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Use of Classes of Antihyperglycemic Agents in People With Type 2 Diabetes Based on Level of Estimated Glomerular Filtration Rate. Can J Diabetes 2023; 47:223-227. [PMID: 36842879 DOI: 10.1016/j.jcjd.2023.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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2
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Alicic RZ, Neumiller JJ, Galindo RJ, Tuttle KR. Use of Glucose-Lowering Agents in Diabetes and CKD. Kidney Int Rep 2022; 7:2589-2607. [PMID: 36506243 PMCID: PMC9727535 DOI: 10.1016/j.ekir.2022.09.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Revised: 08/31/2022] [Accepted: 09/19/2022] [Indexed: 12/15/2022] Open
Abstract
Diabetes is the most common cause of kidney failure worldwide. Patients with diabetes and chronic kidney disease (CKD) are also at markedly higher risk of cardiovascular disease, particularly heart failure (HF), and death. Through the processes of gluconeogenesis and glucose reabsorption, the kidney plays a central role in glucose homeostasis. Insulin resistance is an early alteration observed in CKD, worsened by the frequent presence of hypertension, obesity, and ongoing chronic inflammation, and oxidative stress. Management of diabetes in moderate to severe CKD warrants special consideration because of changes in glucose and insulin homeostasis and altered metabolism of glucose-lowering therapies. Kidney failure and initiation of kidney replacement therapy by dialysis adds to management complexity by further limiting therapeutic options, and predisposing individuals to hypoglycemia and hyperglycemia. Glycemic goals should be individualized, considering CKD severity, presence of macrovascular and microvascular complications, and life expectancy. A general hemoglobin A1c (HbA1c) goal of approximately 7% may be appropriate in earlier stages of CKD, with more relaxed targets often appropriate in later stages. Use of sodium glucose cotransporter2 (SGLT2) inhibitors and glucagon like peptide-1 receptor agonists (GLP-1RAs) meaningfully improves kidney and heart outcomes for patients with diabetes and CKD, irrespective of HbA1c targets, and are now part of guideline-directed medical therapy in this high-risk population. Delivery of optimal care for patients with diabetes and CKD will require collaboration across health care specialties and disciplines.
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Affiliation(s)
- Radica Z. Alicic
- Providence Medical Research Center, Providence Health Care, Spokane, Washington, USA
- Department of Medicine, University of Washington School of Medicine, Spokane and Seattle, Washington, USA
- Correspondence: Radica Z. Alicic, Providence Medical Research Center, 105 West 8th Avenue, Suite 250E, Spokane, Washington 99204, USA.
| | - Joshua J. Neumiller
- Providence Medical Research Center, Providence Health Care, Spokane, Washington, USA
- Department of Pharmacotherapy, College of Pharmacy and Pharmaceutical Sciences, Washington State University, Spokane, Washington, USA
| | - Rodolfo J. Galindo
- Department of Medicine, Division of Endocrinology, Emory University School of Medicine
| | - Katherine R. Tuttle
- Providence Medical Research Center, Providence Health Care, Spokane, Washington, USA
- Department of Medicine, University of Washington School of Medicine, Spokane and Seattle, Washington, USA
- Nephrology Division, Kidney Research Institute and Institute of Translational Health Sciences, University of Washington, Spokane and Seattle, Washington, USA
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Søholm JC, Do NC, Vestgaard M, Ásbjörnsdóttir B, Nørgaard SK, Pedersen BW, Storgaard L, Nielsen BB, Holmager P, Ringholm L, Damm P, Mathiesen ER. Falling Insulin Requirement in Pregnant Women With Diabetes Delivering Preterm: Prevalence, Predictors, and Consequences. J Clin Endocrinol Metab 2022; 107:e2237-e2244. [PMID: 35303076 DOI: 10.1210/clinem/dgac159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Indexed: 11/19/2022]
Abstract
CONTEXT Falling insulin requirements often lead to considerations of whether a pregnancy can continue safely or if delivery is indicated. OBJECTIVE To evaluate prevalence and predictors of falling insulin requirements in pregnant women with preexisting diabetes delivering preterm and to explore the relationship to fetal asphyxia and neonatal morbidity. METHODS A prospective cohort study of 101 consecutive singleton pregnant women with preexisting diabetes delivering preterm < 37 weeks (68 type 1 and 33 type 2 diabetes) where the prevalence of falling insulin requirements (≥20%) before delivery was recorded. RESULTS In total, 27% (27/101) experienced falling insulin requirements of median 30% (interquartile range 24-40) before delivery. In all women with type 1 diabetes, the prevalence was 37% (25/68), whereas it was 43% (24/56) in those with indicated preterm delivery and 6% (2/33) among women with type 2 diabetes. In women with type 1 diabetes and indicated preterm delivery, falling insulin requirements were first identified at 34 + 5 (33 + 6-35 + 4) weeks + days and delivery occurred 3 (1-9) days later. Gestational age at delivery, prevalence of suspected fetal asphyxia, and neonatal morbidity were similar in women with and without falling insulin requirements. Neither glycemic control, nausea, or preeclampsia was associated with falling insulin requirement. CONCLUSION Falling insulin requirements often preceded preterm delivery in women with type 1 diabetes, foremost when preterm delivery was indicated, but was not related to fetal asphyxia or neonatal morbidity. Whether falling insulin requirements in late pregnancy are a warning sign of placental insufficiency or mainly reflects variations in normal physiology needs further investigation.
