Frequency of severe hypoglycemia in patients with non-insulin-dependent diabetes mellitus treated with sulfonylureas or insulin

OBJECTIVE

To assess the frequency of severe hypoglycemia in patients with non-insulin-dependent diabetes mellitus (NIDDM).

METHODS

We surveyed a single diabetologist's clinical practice of consecutive patients with NIDDM during a 3-month period.

RESULTS

Of the 262 study participants interviewed, 172 insulin-using and 90 sulfonylurea-using patients were asked whether they had ever had hypoglycemia severe enough to require the assistance of another person. Of the 90 sulfonylurea-treated patients with NIDDM, 3 (3.3%) reported experiencing severe hypoglycemia on one occasion only. Of the 172 insulin-utilizing patients, 13 (7.6%) had had severe hypoglycemic episodes--8 on one occasion only (5 of these had been iatrogenic circumstances and 3 had been precipitated by exercise or lack of food). Five insulin-requiring patients reported multiple bouts of severe hypoglycemia. With one exception, all patients were thin, and C peptide levels were low or undetectable.

CONCLUSION

On the basis of this study, we conclude that severe hypoglycemia is extremely uncommon in NIDDM. When it occurs, it is usually accidental and seldom recurs. Patients with multiple bouts of severe hypoglycemia have almost complete insulin deficiency. Thus, aggressive treatment of NIDDM to avoid diabetic complications is rarely associated with severe hypoglycemia and is usually well tolerated.

Improved glycemic control with use of oral hypoglycemic therapy with or without insulin

OBJECTIVE

To determine whether combination oral hypoglycemic therapy in insulin-using patients with non-insulin-dependent diabetes mellitus (NIDDM) can improve glycemic control for a prolonged period.

METHODS

We expanded and extended an earlier study to include 130 patients with NIDDM for 10 to 30 years who had been using twice-daily mixed insulin for less than 10 years. Reduction and eventual elimination of the insulin therapy and substitution of metformin and a sulfonylurea were attempted. At follow-up visits, patients were weighed, random plasma glucose levels were determined, and glycosylated hemoglobin values were obtained.

RESULTS

Of 130 C-peptide-positive patients with NIDDM receiving twice-daily mixed insulin, 100 were successfully transferred to combination oral hypoglycemic therapy with glyburide originally and later glimepiride and metformin--a primary failure rate of 23.1%. Secondary failure occurred in 20 patients after a mean duration of 6.4 months. Two patients with successful conversion to oral combination therapy resumed insulin treatment because of cost. Of the patients with primary failures, 6 had gastrointestinal side effects, 10 were successfully managed on combination oral therapy plus evening mixed insulin, and 14 ultimately received twice-daily insulin and metformin. Of the secondary failures, 13 were controlled on combination oral therapy plus evening insulin and 7 on twice-daily insulin in conjunction with metformin. No difference was found in the original C-peptide levels among these three groups. Glycosylated hemoglobin levels were significantly less on combined oral hypoglycemic therapy (9.8% versus 8.3%; P = 0.0001), on combination oral therapy plus evening insulin (11.2% versus 9.7%; P = 0.001), and on return to twice-daily mixed insulin with metformin (11.0% versus 9.9%; P = 0.04). Those eight patients who resumed twice-daily insulin therapy alone, however, had a nonsignificant increase in glycosylated hemoglobin (9.3% versus 9.9%).

CONCLUSION

Improvement in glycosylated hemoglobin level in insulin-using patients with NIDDM can be obtained with combination oral therapy alone, combination oral therapy with once-daily evening insulin, or twice-daily mixed insulin with metformin in comparison with twice-daily insulin alone.

A Comparison of Bedtime Insulin Glargine with Bedtime Neutral Protamine Hagedorn Insulin in Patients with Type 2 Diabetes: Subgroup Analysis of Patients Taking Once-Daily Insulin in a Multicenter, Randomized, Parallel Group Study

BACKGROUND

Basal insulin is frequently administered once daily. This subgroup analysis of a multicenter, randomized, parallel study compared insulin glargine (Lantus Aventis Pharmaceuticals, Bridgewater, NJ) with neutral protamine Hagedorn (NPH) insulin in patients with type 2 diabetes, evaluating only patients treated previously with once-daily NPH insulin.

METHODS

Patients received bedtime insulin glargine or NPH insulin, with preprandial regular insulin. One hundred patients (mean age, 57.9 years; mean glycohemoglobin, 8.4%; mean fasting blood glucose, 167 mg/dL) were treated for up to 28 weeks.

