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Scholes G, Ng E, Bach LA, Sztal-Mazer S. Mixed insulin can improve control of prednisolone-induced hyperglycaemia. Intern Med J 2023; 53:2264-2269. [PMID: 36880383 DOI: 10.1111/imj.16050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Accepted: 02/26/2023] [Indexed: 03/08/2023]
Abstract
BACKGROUND Hyperglycaemia is a common side effect of prednisolone, although there are no widely accepted guidelines for the management of glucocorticoid-induced hyperglycaemia (GIH). Our institution uses mixed insulin in a pre-breakfast or pre-breakfast and pre-lunch regimen, with the rationale that this profile of insulin action matches the physiological effect of prednisolone on blood glucose levels (BGLs). AIM Evaluate the use of the mixed insulin (NovoMix30) in a pre-breakfast or pre-breakfast and pre-lunch regimen as management for GIH in a tertiary hospital setting. METHOD We retrospectively evaluated all inpatients coprescribed prednisolone ≥7.5 mg and NovoMix30 for at least 48 hours over a 19-month period. BGLs were evaluated with repeated-measures analysis within four time periods across the day, beginning from the day prior to NovoMix30 administration. RESULTS A total of 53 patients were identified. NovoMix30 significantly reduced BGLs in the morning (mean 12.7 ± 4.5 vs. 9.2 ± 3.9 mmol/L, P < 0.001), afternoon (mean 13.6 ± 3.8 vs. 11.9 ± 3.8 mmol/L, P = 0.001) and evening (12.1 ± 3.8 vs. 10.8 ± 3.8 mmol/L, P = 0.01). With uptitration of insulin over 3 days, 43% of all BGLs were within the target range, compared with 23% on day 0 (P < 0.001). The final median dose of NovoMix30 was 0.15 (0.10-0.22) units/kg bodyweight, or 0.40 (0.23-0.69) units/mg of prednisolone, which is lower than our hospital guideline recommends. One overnight hypoglycaemic event was observed. CONCLUSION Mixed insulin as a pre-breakfast or pre-breakfast and pre-lunch regimen can target the hyperglycaemic pattern induced by prednisolone and minimise overnight hypoglycaemia. However, higher doses of insulin than those used in our study are likely required for optimal BGL control.
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Affiliation(s)
- Gemma Scholes
- Department of Medicine, Alfred Health, Melbourne, Australia
| | - Elisabeth Ng
- Department of Endocrinology & Diabetes, Alfred Health, Melbourne, Australia
| | - Leon A Bach
- Department of Endocrinology & Diabetes, Alfred Health, Melbourne, Australia
- Department of Medicine (Alfred), Monash University, Melbourne, Australia
| | - Shoshana Sztal-Mazer
- Department of Endocrinology & Diabetes, Alfred Health, Melbourne, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
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Hillebrandt D, Gurtoo A, Kupper T, Richards P, Schöffl V, Shah P, van der Spek R, Wallis N, Milledge J. UIAA Medical Commission Recommendations for Mountaineers, Hillwalkers, Trekkers, and Rock and Ice Climbers with Diabetes. High Alt Med Biol 2023; 24:110-126. [PMID: 30335516 PMCID: PMC10282971 DOI: 10.1089/ham.2018.0043] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Accepted: 08/20/2018] [Indexed: 01/01/2023] Open
Abstract
Hillebrandt, David, Anil Gurtoo, Thomas Kupper, Paul Richards, Volker Schöffl, Pankaj Shah, Rianne van der Spek, Nikki Wallis, and Jim Milledge. UIAA Medical Commission recommendations for mountaineers, hillwalkers, trekkers, and rock and ice climbers with diabetes. High Alt Med Biol. 24: 110-126.-The object of this advice article is not only to give the diabetic mountaineer general guidance but also to inform his or her medical team of practical aspects of care that may not be standard for nonmountaineers. The guidelines are produced in seven sections. The first is an introduction to the guidelines, and the second is an introduction to this medical problem and is designed to be read and understood by diabetic patients and their companions. The third section is for use in an emergency in mountains. The fourth is for rock, ice, and competition climbers operating in a less remote environment. These initial sections are deliberately written in simple language. The fifth and sixth sections are written for clinicians and those with skills to read more technical information, and the seventh looks at modern technology and its pros and cons in diabetes management in a remote area. Sections One and Two could be laminated and carried when in the mountains, giving practical advice.