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Affiliation(s)
- Julie C Søholm
- Center for Pregnant Women with Diabetes, Rigshospitalet, 2100 Copenhagen O, Denmark
| | - Nicoline C Do
- Center for Pregnant Women with Diabetes, Rigshospitalet, 2100 Copenhagen O, Denmark
- Department of Endocrinology and Metabolism, 2100 Rigshospitalet, Denmark
- Department of Clinical Medicine, University of Copenhagen, 2100 Copenhagen, Denmark
| | - Marianne Vestgaard
- Center for Pregnant Women with Diabetes, Rigshospitalet, 2100 Copenhagen O, Denmark
- Department of Endocrinology and Metabolism, 2100 Rigshospitalet, Denmark
- Department of Obstetrics, 2100 Rigshospitalet, Denmark
| | - Björg Ásbjörnsdóttir
- Center for Pregnant Women with Diabetes, Rigshospitalet, 2100 Copenhagen O, Denmark
- Department of Endocrinology and Metabolism, 2100 Rigshospitalet, Denmark
| | - Sidse K Nørgaard
- Center for Pregnant Women with Diabetes, Rigshospitalet, 2100 Copenhagen O, Denmark
- Department of Endocrinology and Metabolism, 2100 Rigshospitalet, Denmark
- Department of Clinical Medicine, University of Copenhagen, 2100 Copenhagen, Denmark
| | - Berit W Pedersen
- Center for Pregnant Women with Diabetes, Rigshospitalet, 2100 Copenhagen O, Denmark
- Department of Obstetrics, 2100 Rigshospitalet, Denmark
| | - Lone Storgaard
- Center for Pregnant Women with Diabetes, Rigshospitalet, 2100 Copenhagen O, Denmark
- Department of Obstetrics, 2100 Rigshospitalet, Denmark
| | - Birgitte B Nielsen
- Center for Pregnant Women with Diabetes, Rigshospitalet, 2100 Copenhagen O, Denmark
- Department of Obstetrics, 2100 Rigshospitalet, Denmark
| | - Pernille Holmager
- Center for Pregnant Women with Diabetes, Rigshospitalet, 2100 Copenhagen O, Denmark
- Department of Endocrinology and Metabolism, 2100 Rigshospitalet, Denmark
- Steno Diabetes Center Copenhagen, 2820 Gentofte, Denmark
| | - Lene Ringholm
- Center for Pregnant Women with Diabetes, Rigshospitalet, 2100 Copenhagen O, Denmark
- Department of Endocrinology and Metabolism, 2100 Rigshospitalet, Denmark
| | - Peter Damm
- Center for Pregnant Women with Diabetes, Rigshospitalet, 2100 Copenhagen O, Denmark
- Department of Clinical Medicine, University of Copenhagen, 2100 Copenhagen, Denmark
- Department of Obstetrics, 2100 Rigshospitalet, Denmark
| | - Elisabeth R Mathiesen
- Center for Pregnant Women with Diabetes, Rigshospitalet, 2100 Copenhagen O, Denmark
- Department of Endocrinology and Metabolism, 2100 Rigshospitalet, Denmark
- Department of Clinical Medicine, University of Copenhagen, 2100 Copenhagen, Denmark
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León-Jiménez D, Miramontes-González JP, Márquez-López L, Astudillo-Martín F, Beltrán-Romero LM, Moreno-Obregón F, Escalada-San Martín J. Basal insulin analogues in people with diabetes and chronic kidney disease. Diabet Med 2022; 39:e14679. [PMID: 34449911 DOI: 10.1111/dme.14679] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Revised: 07/27/2021] [Accepted: 08/25/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Diabetic kidney disease is the leading cause of chronic kidney disease (CKD) and end-stage kidney disease (ESKD) worldwide. ESKD has a high prevalence in patients with diabetes mellitus (DM). CKD increases the chances of hypoglycaemia by different mechanisms, causes insulin resistance and a decrease in insulin metabolism. Both the "Kidney Disease: Improving Global Outcomes" (KDIGO) and "American Diabetes Association" (ADA) guidelines recommend the use of insulin as part of treatment, but the type of basal insulin is not specified. METHODS We reviewed the literature to determine whether first- and second-generation basal insulins are effective and safe in CKD patients. We reviewed specific pivotal studies conducted by pharmaceutical laboratories, as well as independent studies. CONCLUSIONS Basal insulins are safe and effective in patients with CKD and diabetes mellitus but we do not have specific studies. Given that CKD is one of the main complications of type 2 DM, and insulin specific treatment in the final stages, the absence of studies is striking. Real-life data are also important since trials such as pivotal studies do not fully represent actual patients. Treatment should be individualized until we have specific trials in this type of population.
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Affiliation(s)
- David León-Jiménez
- Clinical Epidemiology and Vascular Unit, Internal Medicine, Clinical Unit for Comprehensive Medical Care (UCAMI), Instituto de Biomedicina de Sevilla (IBIS, Hospital Universitario Virgen del Rocío SAS/CSIC, Universidad de Sevilla, Hospital Universitario Virgen del Rocío, Sevilla, Spain
| | - José Pablo Miramontes-González
- Internal Medicine Unit, Facultad de Medicina, Hospital Universitario Río Hortega, Instituto De Investigaciones Biomédicas De Salamanca-IBSAL, Universidad de Valladolid, Valladolid, Spain
| | - Laura Márquez-López
- Internal Medicine, Clinical Unit for Comprehensive Medical Care (UCAMI), Hospital Universitario Virgen del Rocío, Sevilla, Spain
| | | | - Luis M Beltrán-Romero
- Clinical Epidemiology and Vascular Unit, Internal Medicine, Clinical Unit for Comprehensive Medical Care (UCAMI), Instituto de Biomedicina de Sevilla (IBIS, Hospital Universitario Virgen del Rocío SAS/CSIC, Universidad de Sevilla, Hospital Universitario Virgen del Rocío, Sevilla, Spain
| | | | - Javier Escalada-San Martín
- Department Of Endocrinology and Nutrition, Biomedical Research Networking Center For Physiopathology of Obesity and Nutrition (CIBERON), ISCIII, Diabetes and Metabolic Diseases Group, Clínica Universidad De Navarra, Instituto De Investigación Sanitaria De Navarra (IdiSNA), Pamplona, Spain
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5
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Escott GM, da Silveira LG, Cancelier VDA, Dall'Agnol A, Silveiro SP. Monitoring and management of hyperglycemia in patients with advanced diabetic kidney disease. J Diabetes Complications 2021; 35:107774. [PMID: 33168397 DOI: 10.1016/j.jdiacomp.2020.107774] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Revised: 10/10/2020] [Accepted: 10/10/2020] [Indexed: 11/19/2022]
Abstract
Diabetes mellitus is the leading cause of end-stage renal disease, and uncontrolled hyperglycemia is directly related to the increased mortality in this setting. As kidney function decreases, it becomes more challenging to control blood glucose since the risk of hypoglycemia increases. Decreased appetite, changes in glycaemia homeostasis, along with reduced renal excretion of anti-hyperglycemic drugs tend to facilitate the occurrence of hypoglycemia, despite the paradoxical occurrence of insulin resistance in advanced kidney disease. Thus, in patients using insulin and/or oral anti-hyperglycemic agents, dynamic adjustments with drug dose reduction or drug switching are often necessary. Furthermore, in addition to consider these pharmacokinetics alterations, it is of utmost importance to choose drugs with proven cardio-renal benefits in this setting, such as sodium-glucose co-transporter 2 inhibitors and glucagon-like peptide 1 receptor agonists. In this review, we summarize the indications and contraindications, titration of doses and side effects of the available anti-hyperglycemic agents in the presence of advanced diabetic kidney disease (DKD) and dialysis, highlighting the risks and benefits of the different agents. Additionally, basic renal function assessment and monitoring of glycemic control in DKD will be evaluated in order to guide the use of drugs and define the glycemic targets to be achieved.
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Affiliation(s)
- Gustavo Monteiro Escott
- Graduate Program in Medical Sciences: Endocrinology, Universidade Federal do Rio Grande do Sul, Brazil
| | | | | | - Angélica Dall'Agnol
- Graduate Program in Medical Sciences: Endocrinology, Universidade Federal do Rio Grande do Sul, Brazil
| | - Sandra Pinho Silveiro
- Graduate Program in Medical Sciences: Endocrinology, Universidade Federal do Rio Grande do Sul, Brazil; Endocrine Unit, Hospital de Clínicas de Porto Alegre, RS, Brazil.