RESULTS

Patients treated with insulin glargine (n = 52) and NPH insulin (n = 48) achieved similar reductions from baseline in glycohemoglobin (-0.41% versus -0.46%) and fasting blood glucose (-22 mg/dL versus -22 mg/dL) at week 28. The proportion of patients reaching target fasting blood glucose (<120 mg/dL) at 28 weeks was 34.2% with insulin glargine and 24.4% with NPH insulin. Similar proportions of patients achieved glycohemoglobin less than 7% and less than 8% in both groups. Baseline and week-28 mean daily doses of insulin glargine (27.3 IU versus 36.4 IU) were similar to NPH insulin doses (25.5 IU versus 30.2 IU). However, significantly fewer patients reported one or more episodes of hypoglycemia with insulin glargine (46.2%) versus NPH insulin (60.4%; P < 0.05). Significantly fewer patients also reported one or more symptomatic episodes confirmed by blood glucose less than 50 mg/dL with insulin glargine (17.3%) versus NPH insulin (31.3%; P < 0.005).

CONCLUSION

Bedtime insulin glargine is as effective as bedtime NPH insulin in improving glycemic control, with significantly less hypoglycemia.

Health-care charges generated by patients with diabetes

For assessment of health-care charges generated by patients with diabetes, 50 patients (25 who were older than 65 years and 25 who were age 65 or younger) whose primary care had been delivered between 1990 and 1995 by a single diabetologist were randomly selected. Institutional health-care bills were accessed from all but three medical center billing offices (dermatology, psychiatry, and radiation oncology areas did not respond). For each dollar billed by endocrinology, the hospital billed 25.90 dollars, other medical specialties 2.70 dollars, surgery 1.10 dollars, radiology 0.70 dollars and pathology 0.60 dollars. The charges generated by the endocrinologist-diabetologist account for approximately 3% of the total charges for the care of the patient with diabetes mellitus in a fee-for-service practice. Although the endocrinologist-diabetologist provides the most cost-effective medical service for patients with diabetes, low reimbursement jeopardizes the practice of this subspecialty.

Predictive immunophenotypes: disease-related profile in chronic fatigue syndrome

BACKGROUND

There is a growing body of evidence supporting the theory that problems with immune function play an important role in chronic fatigue syndrome (CFS).

METHODS

We studied 90 CFS cases and 50 healthy controls from two different areas of upstate New York to determine whether there were differences in the absolute number and pattern of natural killer (NK) and cytotoxic T-cell phenotypes between CFS cases and healthy controls in the two regions. One group was from a small town where a cluster of cases existed; the other was from a large metropolitan area where there was not a known cluster.

RESULTS

The number of CD56+CD3+CD8+ and CD56+CD3+CD8- cells in cases from the two areas were both significantly elevated over that of controls from the metropolitan area (P < 0.03). The number of CD56+CD3-CD8+ and CD56+CD3-CD8- cells was significantly reduced in the two case groups compared to that of controls from the metropolitan area (P = 0.04). However, controls who were from the same town as the cluster cases had numbers of CD56+CD3+CD8+, CD56+CD3+CD8-, and CD56+CD3-CD8- cells that were more like that of cases than controls. Only the number of CD56+CD3-CD8+ cells (an NK cell subset) was significantly different in cases versus controls from the cluster area (P = 0.022).

CONCLUSIONS

These data suggest that differences in controls from cluster and noncluster areas may be responsible for some of the inconsistencies in results from other studies. Furthermore, they suggest the possibility that NK cell function may play an important role in preventing the development of CFS in individuals who live in a community where a cluster of cases have been identified.

Chronic fatigue syndrome: what role does the autonomic nervous system play in the pathophysiology of this complex illness?

Chronic fatigue syndrome (CFS) is a serious health concern affecting over 800000 Americans of all ages, races and socioeconomic groups and both genders. The etiology and pathophysiology of CFS are unknown, yet studies have suggested an involvement of the autonomic nervous system (ANS). A symposium was organized in December 2000 to explore the possibility of an association between ANS dysfunction and CFS, with special emphasis on the interactions between ANS dysfunction and other abnormalities noted in the immune and endocrine systems of individuals with CFS. This paper represents the consensus of the panel of experts who participated in this meeting.

HFE mutations in African-American women with non-insulin-dependent diabetes mellitus

The aim of this study was to compare the frequencies of HFE mutations in African-American women with non-insulin-dependent diabetes mellitus (NIDDM) to that of controls and to determine whether these mutations are associated with NIDDM and iron overload. We studied 167 African-American women with NIDDM. The 71 non-diabetic controls were African-American female controls. HLA-A and -B typing and HFE mutation analysis for C282Y and H63D alleles were performed using standard molecular genetic techniques. The frequencies of C282Y and H63D were not significantly different in NIDDM patients and controls. C282Y was observed in 0.59% of patients and 1.41% of controls. H63D was observed in 2.99% of patients and 3.08% of controls. All of the NIDDM patients who possessed either C282Y or H63D mutations had normal values of serum ferritin, serum iron and transferrin saturation. A woman who inherited C282Y also possessed HLA-A3, -B7 which is considered part of the ancestral haplotype containing the gene predisposing to hemochromatosis in Caucasians. The frequencies of C282Y and H63D vary in African Americans from different geographic regions of the United States; this variance can be explained by Caucasian admixture. Although most iron overload cases in African Americans bear more resemblance to cases of African iron overload than to those of Caucasian hemochromatosis, rare cases resembling Caucasian hemochromatosis have been observed in African Americans.