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Affiliation(s)
- David Hillebrandt
- Union Internationale des Associations d'Alpinisme Medical Commission (UIAA MedCom), Bern, Switzerland
- Derriton House, Holsworthy, England
| | - Anil Gurtoo
- Union Internationale des Associations d'Alpinisme Medical Commission (UIAA MedCom), Bern, Switzerland
- Department of Medicine, Lady Hardinge Medical College and Associated SSK Hospital, New Delhi, India
| | - Thomas Kupper
- Union Internationale des Associations d'Alpinisme Medical Commission (UIAA MedCom), Bern, Switzerland
- Institute of Occupational and Social Medicine, RWTH Aachen University, Aachen, Germany
| | - Paul Richards
- Faculty of PreHospital Care, Basildon and Brentwood CCG, Essex, England
| | - Volker Schöffl
- Union Internationale des Associations d'Alpinisme Medical Commission (UIAA MedCom), Bern, Switzerland
- Section Sportsmedicine, Department of Trauma and Orthopedic Surgery, Klinikum Bamberg, Bamberg, Germany
- Department of Trauma Surgery, University of Erlangen-Nuermebrg, Germany
- Section of Wilderness Medicine, Department of Emergency Medicine, University of Colorado School of Medicine, Denver, Colorado
| | - Pankaj Shah
- Division of Endocrinology, Mayo Clinic, Rochester, Minnesota
| | - Rianne van der Spek
- Union Internationale des Associations d'Alpinisme Medical Commission (UIAA MedCom), Bern, Switzerland
- Department of Endocrinology and Metabolism, University of Amsterdam, Academic Medical Center, Amsterdam, The Netherlands
| | - Nikki Wallis
- Emergency Department, Ysbyty Gwynedd, Bangor, Wales
| | - Jim Milledge
- Union Internationale des Associations d'Alpinisme Medical Commission (UIAA MedCom), Bern, Switzerland
- Northwick Park Hospital, Harrow, United Kingdom
- Department of Medicine, Medical Research Council, United Kingdom
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Caratti G, Stifel U, Caratti B, Jamil AJM, Chung KJ, Kiehntopf M, Gräler MH, Blüher M, Rauch A, Tuckermann JP. Glucocorticoid activation of anti-inflammatory macrophages protects against insulin resistance. Nat Commun 2023; 14:2271. [PMID: 37080971 PMCID: PMC10119112 DOI: 10.1038/s41467-023-37831-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Accepted: 04/01/2023] [Indexed: 04/22/2023] Open
Abstract
Insulin resistance (IR) during obesity is linked to adipose tissue macrophage (ATM)-driven inflammation of adipose tissue. Whether anti-inflammatory glucocorticoids (GCs) at physiological levels modulate IR is unclear. Here, we report that deletion of the GC receptor (GR) in myeloid cells, including macrophages in mice, aggravates obesity-related IR by enhancing adipose tissue inflammation due to decreased anti-inflammatory ATM leading to exaggerated adipose tissue lipolysis and severe hepatic steatosis. In contrast, GR deletion in Kupffer cells alone does not alter IR. Co-culture experiments show that the absence of GR in macrophages directly causes reduced phospho-AKT and glucose uptake in adipocytes, suggesting an important function of GR in ATM. GR-deficient macrophages are refractory to alternative ATM-inducing IL-4 signaling, due to reduced STAT6 chromatin loading and diminished anti-inflammatory enhancer activation. We demonstrate that GR has an important function in macrophages during obesity by limiting adipose tissue inflammation and lipolysis to promote insulin sensitivity.
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Affiliation(s)
- Giorgio Caratti
- Institute of Comparative Molecular Endocrinology, University of Ulm, Ulm, Germany
- NIHR Oxford Biomedical Research Centre, John Radcliffe Hospital, Oxford, OX3 9DU, UK
- Oxford Centre for Diabetes, Endocrinology and Metabolism, University of Oxford, Oxford, OX37LE, UK
| | - Ulrich Stifel
- Institute of Comparative Molecular Endocrinology, University of Ulm, Ulm, Germany
| | - Bozhena Caratti
- Institute of Comparative Molecular Endocrinology, University of Ulm, Ulm, Germany
| | - Ali J M Jamil
- Molecular Endocrinology & Stem Cell Research Unit, Department of Endocrinology and Metabolism, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Kyoung-Jin Chung
- Institute for Clinical Chemistry and Laboratory Medicine, University Hospital and Faculty of Medicine, Technical University Dresden, Dresden, Germany
| | - Michael Kiehntopf
- SG Sepsis Research Clinic for Anesthesiology and Intensive Care, Jena University Hospital, Jena, Germany
| | - Markus H Gräler
- Department of Anesthesiology and Intensive Care Medicine, Jena University Hospital, Jena, Germany
- Center for Molecular Biomedicine (CMB), Jena University Hospital, Jena, Germany
- Center for Sepsis Control and Care (CSCC), Jena University Hospital, Jena, Germany
| | - Matthias Blüher
- Department of Endocrinology and Nephrology, University of Leipzig, Leipzig, Germany
| | - Alexander Rauch
- Molecular Endocrinology & Stem Cell Research Unit, Department of Endocrinology and Metabolism, Odense University Hospital, Odense, Denmark.
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark.
- Steno Diabetes Center Odense, Odense, Denmark.
| | - Jan P Tuckermann
- Institute of Comparative Molecular Endocrinology, University of Ulm, Ulm, Germany.
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Cairat M, Al Rahmoun M, Gunter MJ, Heudel PE, Severi G, Dossus L, Fournier A. Use of systemic glucocorticoids and risk of breast cancer in a prospective cohort of postmenopausal women. BMC Med 2021; 19:186. [PMID: 34340701 PMCID: PMC8330083 DOI: 10.1186/s12916-021-02004-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Accepted: 05/10/2021] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Glucocorticoids could theoretically decrease breast cancer risk through their anti-inflammatory effects or increase risk through immunosuppression. However, epidemiological evidence is limited regarding the associations between glucocorticoid use and breast cancer risk. METHODS We investigated the association between systemic glucocorticoid use and breast cancer incidence in the E3N cohort, which includes 98,995 women with information on various characteristics collected from repeated questionnaires complemented with drug reimbursement data available from 2004. Women with at least two reimbursements of systemic glucocorticoids in any previous 3-month period since January 1, 2004, were defined as exposed. We considered exposure as a time-varying parameter, and we used multivariable Cox regression models to estimate hazard ratios (HRs) of breast cancer. We performed a competing risk analysis using a cause-specific hazard approach to study the heterogeneity by tumour subtype/stage/grade. RESULTS Among 62,512 postmenopausal women (median age at inclusion of 63 years old), 2864 developed breast cancer during a median follow-up of 9 years (between years 2004 and 2014). Compared with non-exposure, glucocorticoid exposure was not associated with overall breast cancer risk [HR = 0.94 (0.85-1.05)]; however, it was associated with a higher risk of in situ breast cancer and a lower risk of invasive breast cancer [HRinsitu = 1.34 (1.01-1.78); HRinvasive = 0.86 (0.76-0.97); Phomogeneity = 0.01]. Regarding the risk of invasive breast cancer, glucocorticoid exposure was inversely associated with oestrogen receptor (ER)-positive breast cancer [HRER+ = 0.82 (0.72-0.94); HRER- = 1.21 (0.88-1.66); Phomogeneity = 0.03]; it was also inversely associated with the risk of stage 1 or stage 2 tumours but positively associated with the risk of stage 3/4 breast cancers [HRstage1 = 0.87 (0.75-1.01); HRstage2 = 0.67 (0.52-0.86); HRstage3/4 = 1.49 (1.02-2.20); Phomogeneity = 0.01]. CONCLUSION This study suggests that the association between systemic glucocorticoid use and breast cancer risk may differ by tumour subtype and stage.
