Beneficial effect of moderate weight loss in older patients with non-insulin-dependent diabetes mellitus poorly controlled with insulin

Fifteen patients with non-insulin-dependent diabetes mellitus, poorly controlled on insulin, were enrolled in a weight loss program. Criteria included a fasting plasma glucose concentration greater than 200 mg/dl, age in excess of 65 years, and the presence of obesity. Twelve of the 15 patients were able to complete the program, and the average weight loss of the group was 9 kg. Prior to initiation of the weight loss program the 12 patients were receiving (mean +/- SEM) 52 +/- 5 units of insulin per day and had a mean (+/- SEM) fasting plasma glucose concentration of 258 +/- 10 mg/dl. Insulin treatment was discontinued in all subjects during the weight loss period, and did not need to be resumed when weight stabilization had occurred. On the other hand, reasonable diabetic control could not be maintained without medication, and all patients were started on chlorpropamide during the period of weight stabilization. With this approach, a mean (+/- SEM) fasting glucose concentration of 137 +/- 4 mg/dl was achieved with a daily chlorpropamide dose of 354 +/- 30 mg. This dramatic clinical change took place despite the fact that no patient achieved ideal body weight. These results document the ability of a moderate amount of weight loss to transform patients with non-insulin-dependent diabetes mellitus, who are overweight and older than 65 years of age, from treatment failures to treatment successes.

Exfoliation, cholestasis, and apparent biliary sepsis in a woman with adult-onset diabetes

In consultation the authors were requested to evaluate a middle-aged diabetic woman for an apparent episode of biliary sepsis. The patient had been admitted to the dermatology service with a four-day history of rash and pruritus. This was initially thought to represent an allergic reaction to dicloxacillin in someone with a previous history of penicillin hypersensitivity. Persistent right upper quadrant pain, fevers, elevations of serum alkaline phosphatase, and a radionuclide scan which did not demonstrate a functioning gall bladder led to a cholecystectomy for acute cholecystitis and possible biliary sepsis. This diagnosis was not confirmed. Ultimately, this case illustrated the need to review carefully recent changes in any patient's drug regimen. Reactions to commonly prescribed agents may cause syndromes which are difficult to distinguish from episodes of apparent sepsis.

Comparison of diabetic control in type 2 (non-insulin dependent) diabetic patients treated with different sulphonylureas

Diabetic control was compared in groups of Type 2 (non-insulin dependent) diabetic patients treated concurrently for 1 year with five different sulphonylurea drugs: chlorpropamide (21), glipizide (24), gliquidone (22), gliclazide (22) and glibenclamide (23). Glycosylated haemoglobin (HbA1) levels decreased in all groups over the first 2 months, but tended to level off or increase thereafter. In a total of 96 patients assessed after 1 year, gliclazide produced normal HbA1 levels in a significantly greater number of patients than chlorpropamide (p = 0.01) and gliquidone (p = 0.038), and glibenclamide was also significantly better than chlorpropamide (p = 0.02). Significant improvements in HbA1 were produced overall in the gliquidone (p less than 0.01), gliclazide (p less than 0.01) and glibenclamide (p less than 0.02) groups and the gliquidone and gliclazide groups were significantly better than the glipizide group (p less than 0.01 in both cases). Only the glibenclamide group had a significant change in weight (p less than 0.05). There may be differences between different sulphonylureas which could be of clinical advantage in certain patients.

Sulfonylureas enhance in vivo the effectiveness of insulin in type 1 (insulin dependent) diabetes mellitus

Indirect evidence suggests that sulfonylureas, in addition to stimulating insulin release, exert additional effects at extrapancreatic levels which are of value in the management of type 2 diabetes. In order to characterize in vivo some of these effects, insulin sensitivity was studied in 9 type 1 diabetics with no residual insulin secretory activity, during treatment with chlorpropamide (250 mg b.i.d. for 8 days) and with glipizide (5 mg t.i.d. for 8 days). Employing the glucose clamp technique with the aid of an artificial pancreas (Biostator), glucose disposal during insulin infusion (0.1 U/kg in 60 min) was calculated by the amount of glucose required to keep the blood glucose at preinfusion levels. Chlorpropamide and glipizide administration was accompanied by a significant increase of the amount of glucose required to clamp blood glucose levels, while serum (free) insulin levels were superimposable during the different clamping studies. In the absence of endogenous insulin release, these data strongly suggest that the two sulfonylureas employed enhance in vivo the peripheral sensitivity to insulin. Further studies are required to indicate a preferential site of action (liver, muscle, adipose tissue) of sulfonylureas.