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Galindo RJ, Beck RW, Scioscia MF, Umpierrez GE, Tuttle KR. Glycemic Monitoring and Management in Advanced Chronic Kidney Disease. Endocr Rev 2020; 41:5846208. [PMID: 32455432 PMCID: PMC7366347 DOI: 10.1210/endrev/bnaa017] [Citation(s) in RCA: 76] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Accepted: 05/19/2020] [Indexed: 02/06/2023]
Abstract
Glucose and insulin metabolism in patients with diabetes are profoundly altered by advanced chronic kidney disease (CKD). Risk of hypoglycemia is increased by failure of kidney gluconeogenesis, impaired insulin clearance by the kidney, defective insulin degradation due to uremia, increased erythrocyte glucose uptake during hemodialysis, impaired counterregulatory hormone responses (cortisol, growth hormone), nutritional deprivation, and variability of exposure to oral antihyperglycemic agents and exogenous insulin. Patients with end-stage kidney disease frequently experience wide glycemic excursions, with common occurrences of both hypoglycemia and hyperglycemia. Assessment of glycemia by glycated hemoglobin (HbA1c) is hampered by a variety of CKD-associated conditions that can bias the measure either to the low or high range. Alternative glycemic biomarkers, such as glycated albumin or fructosamine, are not fully validated. Therefore, HbA1c remains the preferred glycemic biomarker despite its limitations. Based on observational data for associations with mortality and risks of hypoglycemia with intensive glycemic control regimens in advanced CKD, an HbA1c range of 7% to 8% appears to be the most favorable. Emerging data on the use of continuous glucose monitoring in this population suggest promise for more precise monitoring and treatment adjustments to permit fine-tuning of glycemic management in patients with diabetes and advanced CKD.
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Affiliation(s)
- Rodolfo J Galindo
- Emory University School of Medicine, Division of Endocrinology, Atlanta, Georgia
| | - Roy W Beck
- Jaeb Center for Health Research, Tampa, Florida
| | - Maria F Scioscia
- Emory University School of Medicine, Division of Endocrinology, Atlanta, Georgia
| | | | - Katherine R Tuttle
- University of Washington, Division of Nephrology, Kidney Research Institute, and Institute of Translational Health Sciences, Seattle, Washington.,Providence Medical Research Center, Providence Health Care, Spokane, Washington
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Chawla R, Makkar BM, Aggarwal S, Bajaj S, Das AK, Ghosh S, Gupta A, Gupta S, Jaggi S, Jana J, Keswadev J, Kalra S, Keswani P, Kumar V, Maheshwari A, Moses A, Nawal CL, Panda J, Panikar V, Ramchandani GD, Rao PV, Saboo B, Sahay R, Setty KR, Viswanathan V, Aravind SR, Banarjee S, Bhansali A, Chandalia HB, Das S, Gupta OP, Joshi S, Kumar A, Kumar KM, Madhu SV, Mittal A, Mohan V, Munichhoodappa C, Ramachandran A, Sahay BK, Sai J, Seshiah V, Zargar AH. RSSDI consensus recommendations on insulin therapy in the management of diabetes. Int J Diabetes Dev Ctries 2019. [DOI: 10.1007/s13410-019-00783-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
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Rahhal MN, Gharaibeh NE, Rahimi L, Ismail-Beigi F. Disturbances in Insulin-Glucose Metabolism in Patients With Advanced Renal Disease With and Without Diabetes. J Clin Endocrinol Metab 2019; 104:4949-4966. [PMID: 31162534 DOI: 10.1210/jc.2019-00286] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2019] [Accepted: 05/29/2019] [Indexed: 02/03/2023]
Abstract
CONTEXT Use of insulin in patients with diabetes and advanced chronic kidney disease (CKD; stages 4 to 5) is challenging and shows great variability among individuals. We explored the mechanisms underlying this variability. EVIDENCE ACQUISITION PubMed was searched for articles in English from 1960 to 2018 for advanced CKD and diabetes, glucose and insulin metabolism, insulin clearance, secretion and resistance, plasma insulin concentration, glycemic control, hypoglycemia, insulin dosage, and continuous glucose monitoring (CGM) in CKD. EVIDENCE SYNTHESIS The evidence shows that in most patients the daily dose of insulin needs to be significantly reduced with a high degree of variability; in some the dose remains unchanged, and rarely it is increased. The premise that the marked reduction in insulin requirement is essentially attributable to decreased insulin clearance by kidneys leading to prolongation of its plasma half-life, elevated blood insulin concentration, and hypoglycemia is not entirely correct. Other factors including decreases in food intake, insulin secretion, insulin clearance by peripheral tissues, and renal gluconeogenesis play important roles. There is also heightened resistance to insulin due to metabolic acidosis, uremic toxins, inflammatory state, and vitamin D deficiency. Importantly, the magnitude of changes in each of these factors varies between individuals with the same degree of CKD. CONCLUSIONS In the presence of diabetes with advanced CKD, the insulin regimen should be individualized based on knowledge of the daily glucose patterns. The use of CGM is promising for safer glycemic control in patients with advanced CKD and diabetes and helps prevent extremes of hypoglycemia and hyperglycemia.
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Affiliation(s)
- Marie-Noel Rahhal
- Department of Medicine, Case Western Reserve University, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Naser Eddin Gharaibeh
- Department of Medicine, Case Western Reserve University, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Leili Rahimi
- Department of Medicine, Case Western Reserve University, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Faramarz Ismail-Beigi
- Department of Medicine, Case Western Reserve University, University Hospitals Cleveland Medical Center, Cleveland, Ohio
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9
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Garla V, Kanduri S, Yanes-Cardozo L, Lién LF. Management of diabetes mellitus in chronic kidney disease. MINERVA ENDOCRINOL 2019; 44:273-287. [DOI: 10.23736/s0391-1977.19.03015-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Castellano E, Attanasio R, Giagulli VA, Boriano A, Terzolo M, Papini E, Guastamacchia E, Monti S, Aglialoro A, Agrimi D, Ansaldi E, Babini AC, Blatto A, Brancato D, Casile C, Cassibba S, Crescenti C, De Feo ML, Del Prete A, Disoteo O, Ermetici F, Fiore V, Fusco A, Gioia D, Grassi A, Gullo D, Lo Pomo F, Miceli A, Nizzoli M, Pellegrino M, Pirali B, Santini C, Settembrini S, Tortato E, Triggiani V, Vacirca A, Borretta G. The basal to total insulin ratio in outpatients with diabetes on basal-bolus regimen. J Diabetes Metab Disord 2019; 17:393-399. [PMID: 30918874 PMCID: PMC6405380 DOI: 10.1007/s40200-018-0358-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Accepted: 09/24/2018] [Indexed: 12/28/2022]
Abstract
Objective To evaluate the basal/total ratio of daily insulin dose (b/T) in outpatients with diabetes type 1 (DM1) and type 2 (DM2) on basal-bolus regimen, by investigating whether there is a relationship with HbA1c and episodes of hypoglycemia. Methods Multicentric, observational, cross-sectional study in Italy. Adult DM1 (n = 476) and DM2 (n = 541) outpatients, with eGFR >30 mL/min/1.73 m2, on a basal-bolus regimen for at least six months, were recruited from 31 Italian Diabetes services between March and September 2016. Clinicaltrials.govID: NCT03489031. Results Total daily insulin dose was significantly higher in DM2 patients (52.3 ± 22.5 vs. 46 ± 20.9 U/day), but this difference disappeared when insulin doses were normalized for body weight. The b/T ratio was lower than 0.50 in both groups: 0.46 ± 0.14 in DM1 and 0.43 ± 0.15 in DM2 patients (p = 0.0011). The b/T was significantly higher in the patients taking metformin in both groups, and significantly different according to the type of basal insulin (Degludec, 0.48 in DM1 and 0.44 in DM2; Glargine, 0.44 in DM1 and 0.43 in DM2; Detemir, 0.45 in DM1 and 0.39 in DM2). The b/T ratio was not correlated in either group to HbA1c or incidence of hypoglycemia (<40 mg/dL, or requiring caregiver intervention, in the last three months). In the multivariate analysis, metformin use and age were independent predictors of the b/T ratio in both DM1 and DM2 patients, while the type of basal insulin was an independent predictor only in DM1. Conclusion The b/T ratio was independent of glycemic control and incidence of hypoglycemia.