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Affiliation(s)
- Manon Cairat
- Nutrition and Metabolism Branch, International Agency for Research on Cancer, Lyon, France
| | - Marie Al Rahmoun
- Université Paris-Saclay, UVSQ, Inserm, Gustave Roussy, Exposome and heredity team, CESP, F-94805, Villejuif, France
| | - Marc J Gunter
- Nutrition and Metabolism Branch, International Agency for Research on Cancer, Lyon, France
| | | | - Gianluca Severi
- Université Paris-Saclay, UVSQ, Inserm, Gustave Roussy, Exposome and heredity team, CESP, F-94805, Villejuif, France
- Department of Statistics, Computer Science and Applications "G. Parenti" (DISIA), University of Florence, Florence, Italy
| | - Laure Dossus
- Nutrition and Metabolism Branch, International Agency for Research on Cancer, Lyon, France
| | - Agnès Fournier
- Université Paris-Saclay, UVSQ, Inserm, Gustave Roussy, Exposome and heredity team, CESP, F-94805, Villejuif, France.
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Mareev VY, Orlova YA, Pavlikova EP, Matskeplishvili ST, Krasnova TN, Malahov PS, Samokhodskaya LM, Mershina EA, Sinitsyn VE, Mareev YV, Kalinkin AL, Begrambekova YL, Kamalov AA. [Steroid pulse -therapy in patients With coronAvirus Pneumonia (COVID-19), sYstemic inFlammation And Risk of vEnous thRombosis and thromboembolism (WAYFARER Study)]. ACTA ACUST UNITED AC 2020; 60:15-29. [PMID: 32720612 DOI: 10.18087/cardio.2020.6.n1226] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Accepted: 06/18/2020] [Indexed: 01/29/2023]
Abstract
Introduction Coronavirus pneumonia not only severely affects the lung tissue but is also associated with systemic autoimmune inflammation, rapid overactivation of cytokines and chemokines known as "cytokine storm", and a high risk of thrombosis and thromboembolism. Since there is no specific therapy for this new coronavirus infection (COVID-19), searching for an effective and safe anti-inflammatory therapy is critical.Materials and methods This study evaluated efficacy and safety of pulse therapy with high doses of glucocorticosteroids (GCS), methylprednisolone 1,000 mg for 3 days plus dexamethasone 8 mg for another 3-5 days, in 17 patients with severe coronavirus pneumonia as a part of retrospective comparative analysis (17 patients in control group). The study primary endpoint was the aggregate dynamics of patients' condition as evaluated by an original CCS-COVID scale, which included, in addition to the clinical status, assessments of changes in the inflammation marker, C-reactive protein (CRP); the thrombus formation marker, D-dimer; and the extent of lung injury evaluated by computed tomography (CT). Patients had signs of lung injury (53.2 % and 25.6 %), increases in CRP 27 and 19 times, and a more than doubled level of D-dimer (to 1.41 µg/ml and 1.15 µg/ml) in the active therapy and the control groups, respectively. The GCS treatment group had a more severe condition at baseline.Results The GCS pulse therapy proved effective and significantly decreased the CCS-COVID scores. Median score difference was 5.00 compared to the control group (р=0.011). Shortness of breath considerably decreased; oxygen saturation increased, and the NEWS-2 clinical status scale scores decreased. In the GCS group, concentration of CRP significantly decreased from 134 mg/dl to 41.8 mg/dl (р=0.009) but at the same time, D-dimer level significantly increased from 1.41 µg/ml to 1.98 µg/ml (р=0.044). In the control group, the changes were nonsignificant. The dynamics of lung injury by CT was better in the treatment group but the difference did not reach a statistical significance (р=0.062). Following the GCS treatment, neutrophilia increased (р=0.0001) with persisting lymphopenia, and the neutrophil/lymphocyte (N/L) ratio, a marker of chronic inflammation, increased 2.5 times (р=0.006). The changes in the N/L ratio and D-dimer were found to correlate in the GCS pulse therapy group (r =0.49, p=0.04), which underlined the relationship of chronic autoimmune inflammation with thrombus formation in COVID-19. No significant changes were observed in the control group. In result, four patients developed venous thromboembolic complications (two of them had pulmonary artery thromboembolism) after the GCS pulse therapy despite the concomitant antiplatelet treatment at therapeutic doses. Recovery was slower in the hormone treatment group (median stay in the hospital was 26 days vs 18 days in the control group, р=0.001).Conclusion Pulse therapy with high doses of GCS exerted a rapid anti-inflammatory effect but at the same time, increased the N/L ratio and the D-dimer level, which increased the risk of thromboembolism.