Lichenoid drug reactions to chlorpropamide and tolazamide

Many medications, including gold, antimalarials, quinidine, and thiazide diuretics have been implicated in lichenoid drug reactions. Chlorpropamide and tolazamide are sulfonylurea oral hypoglycemic agents, neither of which has previously been implicated in cutaneous lichenoid reactions. We report a case of lichenoid drug reaction related to both chlorpropamide and tolazamide.

Hereditary central diabetes insipidus: plasma levels of antidiuretic hormone in a family with a possible osmoreceptor defect

A large Canadian kindred of Irish extraction extending from Quebec to British Columbia with autosomal dominant diabetes insipidus responsive to exogenous antidiuretic hormone (ADH) is described. Out of 121 individuals 34 have been identified as affected in seven generations. The disorder is characterized by variability in age at onset and in severity, and by apparently spontaneous abatement in old age. The affected subjects do not appear to manifest hypertension or its sequelae. In three individuals tested the plasma ADH level was very low in spite of adequate osmotic stimulation. However, the level rose in two of them when they were given furosemide, which suggests an osmoreceptor defect and a normal ADH response to volume change.

Correlation of serum lipids with diabetes control in sulfonylurea-treated diabetic patients

The relationships between fasting blood glucose, glycosylated hemoglobin A1, and several lipid parameters were studied in 67 non-insulin-dependent diabetic patients (19 men, 48 women) being treated with tolbutamide, chlorpropamide, or glibenclamide. All patients were over 60 yr of age with a mean age of 76.4 +/- 6.7 yr (+/- SD). There were positive associations between fasting blood glucose and serum cholesterol, LDL cholesterol, and serum triglycerides. A strong association between total cholesterol and triglycerides was also evident. Diabetes control and HDL cholesterol did not correlate with each other. A weak inverse correlation existed between fasting blood glucose and the HDL cholesterol/total cholesterol ratio. HDL cholesterol concentrations were low in the diet- and drug-treated diabetic patients. No deleterious sulfonylurea effects on cholesterol, LDL cholesterol, and triglyceride concentrations or HDL cholesterol/total cholesterol ratio were noted.

Glyburide and glipizide, second-generation oral sulfonylurea hypoglycemic agents

The chemistry, pharmacology, pharmacokinetics, clinical efficacy, adverse effects, and dosage of glyburide and glipizide, two second-generation oral sulfonylurea hypoglycemic agents, are reviewed. Glyburide and glipizide are well absorbed after oral administration. The absorption of glipizide is delayed by food; in contrast, glyburide absorption does not seem to be affected by administration with meals. Both drugs are extensively metabolized by the liver. A two-compartment open model adequately describes the pharmacokinetics of these drugs. The apparent elimination half-life of glyburide in oral dosage forms available in the United States ranges from 7 to 10 hours. Glipizide has a terminal elimination half-life of 2-7 hours. The effects of renal and hepatic disease on the pharmacokinetics of glyburide and glipizide have not been well studied. Based on controlled, comparative studies in patients with new-onset, diet-failed, Type II diabetes, glyburide appears to be at least as effective as chlorpropamide and tolazamide in controlling blood glucose. Glipizide has shown efficacy comparable to or greater than that of chlorpropamide and tolbutamide. Glyburide and glipizide appear to be comparable in terms of their ability to control fasting blood glucose in Type II diabetics. The recommended initial dosage of glyburide in newly diagnosed Type II diabetics is 2.5-5 mg once daily. For glipizide, the initial dosage should be 5 mg once daily. Elderly or debilitated patients and those with renal or hepatic impairment should be started on lower dosages initially. Glyburide and glipizide have adverse effects that are similar to those observed with the first-generation oral hypoglycemic agents. Glyburide and glipizide do not appear to offer major therapeutic advantages over first-generation oral sulfonylurea hypoglycemic agents. However, they may represent therapeutic alternatives for some patients who do not respond satisfactorily to other sulfonylureas.

Correlation between serum concentration and hypoglycemic effect of chlorpropamide in man

The relationship between the serum concentration and some of pharmacokinetic parameters of chlorpropamide and the hypoglycemic effect of this drug was studied. Studies were carried out in a group of 18 patients in whom the concentrations of drug and sugar in blood were determined simultaneously. Close correlation between the concentration and some pharmacokinetic parameters of chlorpropamide and the intensity of decrease of the blood glucose level as well as the time of its occurrence has been found.