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Affiliation(s)
- Elena Castellano
- 1Department of Endocrinology, Diabetes and Metabolism, Santa Croce and Carle Hospital, Via Michele Coppino 26, 12100 Cuneo, Italy
| | - R Attanasio
- 2Endocrinology Service, Galeazzi Institute, IRCCS, Milan, Italy
| | - V A Giagulli
- Outpatient Clinic for Endocrinology and Metabolic Diseases, Conversano Hospital, Conversano, Italy
| | - A Boriano
- 4Medical Physics Department, Santa Croce and Carle Hospital, Cuneo, Italy
| | - M Terzolo
- Internal Medicine, Department of Clinical and Biological Sciences, San Luigi Hospital, Orbassano, Italy
| | - E Papini
- 6Department of Endocrinology and Metabolism, Regina Apostolorum Hospital, Albano Laziale, Italy
| | - E Guastamacchia
- Department of Medicine-Section of Internal Medicine, Geriatrics, Endocrinology and Rare Diseases, Bari, Italy
| | - S Monti
- 8Endocrinology, Department of Clinical and Molecular Medicine, Sant'Andrea Hospital, Rome, Italy
| | - A Aglialoro
- 9Metabolism and Diabetes Unit, San Martino Hospital, Genoa, Italy
| | - D Agrimi
- District Hospital, Azienda Sanitaria Locale, Brindisi, Italy
| | - E Ansaldi
- Department of Endocrinology and Diabetes, Santissimi Antonio e Biagio Hospital, Alessandria, Italy
| | - A C Babini
- Medical Division, Rimini Hospital, Rimini, Italy
| | - A Blatto
- 13Department of Endocrinology, Maria Vittoria Hospital, Torino, Italy
| | - D Brancato
- Department of Internal Medicine and Diabetology, Hospital of Partinico, Partinico, Italy
| | - C Casile
- 15Internal Medicine Department, Papardo Hospital, Messina, Italy
| | - S Cassibba
- 16Endocrinology and Diabetes, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - C Crescenti
- Department of Endocrinology and Diabetes, San Giovanni di Dio Hospital, Florence, Italy
| | - M L De Feo
- 18Endocrinology Unit, Careggi Hospital, Florence, Italy
| | - A Del Prete
- Outpatient Clinic for Diabetes, Azienda Sanitaria Locale, Civita Castellana, Italy
| | - O Disoteo
- 20Diabetology Department, Niguarda Hospital, Milan, Italy
| | - F Ermetici
- 21Endocrinology and Metabolism, IRCCS Policlinico San Donato, San Donato Milanese, Italy
| | - V Fiore
- Angelucci Hospital, Subiaco, Italy
| | - A Fusco
- 23Antidiabetic Center AID, Garibaldi Hospital, Naples, Italy
| | - D Gioia
- Department of Endocrinology, Villa Sofia Hospital, Palermo, Italy
| | - A Grassi
- 25Division of Endocrinology, Mauriziano Umberto I Hospital, Torino, Italy
| | - D Gullo
- Endocrinology, Department of Clinical and Experimental Medicine, Garibaldi-Nesima Medical Center, Catania, Italy
| | - F Lo Pomo
- 27Division of Endocrinology, San Carlo Hospital, Potenza, Italy
| | - A Miceli
- 15Internal Medicine Department, Papardo Hospital, Messina, Italy
| | - M Nizzoli
- Department of Endocrinology, Morgagni Hospital, Forlì, Italy
| | - M Pellegrino
- 1Department of Endocrinology, Diabetes and Metabolism, Santa Croce and Carle Hospital, Via Michele Coppino 26, 12100 Cuneo, Italy
| | - B Pirali
- 29Unit of Internal Medicine, Humanitas Mater Domini, Castellanza, Italy
| | - C Santini
- 30Department of Endocrinology and Diabetology, Bufalini Hospital, Cesena, Italy
| | - S Settembrini
- Diabetology Service, Azienda Sanitaria Locale Na 1, Naples, Italy
| | - E Tortato
- Diabetology Service, Augusto Murri Hospital, Fermo, Italy
| | - V Triggiani
- Department of Medicine-Section of Internal Medicine, Geriatrics, Endocrinology and Rare Diseases, Bari, Italy
| | - A Vacirca
- Department of Internal Medicine, Imola Hospital, Imola, Italy
| | - G Borretta
- 1Department of Endocrinology, Diabetes and Metabolism, Santa Croce and Carle Hospital, Via Michele Coppino 26, 12100 Cuneo, Italy
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Iyengar R, Franzese J, Gianchandani R. Inpatient Glycemic Management in the Setting of Renal Insufficiency/Failure/Dialysis. Curr Diab Rep 2018; 18:75. [PMID: 30112652 DOI: 10.1007/s11892-018-1044-y] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
PURPOSE OF THIS REVIEW Chronic diabetic nephropathy and renal dysfunction from other causes are common in hospitalized patients with diabetes. Available diabetes management guidelines aim to reduce hyperglycemia and hypoglycemia, both independent risk factors for hospital outcomes. Renal dysfunction, which increases the risk of hypoglycemia, adds a layer of complexity in diabetes management. Therefore, modified glucose goals and treatment regimens may be required. RECENT FINDINGS Recent prospective and retrospective studies provide direction on safe insulin therapy for diabetes inpatients with renal compromise. Studies of newer diabetes pharmacotherapy provide data on oral agent use in the inpatient setting. Diabetes therapy should be modified with changing renal function. Glucose management in patients on peritoneal or hemodialysis is challenging. Reducing weight-based doses of insulin and use of newer insulins can reduce hypoglycemia risk. Safety and efficacy of DPP-4 inhibitors has been evaluated in the hospital and nursing home setting. Metformin, SGLT-2 inhibitors, and GLP1 receptor agonists can be used in several stages of renal dysfunction prior to and at discharge.