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Affiliation(s)
- V Yu Mareev
- Medical Research and Educational Center of the M. V. Lomonosov Moscow State University, Moscow, Russia
| | - Ya A Orlova
- Medical Research and Educational Center of the M. V. Lomonosov Moscow State University, Moscow, Russia
| | - E P Pavlikova
- Medical Research and Educational Center of the M. V. Lomonosov Moscow State University, Moscow, Russia
| | - S T Matskeplishvili
- Medical Research and Educational Center of the M. V. Lomonosov Moscow State University, Moscow, Russia
| | - T N Krasnova
- Medical Research and Educational Center of the M. V. Lomonosov Moscow State University, Moscow, Russia
| | - P S Malahov
- Medical Research and Educational Center of the M. V. Lomonosov Moscow State University, Moscow, Russia
| | - L M Samokhodskaya
- Medical Research and Educational Center of the M. V. Lomonosov Moscow State University, Moscow, Russia
| | - E A Mershina
- Medical Research and Educational Center of the M. V. Lomonosov Moscow State University, Moscow, Russia
| | - V E Sinitsyn
- Medical Research and Educational Center of the M. V. Lomonosov Moscow State University, Moscow, Russia
| | - Yu V Mareev
- National Medical Research Centre for Therapy and Preventive Medicine, Moscow, Russia Robertson Centre for Biostatistics. University of Glasgow
| | - A L Kalinkin
- Medical Research and Educational Center of the M. V. Lomonosov Moscow State University, Moscow, Russia
| | - Yu L Begrambekova
- Medical Research and Educational Center of the M. V. Lomonosov Moscow State University, Moscow, Russia
| | - A A Kamalov
- Medical Research and Educational Center of the M. V. Lomonosov Moscow State University, Moscow, Russia
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Cansu GB, Cansu DÜ, Taşkıran B, Bilge ŞY, Bilgin M, Korkmaz C. What is the optimal time for measuring glucose concentration to detect steroid-induced hyperglycemia in patients with rheumatic diseases? Clin Biochem 2019; 67:33-39. [DOI: 10.1016/j.clinbiochem.2019.03.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Revised: 03/17/2019] [Accepted: 03/22/2019] [Indexed: 01/09/2023]
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Bonaventura A, Montecucco F. Steroid-induced hyperglycemia: An underdiagnosed problem or clinical inertia? A narrative review. Diabetes Res Clin Pract 2018. [PMID: 29530386 DOI: 10.1016/j.diabres.2018.03.006] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Corticosteroids are widely diffused drugs. An important side effect is the impairment of glycemic control both in patients with known diabetes and in normoglycemic ones potentially leading to steroid-induced diabetes mellitus (SIDM). In this review based on papers released on PubMed, MEDLINE, and EMBASE from January 2015 to October 2017, we summarized and discussed main updates about the definition, the diagnosis, and the pathophysiology of steroid-induced hyperglycemia (SIH), with a look to new therapies. Main alterations responsible for the diabetogenic effect of corticosteroids are a negative impact on insulin sensitivity along with a derangement on insulin secretion, explaining the typical post-prandial hyperglycemia linked to the promotion of gluconeogenesis. An early and precise diagnosis of SIH and/or SIDM is necessary, but current criteria do not seem sensible enough. As an afterthought, the treatment should be reasoned and tailored according to proposed glycemic thresholds and patient comorbidities, choosing between antidiabetic oral drugs and insulin, the latter being preferable among hospitalized patients. SIDM and SIH are frequent problems, but often underdiagnosed due to old diagnostic criteria. Dedicated guidelines universally shared are mandatory in order to harmonize the treatment of these conditions, thus overtaking single therapeutic strategies mostly arising from literature.
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Affiliation(s)
- Aldo Bonaventura
- First Clinic of Internal Medicine, Department of Internal Medicine, University of Genoa, 6 viale Benedetto XV, 16132 Genoa, Italy.
| | - Fabrizio Montecucco
- First Clinic of Internal Medicine, Department of Internal Medicine, University of Genoa, 6 viale Benedetto XV, 16132 Genoa, Italy; Ospedale Policlinico San Martino, 10 Largo Benzi, 16132 Genoa, Italy; Centre of Excellence for Biomedical Research (CEBR), University of Genoa, 9 viale Benedetto XV, 16132 Genoa, Italy
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Valverde-Megías A, Cifuentes-Canorea P, Ruiz-Medrano J, Peña-García P, Megías-Fresno A, Donate-López J, García-Feijoo J. Systemic Effects of Repeated Intraocular Dexamethasone Intravitreal Implant in Diabetic Patients: A Retrospective Study. Diabetes Ther 2017; 8:1087-1096. [PMID: 28918546 PMCID: PMC5630562 DOI: 10.1007/s13300-017-0307-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2017] [Indexed: 12/15/2022] Open
Abstract
INTRODUCTION The objective of this study is to evaluate the influence of repeated intraocular dexamethasone implant (Ozurdex) injections on metabolic control in type 2 diabetic patients. METHODS Retrospective study of 165 type 2 diabetic patients starting Ozurdex treatment who received no less than three consecutive injections. Glycated hemoglobin (HbA1c), serum creatinine, total cholesterol, high-density lipoprotein (HDL) cholesterol, low-density lipoprotein (LDL) cholesterol, and triglycerides (TGs) were evaluated during 15 months of follow-up after Ozurdex treatment onset. RESULTS Fifty-seven patients met inclusion criteria. Mean baseline values for HbA1c, creatinine, total cholesterol, HDL cholesterol, and TGs before treatment (7.1%, 1.3, 176.7, 51.1, and 125.6 mg/dl, respectively) were similar to mean values after Ozurdex onset (Wilcoxon test p values were 0.68, 0.41, 0.06, 0.87, and 0.33, respectively) and remained stable during the follow-up period. Mean LDL cholesterol levels increased slightly after Ozurdex treatment onset (90.1 vs 88.2 mg/dl, p = 0.04) but after 15 months of follow-up they had returned to baseline values. Transient increase in LDL cholesterol was remarkable in the group of 24 bilaterally treated patients (96.8 vs 88.4 mg/dl, p = 0.03). A third of these patients increased their baseline LDL values by more than 20%. Even with continuous injections of Ozurdex, LDL cholesterol levels also declined back to baseline by month 15. CONCLUSION Ozurdex injections had no influence on HbA1c or renal function. Lipid profile changes were mild and transient. However, a significant temporary increase has been found in LDL cholesterol levels in patients receiving simultaneous bilateral injections. Lipid levels should be monitored in patients starting with bilateral Ozurdex injections especially in those with recent history of acute myocardial infarction.