Prevalence and risk factors of microalbuminuria in a cohort of African-American women with gestational diabetes

OBJECTIVE

To study the prevalence of microalbuminuria (MA) in African-American women with a history of gestational diabetes (GDM) who are at high risk for insulin resistance and renal dysfunction and to study MA's relation to insulin resistance, type 2 diabetes, and hypertension.

RESEARCH DESIGN AND METHODS

MA was assessed using 24-h, timed, and/or random urine samples in a cross-sectional sample (n = 289) from a cohort of African-American women with a history of GDM and followed for a median of 11 years (range 3.0-18.4) since their diabetic pregnancy. Subjects with a urine albumin excretion rate of 30-300 g/24 h or 30-300 microg/mg creatinine in a random sample were classified as having MA if two of three samples over a 3- to 6-month period were positive. These women were evaluated for family history of diabetes, smoking and alcohol use, BMI, diabetes, hypertension, and lipid abnormalities. Insulin sensitivity was determined using the homeostasis model assessment (HOMA) estimates, which used fasting insulin and glucose measurements obtained at the same time as the MA urine sample.

RESULTS

At MA assessment, the women ranged in age from 22 to 57 years, with a median of 39 years. The overall prevalence of MA was 20%; 36% in those with diabetes. Those women with MA had higher rates of diabetes (63.8 vs. 28.6%, odds ratio [OR] = 4.4, P < 0.05), hypertension (82.8 vs. 42.9%, OR = 6.4, P < 0.05), and family history of diabetes (85.7 vs. 61.7%, OR = 3.7, P < 0.05). The proportion of subjects with MA with a family history of hypertension was nonsignificantly increased (92.9 vs. 82.4%). Subjects with MA were more obese (BMI 37.2 +/- 8.9 vs. 34.4 +/- 8.6 kg/m(2)) and had higher levels of HbA(1c) (8.8 +/- 3.3 vs. 6.6 +/- 1.8%, P < 0.001) and systolic (144.3 +/- 25.9 vs. 122.8 +/- 17.2 mmHg, P < 0.0001) and diastolic (95.1 +/- 15.4 vs. 82.5 +/- 11.9 mmHg, P < 0.0001) blood pressures. Lipid fractions were similar in those with and without MA. Although fasting glucose was much higher in subjects with MA (10.3 +/- 5.8 vs. 7.1 +/- 4.2 mmol/l, P = 0.0002), insulin levels were not significantly higher in subjects with MA (17.4 +/- 21.2 vs. 15.2 +/- 12.4 pmol/l). Insulin sensitivity, as measured using log HOMA, was similar (1.5 +/- 0.6 vs. 1.6 +/- 0.6) in women with and without MA, respectively. Multivariable logistic regression analyses indicated that HbA(1c), OR = 1.16 (1.07, 1.27), and systolic blood pressure, OR = 1.27 (1.14, 1.41), were independent risk factors for MA. In those with diabetes, the subjects with MA had higher rates of hypertension-83.8 vs. 56.1%, OR = 4.1 (1.5, 11.10)-which was reflected by their higher systolic and diastolic blood pressures, 146.1 mmHg (P = 0.001) and 94.8 mmHg (P = 0.002), respectively, and lower levels of VLDL (0.45 +/- 0.22 vs. 0.61 +/- 0.33 mmol/l, P = 0.021). In the multivariable analyses of those with diabetes, the two independent risk factors for MA were similar: HbA(1c), OR = 1.13 (1.01, 1.28), and systolic blood pressure, OR = 1.21 (1.04, 1.41).

CONCLUSIONS

African-American women with a history of GDM have one of the highest rates for MA. Presence of MA was not associated with insulin resistance but was significantly independently associated with HbA(1c) levels and hypertension. These results, taken in context of the literature, suggest that hypertension and glucose intolerance, in part, influence MA through different mechanisms. Because of the high prevalence of MA in this population and MA's relation to all-cause and cardiovascular mortality, screening for MA should be considered.

