the United States who were treated with 2 OADs and added a third antidiabetic drug. This retrospective study followed patients with T2DM who added a third OAD (the "3OAD" cohort), insulin ("+Insulin"), or a GLP-1 ("+GLP-1") between July 2000 and March 2009. Patients were followed for up to 2 years. Baseline characteristics and follow-up outcomes--including blood glucose level (HbA1c), hypoglycemia, and health care costs--were examined. Treatment persistence was assessed to determine how long patients continued with their prescribed medications without discontinuing or switching. A total of 51,771 patients adding a third agent to their 2OAD regimen were included in this study. Most patients added a third OAD (n = 41,052) over insulin (n = 6,904) or GLP-1 (n = 3,815). At baseline, +Insulin patients were older, with higher comorbidity burden and higher HbA1c. During follow-up, 3OAD patients were more likely to be persistent with their treatment than +Insulin or +GLP-1 patients, but +Insulin patients had the greatest HbA1c reduction from baseline, while continuing with insulin treatment was associated with higher HbA1c reduction. Among 3OAD patients, most of those who switched a third agent initiated insulin, and those who switched early during the follow-up period had greater HbA1c reduction than those who continued with the 3OAD treatment regimen. Average annual health care costs declined in +Insulin patients but increased among 3OAD and +GLP-1 patients. Treatment persistence and HbA1c reduction in +GLP-1 patients were low. This study found that in current practice, physicians seem to be reluctant to prescribe injectable agents for patients with uncontrolled T2DM despite combination OAD therapy. Despite higher treatment persistence among patients adding a third OAD, this persistence did not translate into better glycemic control and may not necessarily be a long-term cost-saving solution. These data indicate a need for more evidence-based and patient-centered treatment decisions for patients unable to achieve and maintain glycemic targets on multiple OADs.

Comparison of Effects of Gliclazide, Metformin and Pioglitazone Monotherapies on Glycemic Control and Cardiovascular Risk Factors in Patients with Newly Diagnosed Uncontrolled Type 2 Diabetes Mellitus

The objective of this study was to evaluate and compare the effects of gliclazide-modified release (gliclazide-MR), metformine (MET) and pioglitazone (PIO) monotherapies on glycemic control and conventional/non-conventional cardiovascular risk factors in patients with newly diagnosed type 2 diabetes mellitus (T2DM). A single center, randomized, 52-wk comparator-controlled clinical study was carried out in patients with newly diagnosed uncontrolled T2DM. A total of 57 patients were randomized into gliclazide-MR, metformin and pioglitazone groups. Drugs were administered for 12 months. Anthropometric measurements, fasting plasma glucose (FPG), postprandial plasma glucose (PPG), HbA1c, insulin, HOMA-IR, lipid parameters, the markers of coagulation/fibrinolysis, inflammation and endothelial dysfunction were measured at baseline and at months 3, 6, and 12. In the gliclazide-MR group, HC, FPG, HbA1c, insulin, HOMA-IR, TC, trigylcerides, Lp (a), E-selectin and Hcy were significantly decreased after treatment compared to baseline. In the MET group, BMI, WC, FPG, PPG, HbA1c, ICAM-1 and Hcy significantly decreased after treatment compared to baseline. In PIO group, WC, HC, FPG, PPG, HbA1c, C-peptid, HOMA-IR, trigylcerides, vWF, IL-6, ICAM-1, E-selectin and Hcy significantly decreased after treatment compared to baseline, whereas, HDL-C increased. At the end of the month 12, the decreases in insulin and HOMA-IR score were more pronounced with PIO compared to gliclazide. Gliclazide-MR, MET and PIO monotherapies, were equally effective in proving glycemic control in patients with newly diagnosed, oral antidiabetic (OAD)-naive T2DM. But, improvements in conventional/non-conventional cardiovascular risk factors were more pronounced in patients on PIO therapy compared to gliclazide and MET therapies. Also, all of the 3 drugs represent effective and safe first-line pharmacological treatment options in these patients.

Adipose tissue cytokines: Relation to glycemic control, insulin resistance and biochemical bone markers in type 2 diabetic Saudi male patients

To assess the plasma levels and relations of adipocytokines and biochemical bone markers in type 2 diabetes mellitus (T2DM) Saudi males with insulin resistance. This case-control study included 80 overweight/obese males with T2DM on oral anti-diabetic medications recruited from the diabetic center and 40 healthy lean males of matched age. Measurements included fasting plasma glucose (FBG), fasting plasma insulin, serum calcium (Ca 2 + ), HbA1c, plasma adiponectin and resistin, serum bone-specific alkaline phosphatase (B-ALP), plasma osteocalcin (OC), and plasma osteoprotegerin (OPG). Waist and hip circumferences were measured. Body mass index, waist/hip ratio (WHR), and insulin resistance (HOMA-IR) were calculated. Compared to the control group, diabetic patients showed significantly both lower adiponectin ( p = 0.000) and Ca 2 + ( p = 0.000) but significantly higher resistin ( p = 0.000), OC ( p = 0.000), B-ALP level ( p = 0.000) and OPG ( p = 0.000). After multivariate adjustment in diabetic patients, resistin predicted OC, (beta = −0.30, p = 0.005), WC and resistin predicted Ca 2+ (beta = −0.34, p = 0.035 and beta = −0.25, p = 0.033), adiponectin and resistin predicted B-ALP, (beta = −0.35, p = 0.010 and beta = 0.35, p = 0.004), and FBG, HOMA-IR and age predicted OPG, (beta = −0.66, p = 0.010, beta = 0.58, p = 0.024 and beta = 0.27, p = 0.031 respectively). Also, FBG, WHR and HOMA-IR predicted adiponectin (beta = −0.79, p = 0.001, beta = −0.60, p = 0.001 and beta = 0.80, p = 0.001 respectively), while OC and OPG predicted HbA1c (beta = −0.32, p = 0.007 and beta = 0.28, p = 0.016 respectively). Uncontrolled T2DM Saudi males with insulin resistance have abnormal bone markers with unfavorable levels of adipocytokines. Strong associations between bone markers, adipocytokines, insulin resistance and metabolic control may suggest interaction in multiple direction feedback loops exacerbating hyperglycemia.