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Affiliation(s)
- Alicia Valverde-Megías
- Retina Service, Ophthalmology Department, Clínico San Carlos University Hospital, Madrid, Spain.
| | | | | | - Pablo Peña-García
- Ophthalmology Department, Castilla-La Mancha University, Albacete, Spain
| | - Alicia Megías-Fresno
- Department of Biochemistry and Molecular Biology I, Faculty of Biology, Complutense University, Madrid, Spain
| | - Juan Donate-López
- Retina Service, Ophthalmology Department, Clínico San Carlos University Hospital, Madrid, Spain
| | - Julián García-Feijoo
- Retina Service, Ophthalmology Department, Clínico San Carlos University Hospital, Madrid, Spain
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Dube S, Slama MQ, Basu A, Rizza RA, Basu R. Glucocorticoid Excess Increases Hepatic 11β-HSD-1 Activity in Humans: Implications in Steroid-Induced Diabetes. J Clin Endocrinol Metab 2015; 100:4155-62. [PMID: 26308294 PMCID: PMC4702452 DOI: 10.1210/jc.2015-2673] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
CONTEXT Animal studies indicate that glucocorticoids increase hepatic 11β-hydroxysteroid dehydrogenase type 1 (11β-HSD-1) expression and activity. OBJECTIVE Our goal was to determine whether glucocorticoid excess increases cortisol production in the liver via 11β-HSD-1 enzyme pathway in humans. DESIGN A total of 1 mg each [4-(13)C] cortisone and [9,12,12-(2)H3] cortisol were ingested, and [1,2,6,7-(3)H] cortisol was infused to measure C13 cortisol (derived from ingested [4-(13)C] cortisone) turnover using the triple tracer technique, whereas glucose turnover was measured using isotope dilution technique following [6-6(2)H2] glucose infusion during a saline clamp. SETTING This study took place at the Mayo Clinic Clinical Research Unit. PARTICIPANTS Thirty nondiabetic healthy subjects participated. INTERVENTION Subjects were randomized to hydrocortisone (n = 15) or placebo 50 mg twice daily (n = 15) for 1 week. OUTCOME MEASURES Hepatic cortisol production and endogenous glucose production were measured. RESULTS Plasma cortisol concentrations were higher throughout the study period in hydrocortisone group. Rates of appearance of C13 cortisol and hepatic C13 cortisol production were higher in hydrocortisone vs placebo group, indicating increased hepatic 11β-HSD-1 activity. Higher plasma cortisol and presumably higher intrahepatic cortisol was associated with impaired suppression of endogenous glucose production in hydrocortisone vs placebo group. CONCLUSION Chronic glucocorticoid excess increases intrahepatic cortisone to cortisol conversion via the 11β-HSD-1 pathway. The extent to which this causes or exacerbates steroid induced hepatic insulin resistance remains to be determined.
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Affiliation(s)
- Simmi Dube
- Endocrine Research Unit (S.D., M.Q.S., A.B., R.A.R., R.B.), Division of Endocrinology, Diabetes, Nutrition; Mayo Clinic, Rochester, MN 55905
| | - Michael Q Slama
- Endocrine Research Unit (S.D., M.Q.S., A.B., R.A.R., R.B.), Division of Endocrinology, Diabetes, Nutrition; Mayo Clinic, Rochester, MN 55905
| | - Ananda Basu
- Endocrine Research Unit (S.D., M.Q.S., A.B., R.A.R., R.B.), Division of Endocrinology, Diabetes, Nutrition; Mayo Clinic, Rochester, MN 55905
| | - Robert A Rizza
- Endocrine Research Unit (S.D., M.Q.S., A.B., R.A.R., R.B.), Division of Endocrinology, Diabetes, Nutrition; Mayo Clinic, Rochester, MN 55905
| | - Rita Basu
- Endocrine Research Unit (S.D., M.Q.S., A.B., R.A.R., R.B.), Division of Endocrinology, Diabetes, Nutrition; Mayo Clinic, Rochester, MN 55905
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Perez A, Jansen-Chaparro S, Saigi I, Bernal-Lopez MR, Miñambres I, Gomez-Huelgas R. Glucocorticoid-induced hyperglycemia. J Diabetes 2014; 6:9-20. [PMID: 24103089 DOI: 10.1111/1753-0407.12090] [Citation(s) in RCA: 138] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2013] [Revised: 07/17/2013] [Accepted: 09/12/2013] [Indexed: 12/19/2022] Open
Abstract
Corticosteroid-induced hyperglycemia is a common medical problem that can lead to frequent emergency room visits, hospital admissions and prolonged hospital stay, in addition to the well known morbidity associated with hyperglycemia. However, the diagnosis and treatment of corticosteroid-induced hyperglycemia is surprisingly undervalued by most professionals, probably because of the lack of quality studies to determine specific strategies of action. In the present review, we discuss the pathophysiology of corticosteroid-induced hyperglycemia, focusing on diverse patterns of hyperglycemia induced by the different formulations, and provide clues for diagnosis based on the duration of treatment and the administration schedule of corticosteroids. We propose a treatment strategy based on both the pathophysiology of the process and the mechanism of action of different corticosteroids, and take into account dosing and administration timing to predict the duration of therapy. Finally, we propose treatment goals that differ slightly between the transient and continuous use of corticosteroids based on evidence from clinical practice guidelines of diabetes care both in ambulatory and hospital settings.