Drugs for cardiovascular risk reduction in the diabetic patient

The diabetic patient is at increased risk for cardiac events. Lowering hemoglobin A1c levels even within the normal range is associated with less cardiac risk. Oral agents for diabetes that reduce insulin resistance and its associated cardiac risk factors in addition to lowering glucose should be used. Energetic reduction of blood pressure with an emphasis on the use of angiotensin-converting enzyme inhibitors and beta blockers will further reduce cardiac risk. Reduction of low-density lipoprotein and triglyceride levels and elevation of high-density lipoprotein levels through judicious use of statins and other anti-lipid agents is essential and will lower the rate of cardiac events in the diabetic patients even more than in the nondiabetic patients. In addition, aspirin and folic acid supplementation should be utilized. Use of a multiple risk factor management strategy with these drugs will lower morbidity and mortality, improve quality of life, and save cost for the diabetic patient.

Importance of postprandial glucose control

Although a traditional goal of glycemic control in the treatment of diabetes mellitus is to normalize fasting plasma glucose, emerging data indicate that modulation of postprandial plasma glucose levels plays an important role in overall glycemic control. This article reviews the evidence linking postprandial glucose levels with long-term indices of diabetes control, such as glycosylated hemoglobin, lipid abnormalities, and the risk of microvascular and macrovascular complications. Early in the development of type 2 diabetes, the initial burst of insulin release in response to food intake is compromised, allowing postprandial hyperglycemia to develop. Meal-associated hyperglycemia further contributes to increase insulin resistance and decrease insulin production. Evidence of a strong correlation between high postprandial glycemic levels and the development of vascular complications underscores the significance of treating mealtime glycemia. Emerging drugs that reduce postprandial hyperglycemia include the D-phenylalanine derivative nateglinide, amylin derivative pramlintide, and glucagon-like insulinotropic peptide.

Thirteen-year follow-up of children and adolescents with chronic fatigue syndrome

OBJECTIVE

To describe the educational, social, and symptomatic outcome of children and adolescents with chronic fatigue syndrome 13 years after illness onset.

METHODS

Between January 1984 and December 1987, 46 children and adolescents developed an illness suggestive of chronic fatigue syndrome. Follow-up questionnaires were obtained from 35 participants an average of 13 years after illness onset. Data were obtained concerning subsequent medical diagnoses, amount of school missed, presence and severity of current symptoms, and subjective assessment of degree of illness resolution.

RESULTS

Of the 35 participants, 24 were female (68.6%) and 11 were male (31.4%). Average age at illness onset was 12.1 years. Eight participants (22.9%) had an acute onset of symptoms, 27 (77.1%) had a gradual onset. No participant received an alternative medical diagnosis that could have explained the symptom complex between illness onset and follow-up. Thirteen participants (37.1%) considered themselves resolved of illness at follow-up; 15 participants (42.9%) considered themselves well but not resolved; 4 (11.4%) considered themselves chronically ill; and 3 (8.6%) considered themselves more ill than during the early years of illness. Correlation with the Medical Outcomes Study Short Form Health Survey was good for current level of symptoms and degree of recovery. Eight participants (22.9%) missed >2 years of school, and 5 of these were still ill at follow-up. Amount of school missed correlated with both illness severity at follow-up and perceived social impact of the illness.

CONCLUSIONS

These data demonstrate the presence of an illness consistent with the current definition of chronic fatigue syndrome. Eighty percent of children and adolescents affected had a satisfactory outcome from their fatiguing illness, although the majority of these participants had mild to moderate persisting symptoms. Twenty percent of participants remain ill with significant symptoms and activity limitation 13 years after illness onset. Chronic fatigue syndrome in children and adolescents may result in persistent somatic symptoms and disability in a minority of those affected.

Use of soy protein supplement and resultant need for increased dose of levothyroxine

OBJECTIVE

To report a case of difficulty in achieving suppressive serum levels of thyroid hormone because of malabsorption of exogenous levothyroxine attributable to daily ingestion in close temporal relationship to the intake of a soy protein-containing food supplement.

METHODS

We present the relevant history and laboratory data of the current case and provide supportive documentation from the literature.

RESULTS

A 45-year-old woman who had hypothyroidism after a near-total thyroidectomy and radioactive iodine ablative therapy for papillary carcinoma of the thyroid required unusually high oral doses of levothyroxine to achieve suppressive serum levels of free thyroxine (T(4)) and thyrotropin (thyroid-stimulating hormone or TSH). She had routinely been taking a "soy cocktail" protein supplement immediately after her levothyroxine. Temporal separation of the intake of the soy protein cocktail from the administration of the levothyroxine resulted in attainment of suppressive serum levels of free T(4) and TSH with use of lower doses of levothyroxine.

CONCLUSION

Administration of levothyroxine concurrently with a soy protein dietary supplement results in decreased absorption of levothyroxine and the need for higher oral doses of levothyroxine to attain therapeutic serum thyroid hormone levels.