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Affiliation(s)
- Ravi Iyengar
- Department of Metabolism, Endocrinology, and Diabetes, Department of Internal Medicine, University of Michigan, Domino's Farms (Lobby G, Suite 1500) 24 Frank Lloyd Wright Drive, Ann Arbor, MI, 48106, USA
| | - Jennifer Franzese
- Department of Metabolism, Endocrinology, and Diabetes, Department of Internal Medicine, University of Michigan, Domino's Farms (Lobby G, Suite 1500) 24 Frank Lloyd Wright Drive, Ann Arbor, MI, 48106, USA
| | - Roma Gianchandani
- Department of Metabolism, Endocrinology, and Diabetes, Department of Internal Medicine, University of Michigan, Domino's Farms (Lobby G, Suite 1500) 24 Frank Lloyd Wright Drive, Ann Arbor, MI, 48106, USA.
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12
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Clinical assessment and treatment of diabetes in patients with chronic kidney disease. Rev Clin Esp 2018. [DOI: 10.1016/j.rceng.2018.03.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Carretero Gómez J, Arévalo Lorido JC. Clinical assessment and treatment of diabetes in patients with chronic kidney disease. Rev Clin Esp 2018; 218:305-315. [PMID: 29691065 DOI: 10.1016/j.rce.2018.03.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2018] [Accepted: 03/19/2018] [Indexed: 12/25/2022]
Abstract
Diabetes mellitus type 2 is the main cause of chronic kidney disease. Patients with this disease have higher morbidity and mortality and risk of hypoglycaemia than those without this disease. In 2010, type 2 diabetes was the reason for starting renal replacement therapy in 24.7% of patients. The prevalence of microalbuminuria, proteinuria and a reduced glomerular filtration rate is 36%, 8% and 22%, respectively. The presence of albuminuria is a predictor of chronic kidney disease. Diabetic kidney disease, previously known as diabetic nephropathy, refers to kidney disease caused by diabetes. Renal hyperfiltration is a marker of intraglomerular hypertension and a risk factor for onset and progression. The new antidiabetic drugs, mainly dipeptidyl peptidase-4 inhibitors, sodium-glucose cotransporter inhibitors and glucagon-like peptide-1 agonists, have been shown to prevent or slow the progression of kidney disease.
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Affiliation(s)
- J Carretero Gómez
- Servicio de Medicina Interna, Hospital Comarcal de Zafra, Badajoz, España.
| | - J C Arévalo Lorido
- Servicio de Medicina Interna, Hospital Comarcal de Zafra, Badajoz, España
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14
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Umpierrez GE, Bailey TS, Carcia D, Shaefer C, Shubrook JH, Skolnik N. Improving postprandial hyperglycemia in patients with type 2 diabetes already on basal insulin therapy: Review of current strategies. J Diabetes 2018; 10:94-111. [PMID: 28581207 DOI: 10.1111/1753-0407.12576] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2016] [Revised: 05/02/2017] [Accepted: 05/21/2017] [Indexed: 11/28/2022] Open
Abstract
A large number of patients with type 2 diabetes (T2D) on basal insulin do not reach their HbA1c goals and require additional therapy to address postprandial hyperglycemia. Guidelines from expert bodies have outlined several approaches to accomplish postprandial glucose (PPG) control, and recent literature suggests several more. This article provides strategies for primary care physicians caring for patients with T2D who do not achieve glycemic control with basal insulin alone. Current treatment guidelines and strategies for improving PPG control are reviewed, including the efficacy, safety, and cost-effectiveness of rapid-acting insulin (RAI) analogs, premixed insulin, glucagon-like peptide-1 (GLP-1) receptor agonists (RAs), dipeptidyl peptidase 4 inhibitors, sodium-glucose cotransporter 2 inhibitors, and α-glucosidase inhibitors. Other approaches, such as combinations of newer basal insulin plus RAI and a fixed-ratio combination of basal insulin and a GLP-1 RA, are also described.
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Affiliation(s)
| | | | - Danielle Carcia
- Abington Hospital Jefferson Health, Abington, Pennsylvania, USA
| | | | | | - Neil Skolnik
- Abington Hospital Jefferson Health, Abington, Pennsylvania, USA
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15
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Padmanabhan S, Lee VW, Mclean M, Athayde N, Lanzarone V, Khoshnow Q, Peek MJ, Cheung NW. The Association of Falling Insulin Requirements With Maternal Biomarkers and Placental Dysfunction: A Prospective Study of Women With Preexisting Diabetes in Pregnancy. Diabetes Care 2017; 40:1323-1330. [PMID: 28798085 DOI: 10.2337/dc17-0391] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2017] [Accepted: 07/09/2017] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To investigate the association of falling insulin requirements (FIR) among women with preexisting diabetes with adverse obstetric outcomes and maternal biomarkers longitudinally in pregnancy. RESEARCH DESIGN AND METHODS A multicenter prospective cohort study of 158 women (41 with type 1 diabetes and 117 with type 2 diabetes) was conducted. Women with FIR of ≥15% from the peak total daily dose after 20 weeks' gestation were considered case subjects (n = 32). The primary outcome was a composite of clinical markers of placental dysfunction (preeclampsia, small for gestational age [≤5th centile], stillbirth, premature delivery [<30 weeks], and placental abruption). Maternal circulating angiogenic markers (placental growth factor [PlGF] and soluble fms-like tyrosine kinase 1 [sFlt-1]), placental hormones (human placental lactogen, progesterone, and tumor necrosis factor-α), HbA1c, and creatinine were studied serially during pregnancy. RESULTS FIR ≥15% were associated with an increased risk of the composite primary outcome (odds ratio [OR] 4.38 [95% CI 1.9-10.3]; P < 0.001), preeclampsia (OR 6.76 [95% CI 2.7-16.7]; P < 0.001), and was more common among women with type 1 diabetes (36.6 vs. 14.5%; P = 0.002). Creatinine was modestly elevated among women with FIR ≥15%; however, there was no difference in HbA1c. The ratio of sFlt-1 to PlGF was significantly higher among women with FIR at 25, 30, and 36 weeks, with differences maintained in the subgroup that developed preeclampsia. There was no difference in placental hormones between the groups. CONCLUSIONS This is the first prospective study to associate FIR with altered expression of placental antiangiogenic factors and preeclampsia. FIR are an important clinical sign, among women with preexisting diabetes, that should alert the clinician to investigate underlying placental dysfunction.