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Affiliation(s)
- Antonio Perez
- Endocrinology and Nutrition Department, Hospital de la Santa Creu i San Pau, Barcelona, Spain; CIBER of Diabetes and Metabolic Diseases (CIBERDEM), Barcelona, Spain
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Richards P, Hillebrandt D. The Practical Aspects of Insulin at High Altitude. High Alt Med Biol 2013; 14:197-204. [DOI: 10.1089/ham.2013.1020] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Affiliation(s)
- Paul Richards
- Centre for Altitude, Space and Extreme Environmental Medicine, University College, London, United Kingdom
- South Essex Travel Clinic, The Surgery, Wickford, Essex, United Kingdom
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Hazlehurst JM, Gathercole LL, Nasiri M, Armstrong MJ, Borrows S, Yu J, Wagenmakers AJM, Stewart PM, Tomlinson JW. Glucocorticoids fail to cause insulin resistance in human subcutaneous adipose tissue in vivo. J Clin Endocrinol Metab 2013; 98:1631-40. [PMID: 23426618 DOI: 10.1210/jc.2012-3523] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
CONTEXT It is widely believed that glucocorticoids cause insulin resistance in all tissues. We have previously demonstrated that glucocorticoids cause insulin sensitization in human adipose tissue in vitro and induce insulin resistance in skeletal muscle. OBJECTIVE Our aim was to determine whether glucocorticoids have tissue-specific effects on insulin sensitivity in vivo. DESIGN Fifteen healthy volunteers were recruited into a double-blind, randomized, placebo-controlled, crossover study, receiving both an overnight hydrocortisone and saline infusion. The tissue-specific actions of insulin were determined using paired 2-step hyperinsulinemic euglycemic clamps incorporating stable isotopes with concomitant adipose tissue microdialysis. SETTING The study was performed in the Wellcome Trust Clinical Research Facility, Queen Elizabeth Hospital, Birmingham, United Kingdom. MAIN OUTCOME MEASURES The sensitivity of sc adipose tissue to insulin action was measured. RESULTS Hydrocortisone induced systemic insulin resistance but failed to cause sc adipose tissue insulin resistance as measured by suppression of adipose tissue lipolysis and enhanced insulin-stimulated pyruvate generation. In primary cultures of human hepatocytes, glucocorticoids increased insulin-stimulated p-ser473akt/protein kinase B. Similarly, glucocorticoids enhanced insulin-stimulated p-ser473akt/protein kinase B and increased Insulin receptor substrate 2 mRNA expression in sc, but not omental, intact human adipocytes, suggesting a depot-specificity of action. CONCLUSIONS This study represents the first description of sc adipose insulin sensitization by glucocorticoids in vivo and demonstrates tissue-specific actions of glucocorticoids to modify insulin action. It defines an important advance in our understanding of the actions of both endogenous and exogenous glucocorticoids and may have implications for the development and targeting of future glucocorticoid therapies.
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Affiliation(s)
- Jonathan M Hazlehurst
- Centre for Endocrinology, Diabetes, and Metabolism, School of Clinical and Experimental Medicine, Institute of Biomedical Research, University of Birmingham, Queen Elizabeth Hospital, Birmingham, United Kingdom
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Brands M, van Raalte DH, João Ferraz M, Sauerwein HP, Verhoeven AJ, Aerts JMFG, Diamant M, Serlie MJ. No difference in glycosphingolipid metabolism and mitochondrial function in glucocorticoid-induced insulin resistance in healthy men. J Clin Endocrinol Metab 2013; 98:1219-25. [PMID: 23386653 DOI: 10.1210/jc.2012-3266] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
OBJECTIVE Glucocorticoids (GCs) are well known to induce insulin resistance; however, mechanisms that cause the impairement of the insulin signaling pathway have not yet been identified. In this study we measured whether GC-induced insulin resistance in humans is related to changes in muscle ceramide, GM3, and muscle mitochondrial function. METHODS In a randomized, placebo-controlled, double-blind, dose-response intervention study, 32 healthy males (aged 22 ± 3 years; body mass index 22.4 ± 1.7 kg/m(-2)) were allocated to prednisolone (PRED) 7.5 mg once daily (n = 12), PRED 30 mg once daily (n = 12), or placebo (n = 8) for 2 weeks using block randomization. Insulin sensitivity was measured by hyperinsulinemic-euglycemic clamp before and after treatment. Muscle biopsies were performed to measure ceramide, monosialodihexosylganglioside (GM3), and mitochondrial function. RESULTS Peripheral insulin sensitivity was dose dependently decreased after the PRED treatment. Muscle ceramide and GM3 concentration and mitochondrial function were not altered by 2 weeks of PRED treatment. CONCLUSION Short-term GC treatment dose dependently impaired whole-body insulin sensitivity in healthy males, without concomitant changes in muscle ceramide, GM3, or mitochondrial function. These findings suggest that other mechanisms play a role in GC-related impairment of insulin sensitivity.
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Affiliation(s)
- M Brands
- Department of Endocrinology and Metabolism, Academic Medical Center, Meibergdreef 9 F5-167, 1105 AZ, Amsterdam, The Netherlands.