Drug interaction between chlorpropamide and non-steroidal anti-inflammatory drugs, ibuprofen and phenylbutazone

Diabetics well controlled on chlorpropamide received, in randomized manner either 1200 mg of ibuprofen or 300 mg of phenylbutazone per day for rheumatic pains, for a period of 4 weeks. Fasting and postlunch, whole blood, true sugars (FBS and PLBS) were estimated at weekly intervals. Subjects taking phenylbutazone showed reduction in FBS values throughout the treatment; the reduction became statistically significant at the 3rd and 4th week. Clinical hypoglycemia, however, was not observed. The FBS values returned to pretreatment levels after stopping phenylbutazone. No significant reduction was seen in FBS in subjects taking ibuprofen. There was no significant change in PLBS values in either group.

Effect of chlorpropamide and gliclazide on plasminogen activator activity in vascular walls in patients with maturity onset diabetes

The components of the fibrinolytic system were studied in patients with maturity onset diabetes, treated with chlorpropamide for three years or more. Half of the patients (7/15) were shown to have abnormally low plasminogen activator activity of the vascular walls. The patients were then shifted to gliclazide, a new sulfonylurea, and after six months all patients had a normal vascular plasminogen activator activity. At follow up after 24 and 48 months the results remained the same. The normalization of the vascular fibrinolytic defence system could not be explained by improvement of glucose control.

Improvement of metabolic control in diabetic patients during mebendazole administration: preliminary studies

After the observation of decreasing insulin resistance in a diabetic patient during treatment with mebendazole for nematosis, we investigated the effect of mebendazole on metabolic control in six Type 1 (insulin-dependent) and six Type 2 (non-insulin-dependent) diabetic patients, eight of whom were chronically resistant to conventional treatment. Before and after mebendazole treatment for 1 month, plasma glucose and serum C-peptide concentrations were determined both fasting and 4 h after a mixed breakfast. Improvements in fasting blood glucose concentrations occurred in Type 1 (12.83 +/- 1.11 versus 6.56 +/- 0.56 mmol/l; p less than 0.05) and Type 2 (10.22 +/- 0.56 versus 7.56 +/- 0.67 mmol/l; p less than 0.05) diabetic patients and were associated with increases in post-cibal C-peptide responses in Type 1 and Type 2 diabetic patients. Following discontinuation of mebendazole, metabolic control deteriorated in five out of the six Type 1 diabetic patients and in all the Type 2 diabetic patients. We conclude that mebendazole increases insulin secretion, and decreases plasma glucose concentration in Type 1 and Type 2 diabetic patients. However, these beneficial effects may be transient.

Alterations of plasma opioid activity in human diabetics

Plasma opioid levels were determined in 9 obese non-diabetic subjects, their 8 age matched controls, and in 29 diabetic patients; 10 maintained on diet alone, 6 on an oral hypoglycemic agent (chlorpropamide) and 13 treated with insulin. Five age matched controls for the diabetic groups were also studied for comparison. beta-endorphin and met-enkephalin levels were measured by radioimmunoassay. Enkephalin-like activity was measured by a receptor assay. Among the study groups, diabetic patients receiving insulin showed a 64% elevation of plasma beta-endorphins and diabetic patients on chlorpropamide showed a 121% increase in enkephalin-like activity. There were no statistically significant differences in the plasma met-enkephalin values in the treatment groups though levels were decreased (p less than 0.05) in diabetics vs non-diabetics. The pathophysiological importance of these alterations remains to be elucidated.

Hypernatremia and adipsia in a dog

Primary adipsia and defective osmoreceptor function were diagnosed in a 7-month-old female Miniature Schnauzer. Also, the dog was noted to be dehydrated and to have chronic hypernatremia. On multiple occasions the dog's urine osmolality: plasma osmolality was greater than 4. The dog had inappropriate responses to isoosmotic and hypertonic NaCl infusions. Chlorpropamide administration initiated water intake but the volume was insufficient to avoid hypernatremia. The chronic hypernatremia and dehydration were treated successfully by mixing the calculated maintenance fluid volume in canned food. At 25 months of age, the dog died several days after becoming dehydrated and severely hypernatremic. Astrogliosis and neuronal degeneration were noted in both the thalamic and hypothalamic regions, but were believed to be nonspecific degenerative lesions compatible with seizures and severe dehydration.

Diabetes insipidus: occurrence after minor head trauma

Post-traumatic diabetes insipidus is a rare entity, usually associated with severe head trauma, often with skull fracture and cranial nerve dysfunction. A 24-year-old male presented to a medical clinic 2 weeks after a minor head injury with presenting symptoms of polyuria with nocturia and intense polydipsia. A diagnosis of post-traumatic diabetes insipidus was made. Although other causes of polyuria syndromes must be ruled out, plotting urine versus plasma osmolalities can provide rapid preliminary diagnostic help when considering diabetes insipidus. First-line treatment should include a trial of chlorpropamide and hydrochlorothiazide. Caution should be exercised in not overlooking associated anterior pituitary damage, which may develop several years post-trauma.