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Affiliation(s)
- Suja Padmanabhan
- Diabetes and Endocrinology, Westmead Hospital, Sydney, New South Wales, Australia .,Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
| | - Vincent W Lee
- Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia.,Renal Medicine, Westmead Hospital, Sydney, New South Wales, Australia
| | - Mark Mclean
- Diabetes and Endocrinology, Westmead Hospital, Sydney, New South Wales, Australia.,Diabetes and Endocrinology, Blacktown Hospital, Sydney, New South Wales, Australia.,Western Sydney University, Sydney, New South Wales, Australia
| | - Neil Athayde
- Obstetric Medicine, Westmead Hospital, Sydney, New South Wales, Australia
| | - Valeria Lanzarone
- Obstetric Medicine, Nepean Hospital, Sydney, New South Wales, Australia
| | - Qemer Khoshnow
- Obstetric Medicine, Nepean Hospital, Sydney, New South Wales, Australia
| | - Michael J Peek
- College of Medicine, Biology and Environment, The Australian National University, Canberra, Australian Capital Territory, Australia
| | - N Wah Cheung
- Diabetes and Endocrinology, Westmead Hospital, Sydney, New South Wales, Australia.,Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
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16
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Rajput R, Sinha B, Majumdar S, Shunmugavelu M, Bajaj S. Consensus statement on insulin therapy in chronic kidney disease. Diabetes Res Clin Pract 2017; 127:10-20. [PMID: 28315574 DOI: 10.1016/j.diabres.2017.02.032] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2017] [Accepted: 02/16/2017] [Indexed: 01/26/2023]
Abstract
INTRODUCTION Diabetes mellitus (DM) is one of the leading causes of chronic kidney disease (CKD) which eventually leads to insulin resistance and decreased insulin degradation. In patients with diabetic kidney disease (DKD), the overall insulin requirement declines which necessitates the reassessment for individualization, adjustment and titration of insulin doses depending on the severity of kidney disease. OBJECTIVE To provide simple and easily implementable guidelines to primary care physicians on appropriate insulin dosing and titration of various insulin regimens in patients with DKD. METHODS Each insulin regimen (basal, prandial, premix and basal-bolus) was presented and evaluated for dosing and titration based on data from approved medical literatures on chronic kidney disease. These evaluations were then factored into the national context based on the expert committee representatives' and key opinion leaders' clinical experience and common therapeutic practices followed in India. RESULTS Recommendations based on dosing and titration of insulins has been developed. Moreover, the consensus group also recommended the strategy for dose estimation of insulin, optimal glycaemic targets and self-monitoring in patients with DKD. CONCLUSION The consensus based recommendations will be a useful reference tool for health care practitioners to initiate, optimise and intensify insulin therapy in patients with DKD.
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Affiliation(s)
| | | | - Sujoy Majumdar
- G D Diabetes Institute & Peerless Hospital Kolkata, India
| | - M Shunmugavelu
- Trichy Diabetes Speciality Centre (P) Ltd, Trichy, Tamil Nadu, India
| | - Sarita Bajaj
- Dept of Medicine, MLN Medical College, Allahabad, India
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17
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Garla V, Yanes-Cardozo L, Lien LF. Current therapeutic approaches in the management of hyperglycemia in chronic renal disease. Rev Endocr Metab Disord 2017; 18:5-19. [PMID: 28258533 DOI: 10.1007/s11154-017-9416-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Diabetes mellitus (DM) and chronic kidney disease (CKD) are intricately intertwined. DM is the most common cause of CKD. Adequate control of DM is necessary for prevention of progression of CKD, while careful management of the metabolic abnormalities in CKD will assist in achieving better control of DM. Two of the key organs involved in glucose production are the kidney and the liver. Furthermore, the kidney also plays a role in glucose filtration and reabsorption. In CKD, monitoring of glycemic control using traditional methods such as Hemoglobin A1c (Hba1c) must be done with caution secondary to associated hematological abnormalities in CKD. With regard to medication management in the care of patients with DM, CKD has significant effects. For example, the dosages of oral and non-insulin anti-hyperglycemic agents often need to be modified according to renal function. Insulin metabolism is altered in CKD, and a reduction in insulin dose is almost always needed. Dialysis also affects various aspects of glucose homeostasis, necessitating appropriate changes in therapy. Due to the aforementioned factors glycemic management in patients with DM and CKD can be quiet challenging.
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Affiliation(s)
- Vishnu Garla
- Division of Endocrinology, Metabolism and Diabetes, Department of Medicine, University of Mississippi Medical Center, 2500 North State Street, Jackson, MS, 39216, USA.
| | - Licy Yanes-Cardozo
- Division of Endocrinology, Metabolism and Diabetes, Department of Medicine, University of Mississippi Medical Center, 2500 North State Street, Jackson, MS, 39216, USA
| | - Lillian F Lien
- Division of Endocrinology, Metabolism and Diabetes, Department of Medicine, University of Mississippi Medical Center, 2500 North State Street, Jackson, MS, 39216, USA
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18
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Gianchandani RY, Neupane S, Iyengar JJ, Heung M. PATHOPHYSIOLOGY AND MANAGEMENT OF HYPOGLYCEMIAIN END-STAGE RENAL DISEASE PATIENTS: A REVIEW. Endocr Pract 2016; 23:353-362. [PMID: 27967230 DOI: 10.4158/ep161471.ra] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE This review focuses on hypoglycemia in patients with end-stage renal disease (ESRD). It discusses the pathophysiology of glucose metabolism in the kidney, the impact of dialysis on glucose and insulin metabolism, and the challenges of glucose monitoring in ESRD. The clinical relevance of these changes is reviewed in relation to altered blood glucose targets and modification of antidiabetes therapy to prevent hypoglycemia. Based on current data and guidelines, recommendations for the outpatient and inpatient setting are provided for diabetes management in ESRD. METHODS PubMed, OVID, and Google Scholar were searched to identify related articles through May 2016 using the following keywords: "glucose metabolism," "kidney," "diabetes," "hypoglycemia," "ESRD," and "insulin" in various combinations for this review. RESULTS In ESRD, a combination of impaired insulin clearance, changes in glucose metabolism, and the dialysis process make patients vulnerable to low blood glucose levels. Hypoglycemia accounts for up to 3.6% of all ESRD-related admissions. At admission or during hospitalization, hypoglycemia in ESRD has a poor prognosis, with mortality rates reported at 30%. Several guidelines suggest a modified hemoglobin A1c (A1c) goal of 7 to 8.5% (53 to 69 mmol/mol) and an average blood glucose goal of 150 to 200 mg/dL. Noninsulin antidiabetes agents like dipeptidyl peptidase 4 inhibitors, repaglinide, and glipizide in appropriate doses and reduction of insulin doses up to 50% may help decrease hypoglycemia. CONCLUSION Patients with ESRD are at high risk for hypoglycemia. Increased awareness by providers regarding these risks and appropriate diabetes regimen adjustments can help minimize hypoglycemic events. ABBREVIATIONS ADA = antidiabetes agent BG = blood glucose CKD = chronic kidney disease DPP-4 = dipeptidyl peptidase 4 eGFR = estimated glomerular filtration rate ESRD = end-stage renal disease GFR = glomerular filtration rate HD = hemodialysis NPH = neutral protamine Hagedorn PD = peritoneal dialysis SA = short acting SU = sulfonylurea.