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Verhoeven JJ, Koenraads M, Hop WCJ, Brand JB, van de Polder MM, Joosten KFM. Baseline insulin/glucose ratio as a marker for the clinical course of hyperglycemic critically ill children treated with insulin. Nutrition 2011; 28:25-9. [PMID: 21820870 DOI: 10.1016/j.nut.2011.04.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2010] [Revised: 04/19/2011] [Accepted: 04/23/2011] [Indexed: 10/17/2022]
Abstract
OBJECTIVE The objective of this study was to investigate the relations of baseline insulin/glucose ratio to the clinical course of critically ill children. Such information will provide insight into the pathophysiologic mechanisms leading to hyperglycemia and will optimize preventive and therapeutic measures for hyperglycemia in critically ill children. METHODS Sixty-four consecutively admitted critically ill children with hyperglycemia, defined as a blood glucose level higher than 8 mmol/L (>145 mg/dL) and treated with insulin according to a glucose-control protocol, were included. Demographic data and clinical and laboratory parameters were collected. Insulin sensitivity was investigated by calculating the ratio of insulin to the blood glucose level just before the start of insulin administration. Results are expressed as median (range). RESULTS Sixty-four children (24 girls) 7.0 y of age (0.3-16.9 y) with various diagnoses were included. A hyperinsulinemic response, indicated by an increased insulin/glucose ratio (>18 pmol/mmol), was seen in 55% of children. The durations of insulin therapy, mechanical ventilation, and pediatric intensive care unit length of stay in children with a hyperinsulinemic response were longer than in children with a hypoinsulinemic response. CONCLUSION Hyper- and hypoinsulinemic responses play a role in the occurrence of hyperglycemia in critically ill children. Each is associated with a particular clinical course after the initiation of insulin therapy. It would be worthwhile to further investigate if the insulinemic response to hyperglycemia, determined by the insulin/glucose ratio in combination with the type of organ dysfunction, could be used in clinical practice to determine the need for insulin therapy.
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Affiliation(s)
- Jennifer J Verhoeven
- Intensive Care, Erasmus MC-Sophia Children's Hospital, Erasmus MC, Rotterdam, The Netherlands.
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Kuroki Y, Kaji H, Kawano S, Kanda F, Takai Y, Kajikawa M, Sugimoto T. Prospective short-term effects of glucocorticoid treatment on glucose and lipid metabolism in Japanese. Intern Med 2010; 49:897-902. [PMID: 20467173 DOI: 10.2169/internalmedicine.49.3161] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
OBJECTIVE Glucocorticoid (GC) causes various metabolic abnormalities; however, few prospective studies have examined the changes in glucose and lipid metabolism in newly GC-treated patients. METHODS AND PATIENTS The present study was therefore performed to analyze markers of glucose and lipid metabolism on days 0, 3, 7, 14, 28 and at month 3 of treatment in patients starting GC therapy. Then, we analyzed the relationships between the changes in these parameters and the initial dose of prednisolone (PSL), separating groups into different regimens by the GC dose. RESULTS The fasting plasma glucose (FPG) level transiently increased on day 3 of PSL administration but was restored by day 7. The immunoreactive insulin (IRI) level and HOMA-R transiently increased on day 3 and then fell, although remaining significantly higher than each basal level by day 7. A transient elevation in FPG level on day 3 was observed only in groups with a PSL dose >or=40 mg. On the other hand, total cholesterol and low-density lipoprotein cholesterol levels increased on day 3 of PSL administration and similar levels were maintained after day 7. High density-lipoprotein cholesterol levels were significantly increased on day 3; subsequently then gradually increased from days 3 to day 28. Triglyceride levels did not change during treatment. No relationship was apparent between the GC dose and the changes in each lipid parameter. CONCLUSION GC treatment induced changes in FPG, IRI, LDL-CHOL and HDL-CHOL levels from day 3 after start of GC. The dose of GC seemed to influence glucose metabolism, but not lipid metabolism.
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Affiliation(s)
- Yasuo Kuroki
- Internal Medicine, Kobe Century Memorial Hospital
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Mieske K, Flaherty G, O'Brien T. Journeys to high altitude--risks and recommendations for travelers with preexisting medical conditions. J Travel Med 2010; 17:48-62. [PMID: 20074100 DOI: 10.1111/j.1708-8305.2009.00369.x] [Citation(s) in RCA: 67] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Kelly Mieske
- Department of Medicine, National University of Ireland, Galway, Ireland.
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Ma Y, Liu W, Peng J, Huang L, Zhang P, Zhao X, Cheng Y, Qin H. A pilot study of gas chromatograph/mass spectrometry-based serum metabolic profiling of colorectal cancer after operation. Mol Biol Rep 2009; 37:1403-11. [DOI: 10.1007/s11033-009-9524-4] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2008] [Accepted: 03/20/2009] [Indexed: 01/09/2023]
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Johnson PJ, Wiedmeyer CE, Messer NT, Ganjam VK. Medical implications of obesity in horses--lessons for human obesity. J Diabetes Sci Technol 2009; 3:163-74. [PMID: 20046661 PMCID: PMC2769846 DOI: 10.1177/193229680900300119] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
There is growing recognition that obesity is common and represents a significant detriment to the health of companion animals in a manner similar to that by which it is affecting the human population. As is the case for other species, obesity appears to promote insulin resistance in horses and it is through this pathophysiological process that many of the adverse medical consequences of obesity are being characterized. Equine medical conditions that have been described in the context of obesity and insulin resistance differ from those in humans. Chronic human conditions that have been attributed to obesity and insulin resistance, such as atherosclerosis and diabetes mellitus, are rarely described in obese horses. Significant current interest is centered on the recognition that insulin resistance plays a role in the pathogenesis of laminitis, a potentially severe and debilitating cause of lameness in the equine species. Other equine medical conditions that are more likely in obese, insulin-resistant individuals include hyperlipemia (hepatic lipidosis) and developmental orthopedic disease (osteochondrosis). Pituitary pars intermedia dysfunction (equine Cushing's syndrome) represents another common endocrinopathic condition of older horses associated with insulin resistance. This review presents an introductory overview of the present understanding of obesity and insulin resistance and how these conditions may be associated with disease conditions in horses.
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Affiliation(s)
- Philip J Johnson
- Department of Veterinary Medicine and Surgery, College of Veterinary Medicine, University of Missouri, Columbia, Missouri 65211, USA.