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19
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Labochka D, Moszczuk B, Kukwa W, Szczylik C, Czarnecka AM. Mechanisms through which diabetes mellitus influences renal cell carcinoma development and treatment: A review of the literature. Int J Mol Med 2016; 38:1887-1894. [DOI: 10.3892/ijmm.2016.2776] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2016] [Accepted: 10/06/2016] [Indexed: 11/05/2022] Open
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20
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Hermansen K, Bohl M, Schioldan AG. Insulin Aspart in the Management of Diabetes Mellitus: 15 Years of Clinical Experience. Drugs 2016; 76:41-74. [PMID: 26607485 PMCID: PMC4700065 DOI: 10.1007/s40265-015-0500-0] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Limiting excessive postprandial glucose excursions is an important component of good overall glycemic control in diabetes mellitus. Pharmacokinetic studies have shown that insulin aspart, which is structurally identical to regular human insulin except for the replacement of a single proline amino acid with an aspartic acid residue, has a more physiologic time-action profile (i.e., reaches a higher peak and reaches that peak sooner) than regular human insulin. As expected with this improved pharmacokinetic profile, insulin aspart demonstrates a greater glucose-lowering effect compared with regular human insulin. Numerous randomized controlled trials and a meta-analysis have also demonstrated improved postprandial control with insulin aspart compared with regular human insulin in patients with type 1 or type 2 diabetes, as well as efficacy and safety in children, pregnant patients, hospitalized patients, and patients using continuous subcutaneous insulin infusion. Studies have demonstrated that step-wise addition of insulin aspart is a viable intensification option for patients with type 2 diabetes failing on basal insulin. Insulin aspart has shown a good safety profile, with no evidence of increased receptor binding, mitogenicity, stimulation of anti-insulin antibodies, or hypoglycemia compared with regular human insulin. In one meta-analysis, there was evidence of a lower rate of nocturnal hypoglycemia compared with regular human insulin and, in a trial that specifically included patients with a history of recurrent hypoglycemia, a significantly lower rate of severe hypoglycemic episodes. The next generation of insulin aspart (faster-acting insulin aspart) is being developed with a view to further improving on these pharmacokinetic/pharmacodynamic properties.
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Affiliation(s)
- Kjeld Hermansen
- Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Tage-Hansens Gade 2, 8000, Aarhus C, Denmark.
| | - Mette Bohl
- Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Tage-Hansens Gade 2, 8000, Aarhus C, Denmark
| | - Anne Grethe Schioldan
- Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Tage-Hansens Gade 2, 8000, Aarhus C, Denmark
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21
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Hasslacher C, Kulozik F, Lorenzo Bermejo J. Treatment with insulin analogs, especially Glargine and Lispro, associates with better renal function and higher hemoglobin levels in Type 1 diabetic patients with impaired kidney function. Ther Adv Endocrinol Metab 2016; 7:166-77. [PMID: 27540462 PMCID: PMC4973404 DOI: 10.1177/2042018816644393] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
OBJECTIVES The influence of type of insulin treatment - insulin analogs versus human insulin - on the development of diabetes related vascular complications has been sparsely investigated. We examine here possible differences regarding kidney function and hemoglobin levels. METHODS Multiple linear regression was used to investigate the relationship between the following characteristics measured in 509 type 1 diabetic patients who were recruited in an outpatient practice: current clinical status and treatment modalities, type of injected insulin and the routine laboratory parameters hemoglobin, HbA1c, serum creatinine, eGFR, hs CRP and urinary albumin/creatinine ratio. RESULTS Compared with human insulin, multiple regression analysis taking into account possible confounders revealed that treatment with insulin analogs was associated with increased eGFR (+7.1 ml/min; P=0.0002), lower urinary albumin/creatinine ratio (ratio logarithm -0.4; P=0.003) and higher hemoglobin concentration (+0.31 g/dl; P=0.04). Stratification by type of insulin showed the best renal status for treatment with insulins Glargine and Lispro. Differences were consistent both for patients with normal (eGFR → 90 ml/min) and with an impaired (eGFR ← 90 ml/min) kidney function. CONCLUSIONS Present results suggest that treatment of type 1 diabetic patients with normal and impaired renal function with insulin analogs, especially Glargine and Lispro, is associated with better kidney function, lower urinary albumin/creatinine ratio and lower hemoglobin concentration compared to therapy with human insulin. If confirmed by other studies, treatment with insulin analogs may be a further possibility in delaying progression of nephropathy and in preventing early hemoglobin decline.
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Affiliation(s)
| | - Felix Kulozik
- Diabetesinstitut Heidelberg and Department of Clinical Studies, St. Josefskrankenhaus Heidelberg GmbH, Germany
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22
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Pecoits-Filho R, Abensur H, Betônico CCR, Machado AD, Parente EB, Queiroz M, Salles JEN, Titan S, Vencio S. Interactions between kidney disease and diabetes: dangerous liaisons. Diabetol Metab Syndr 2016; 8:50. [PMID: 27471550 PMCID: PMC4964290 DOI: 10.1186/s13098-016-0159-z] [Citation(s) in RCA: 93] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2016] [Accepted: 07/10/2016] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Type 2 diabetes mellitus (DM) globally affects 18-20 % of adults over the age of 65 years. Diabetic kidney disease (DKD) is one of the most frequent and dangerous complications of DM2, affecting about one-third of the patients with DM2. In addition to the pancreas, adipocytes, liver, and intestines, the kidneys also play an important role in glycemic control, particularly due to renal contribution to gluconeogenesis and tubular reabsorption of glucose. METHODS In this review article, based on a report of discussions from an interdisciplinary group of experts in the areas of endocrinology, diabetology and nephrology, we detail the relationship between diabetes and kidney disease, addressing the care in the diagnosis, the difficulties in achieving glycemic control and possible treatments that can be applied according to the different degrees of impairment. DISCUSSION Glucose homeostasis is extremely altered in patients with DKD, who are exposed to a high risk of both hyperglycemia and hypoglycemia. Both high and low glycemic levels are associated with increased morbidity and shortened survival in this group of patients. Factors that are associated with an increased risk of hypoglycemia in DKD patients include decreased renal gluconeogenesis, deranged metabolic pathways (including altered metabolism of medications) and decreased insulin clearance. On the other hand, decrease glucose filtration and excretion, and inflammation-induce insulin resistance are predisposing factors to hyperglycemic episodes. CONCLUSION Appropriate glycaemic monitoring and control tailored for diabetic patients is required to avoid hypoglycaemia and other glycaemic disarrays in patients with DM2 and kidney disease. Understanding the renal physiology and pathophysiology of DKD has become essential to all specialties treating diabetic patients. Disseminating this knowledge and detailing the evidence will be important to initiate breakthrough research and to encourage proper treatment of this group of patients.
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Affiliation(s)
- Roberto Pecoits-Filho
- School of Medicine, Pontificia Universidade Católica do Paraná, Imaculada Conceição, 1155, Curitiba, PR 80215-901 Brazil
| | - Hugo Abensur
- School of Medicine, University of São Paulo, São Paulo, Brazil
| | - Carolina C. R. Betônico
- Hospital Regional de Presidente Prudente, Universidade do Oeste Paulista, Presidente Prudente, São Paulo, Brazil
| | | | | | - Márcia Queiroz
- School of Medicine, University of São Paulo, São Paulo, Brazil
| | | | - Silvia Titan
- School of Medicine, University of São Paulo, São Paulo, Brazil
| | - Sergio Vencio
- Institute of Pharmaceutical Sciences, Goiania, Brazil
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23
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Thijs AMJ, Tack CJ, van der Graaf WTA, Rongen GA, van Herpen CML. The early effect of sunitinib on insulin clearance in patients with metastatic renal cell carcinoma. Br J Clin Pharmacol 2016; 81:768-72. [PMID: 26447463 DOI: 10.1111/bcp.12797] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2015] [Revised: 09/29/2015] [Accepted: 10/01/2015] [Indexed: 11/30/2022] Open
Abstract
AIMS In patients with diabetes treated with sunitinib symptomatic hypoglycaemia has been reported. To explore the mechanism of this adverse effect we performed a prospective study to investigate the effect of sunitinib on insulin concentration, insulin clearance and insulin sensitivity. METHODS We studied the early effects of sunitinib on insulin sensitivity and insulin clearance with a hyperinsulinaemic euglycaemic clamp (insulin infusion rate 60 mU m−2 min−1; steady-state 90–120 min) in patients with renal cell carcinoma before and 1 week after the start of sunitinib 50 mg day−1. Insulin sensitivity index (SI) was defined as steady-state glucose disposal divided by the steady-state plasma insulin. RESULTS Ten patients (one with diabetes, treated with metformin) were included in the study protocol. Steady-state insulin concentrations during the clamp increased after 1 week of sunitinib (from 128.9 ± 9.0 mU l−1 to 170.8 ± 12.8 mU l−1, P < 0.05; 95% CI on difference − 64.3, −19.6). The calculated insulin sensitivity index decreased from 0.22 ± 0.04 before to 0.18 ± 0.02 μmol kg−1 min−1 per mU l−1 insulin (P < 0.05; 95% CI on difference 0.07, 0.08). As the insulin infusion rate was similar for both clamps, the increased steady-state insulin concentration indicates reduced insulin clearance. CONCLUSION Sunitinib affects insulin clearance which could possibly lead to overexposure to insulin in patients using insulin or insulin-secretion stimulating agents.
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Affiliation(s)
- Anna Maria J Thijs
- Department of Pharmacology-Toxicology, Radboudumc, Nijmegen.,Department of Medical Oncology, Radboudumc, Nijmegen
| | - Cees J Tack
- Department of Internal Medicine, Radboudumc, Nijmegen, The Netherlands
| | - Winette T A van der Graaf
- Department of Medical Oncology, Radboudumc, Nijmegen.,The Institute of Cancer Research and the Royal Marsden NHS Foundation Trust, London, UK
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Betônico CCR, Titan SMO, Correa-Giannella MLC, Nery M, Queiroz M. Management of diabetes mellitus in individuals with chronic kidney disease: therapeutic perspectives and glycemic control. Clinics (Sao Paulo) 2016; 71:47-53. [PMID: 26872083 PMCID: PMC4732385 DOI: 10.6061/clinics/2016(01)08] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2015] [Revised: 11/26/2015] [Accepted: 11/26/2015] [Indexed: 12/16/2022] Open
Abstract
The purpose of this study was to evaluate the therapeutic options for diabetes treatment and their potential side effects, in addition to analyzing the risks and benefits of tight glycemic control in patients with diabetic kidney disease. For this review, a search was performed using several pre-defined keyword combinations and their equivalents: "diabetes kidney disease" and "renal failure" in combination with "diabetes treatment" and "oral antidiabetic drugs" or "oral hypoglycemic agents." The search was performed in PubMed, Endocrine Abstracts and the Cochrane Library from January 1980 up to January 2015. Diabetes treatment in patients with diabetic kidney disease is challenging, in part because of progression of renal failure-related changes in insulin signaling, glucose transport and metabolism, favoring both hyperglycemic peaks and hypoglycemia. Additionally, the decline in renal function impairs the clearance and metabolism of antidiabetic agents and insulin, frequently requiring reassessment of prescriptions. The management of hyperglycemia in patients with diabetic kidney disease is even more difficult, requiring adjustment of antidiabetic agents and insulin doses. The health team responsible for the follow-up of these patients should be vigilant and prepared to make such changes; however, unfortunately, there are few guidelines addressing the nuances of the management of this specific population.
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Affiliation(s)
- Carolina C R Betônico
- Universidade Oeste Paulista, Hospital Regional de Presidente Prudente, Divisão de Endocrinologia, Presidente Prudente/, SP, Brazil
| | - Silvia M O Titan
- Faculdade de Medicina da Universidade de São Paulo, Departamento de Medicina Interna, Divisão de Nefrologia
| | | | - Márcia Nery
- Divisão de Endocrinologia, São Paulo/, SP, Brazil
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25
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Roussel R, Lorraine J, Rodriguez A, Salaun-Martin C. Overview of Data Concerning the Safe Use of Antihyperglycemic Medications in Type 2 Diabetes Mellitus and Chronic Kidney Disease. Adv Ther 2015; 32:1029-64. [PMID: 26581749 DOI: 10.1007/s12325-015-0261-x] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2015] [Indexed: 12/26/2022]
Abstract
INTRODUCTION It can be a challenge to manage glycemic control in patients with type 2 diabetes mellitus (T2DM) and chronic kidney disease (CKD), due to both patient and medication issues. Although most antihyperglycemic medications can be used in mild kidney disease, many medications are either not advised or require dose adjustments in more advanced CKD. This review summarizes product label information, pharmacokinetic and clinical studies, and clinical guidelines relevant to use of antihyperglycemic medications in CKD. METHODS Product labels and guidelines from North America and Europe, as well as pharmacokinetic and clinical studies of diabetes medication use in CKD were identified through Medline and PubMed searches, up to February 2015. Available data are summarized and correlations between treatment recommendations and available research are discussed, as are glycemic targets for patients with CKD. RESULTS Newer medications have significantly more data available than older medications regarding use in CKD, although larger clinical studies are still lacking for some drugs. As CKD advances, dose adjustment is needed for many medications [numerous dipeptidyl peptidase-4 inhibitors, some insulins, sodium glucose co-transporter 2 (SGLT2) inhibitors], although not for others (thiazolidinediones, meglitinides). Some medications are not recommended for use in more advanced CKD (metformin, SGLT2 inhibitors, some glucagon-like protein-1 receptor agonists) for safety or efficacy reasons. There is not always good alignment between label recommendations, pharmacokinetic or clinical studies, and guideline recommendations for use of these drugs in CKD. In particular, controversy remains about the use of metformin in moderate CKD and appropriate use of liraglutide and sulfonylureas in advanced CKD. CONCLUSION Considerable variability exists with respect to recommendations and clinical data for the many antihyperglycemic drugs used in patients with T2DM and CKD. FUNDING Eli Lilly and Company.
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Affiliation(s)
- Ronan Roussel
- Division of Endocrinology Diabetes and Nutrition, DHU FIRE, Groupe Hospitalier Bichat-Claude Bernard, AP-HP, Paris, France.
- INSERM U 1138, Cordeliers Research Center, Paris, France.
- University Paris Diderot-Paris 7, Paris, France.
| | | | | | - Carole Salaun-Martin
- Eli Lilly, Neuilly Cedex, France
- Division of Endocrinology Diabetes and Nutrition, Hopital Max Fourestier, Nanterre, France
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