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Lack of association between glucocorticoid use and presence of the metabolic syndrome in patients with rheumatoid arthritis: a cross-sectional study. Arthritis Res Ther 2008; 10:R145. [PMID: 19091101 PMCID: PMC2656250 DOI: 10.1186/ar2578] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2008] [Revised: 11/23/2008] [Accepted: 12/17/2008] [Indexed: 12/22/2022] Open
Abstract
Introduction Rheumatoid arthritis (RA) associates with excessive cardiovascular morbidity and mortality, attributed to both traditional and novel cardiovascular risk factors. The metabolic syndrome, a cluster of classical cardiovascular risk factors, including hypertension, obesity, glucose intolerance, and dyslipidaemia, is highly prevalent in RA. Reports suggest that long-term glucocorticoid (GC) use may exacerbate individual cardiovascular risk factors, but there have been no studies in RA to assess whether it associates with the metabolic syndrome. We examined whether GC exposure associates with the presence of metabolic syndrome in patients with RA. Methods RA patients (n = 398) with detailed clinical and laboratory assessments were categorised into three groups according to GC exposure: no/limited (<3 months) exposure (NE), low-dose (<7.5 mg/day) long-term exposure (LE), and medium-dose (greater than or equal to 7.5 mg to 30 mg/day) long-term exposure (ME). The metabolic syndrome was defined using the National Cholesterol Education Programme III guidelines. The association of GC exposure with the metabolic syndrome was evaluated using binary logistic regression. Results The metabolic syndrome was present in 40.1% of this population and its prevalence did not differ significantly between the GC exposure groups (NE 37.9% versus LE 40.7% versus ME 50%, P = 0.241). Binary logistic regression did not demonstrate any increased odds for the metabolic syndrome when comparing ME with LE (odds ratio = 1.64, 95% confidence interval 0.92 to 2.92, P = 0.094) and remained non significant after adjusting for multiple potential confounders. Conclusions Long-term GC exposure does not appear to associate with a higher prevalence of the metabolic syndrome in patients with RA. The components of the metabolic syndrome may already be extensively modified by other processes in RA (including chronic inflammation and treatments other than GCs), leaving little scope for additive effects of GCs.
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Bevier WC, Zisser HC, Jovanovič L, Finan DA, Palerm CC, Seborg DE, Doyle FJ. Use of continuous glucose monitoring to estimate insulin requirements in patients with type 1 diabetes mellitus during a short course of prednisone. J Diabetes Sci Technol 2008; 2:578-83. [PMID: 19885233 PMCID: PMC2769767 DOI: 10.1177/193229680800200408] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
BACKGROUND Insulin requirements to maintain normoglycemia during glucocorticoid therapy and stress are often difficult to estimate. To simulate insulin resistance during stress, adults with type 1 diabetes mellitus (T1DM) were given a three-day course of prednisone. METHODS Ten patients (7 women, 3 men) using continuous subcutaneous insulin infusion pumps wore the Medtronic Minimed CGMS (Northridge, CA) device. Mean (standard deviation) age was 43.1 (14.9) years, body mass index 23.9 (4.7) kg/m(2), hemoglobin A1c 6.8% (1.2%), and duration of diabetes 18.7 (10.8) years. Each patient wore the CGMS for one baseline day (day 1), followed by three days of self-administered prednisone (60 mg/dl; days 2-4), and one post-prednisone day (day 5). RESULTS Analysis using Wilcoxon signed rank test (values are median [25th percentile, 75th percentile]) indicated a significant difference between day 1 and the mean of days on prednisone (days 2-4) for average glucose level (110.0 [81.0, 158.0] mg/dl vs 149.2 [137.7, 168.0] mg/dl; p = .022), area under the glucose curve and above the upper limit of 180 mg/dl per day (0.5 [0, 8.0] mg/dl.d vs 14.0 [7.7, 24.7] mg/dl.d; p = .002), and total daily insulin dose (TDI) , (0.5 [0.4, 0.6] U/kg.d vs 0.9 [0.8, 1.0] U/kg.d; p = .002). In addition, the TDI was significantly different for day 1 vs day 5 (0.5 [0.4, 0.6] U/kg.d vs 0.6 [0.5, 0.8] U/kg.d; p = .002). Basal rates and insulin boluses were increased by an average of 69% (range: 30-100%) six hours after the first prednisone dose and returned to baseline amounts on the evening of day 4. CONCLUSIONS For adults with T1DM, insulin requirements during prednisone induced insulin resistance may need to be increased by 70% or more to normalize blood glucose levels.
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Affiliation(s)
- Wendy C. Bevier
- Sansum Diabetes Research Institute, Santa Barbara, California
| | - Howard C. Zisser
- Sansum Diabetes Research Institute, Santa Barbara, California
- Department of Chemical Engineering, University of California at Santa Barbara, Santa Barbara, California
| | - Lois Jovanovič
- Sansum Diabetes Research Institute, Santa Barbara, California
- Department of Chemical Engineering, University of California at Santa Barbara, Santa Barbara, California
| | - Daniel A. Finan
- Sansum Diabetes Research Institute, Santa Barbara, California
- Department of Chemical Engineering, University of California at Santa Barbara, Santa Barbara, California
| | - Cesar C. Palerm
- Department of Chemical Engineering, University of California at Santa Barbara, Santa Barbara, California
- Currently with Medtronic Diabetes, Northridge, California
| | - Dale E. Seborg
- Sansum Diabetes Research Institute, Santa Barbara, California
- Department of Chemical Engineering, University of California at Santa Barbara, Santa Barbara, California
| | - Francis J. Doyle
- Sansum Diabetes Research Institute, Santa Barbara, California
- Department of Chemical Engineering, University of California at Santa Barbara, Santa Barbara, California
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