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Colclough K, van Heugten R, Patel K. An update on the diagnosis and management of monogenic diabetes. PRACTICAL DIABETES 2022. [DOI: 10.1002/pdi.2410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Kevin Colclough
- Exeter Genomics Laboratory, Royal Devon & Exeter NHS Foundation Trust Exeter UK
| | - Rachel van Heugten
- Exeter Genomics Laboratory, Royal Devon & Exeter NHS Foundation Trust Exeter UK
| | - Kashyap Patel
- Institute of Biomedical and Clinical Science University of Exeter Medical School Exeter UK
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Role of Actionable Genes in Pursuing a True Approach of Precision Medicine in Monogenic Diabetes. Genes (Basel) 2022; 13:genes13010117. [PMID: 35052457 PMCID: PMC8774614 DOI: 10.3390/genes13010117] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 01/04/2022] [Accepted: 01/05/2022] [Indexed: 12/16/2022] Open
Abstract
Monogenic diabetes is a genetic disorder caused by one or more variations in a single gene. It encompasses a broad spectrum of heterogeneous conditions, including neonatal diabetes, maturity onset diabetes of the young (MODY) and syndromic diabetes, affecting 1-5% of patients with diabetes. Some of these variants are harbored by genes whose altered function can be tackled by specific actions ("actionable genes"). In suspected patients, molecular diagnosis allows the implementation of effective approaches of precision medicine so as to allow individual interventions aimed to prevent, mitigate or delay clinical outcomes. This review will almost exclusively concentrate on the clinical strategy that can be specifically pursued in carriers of mutations in "actionable genes", including ABCC8, KCNJ11, GCK, HNF1A, HNF4A, HNF1B, PPARG, GATA4 and GATA6. For each of them we will provide a short background on what is known about gene function and dysfunction. Then, we will discuss how the identification of their mutations in individuals with this form of diabetes, can be used in daily clinical practice to implement specific monitoring and treatments. We hope this article will help clinical diabetologists carefully consider who of their patients deserves timely genetic testing for monogenic diabetes.
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Stanik J, Barak L, Dankovcikova A, Valkovicova T, Skopkova M, Gasperikova D. Diabetes treatment in two pregnant women with permanent neonatal diabetes mellitus due to a KCNJ11 mutation. Diabet Med 2020; 37:1956-1958. [PMID: 32634858 DOI: 10.1111/dme.14363] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Revised: 06/14/2020] [Accepted: 06/17/2020] [Indexed: 01/07/2023]
Affiliation(s)
- J Stanik
- DIABGENE Laboratory, Institute of Experimental Endocrinology, Biomedical Research Centre of Slovak Academy of Sciences, Bratislava
- Children Diabetes Centre of the Slovak Republic at the Department of Paediatrics, Medical Faculty of Comenius University and National Institute for Children´s Diseases, Bratislava
| | - L Barak
- Children Diabetes Centre of the Slovak Republic at the Department of Paediatrics, Medical Faculty of Comenius University and National Institute for Children´s Diseases, Bratislava
| | - A Dankovcikova
- Department of Paediatrics, Children Faculty Hospital, Kosice, Slovakia
| | - T Valkovicova
- DIABGENE Laboratory, Institute of Experimental Endocrinology, Biomedical Research Centre of Slovak Academy of Sciences, Bratislava
| | - M Skopkova
- DIABGENE Laboratory, Institute of Experimental Endocrinology, Biomedical Research Centre of Slovak Academy of Sciences, Bratislava
| | - D Gasperikova
- DIABGENE Laboratory, Institute of Experimental Endocrinology, Biomedical Research Centre of Slovak Academy of Sciences, Bratislava
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Kelty E, Tran DD, Atkinson A, Preen DB, Havard A. Maternal and Neonatal Health Outcomes Associated with the Use of Gliclazide and Metformin for the Treatment of Diabetes in Pregnancy: A Record Linkage Study. Diabetes Technol Ther 2020; 22:96-102. [PMID: 31621408 DOI: 10.1089/dia.2019.0241] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Background: Gliclazide is commonly used in the treatment of diabetes mellitus; however, very little is known regarding the safety of its use in pregnancy. The aims of this study was to examine the rate of maternal hospitalizations, congenital anomalies, and adverse neonatal outcomes in pregnant women treated with gliclazide compared with pregnant women treated with metformin. Methods: Women who used gliclazide during pregnancy (n = 108) between 2003 and 2012 were identified by linking national medication dispensing data with the New South Wales perinatal data collection. A comparison group of women treated with only metformin during pregnancy (n = 108) were selected using propensity score matching. Data on hospital admissions, mortality, and congenital anomalies were extracted to examine the health of mothers and their children across groups. Results: Rates of maternal hospitalizations during pregnancy were not significantly different between women in the two groups (incident rate ratio: 1.10, 95% CI: 0.90-1.34, P = 0.339). There was no significant difference in average birth weight (3402 g compared with 3572 g, P = 0.072), incidence of neonatal hypoglycemia (<4.6% compared with <4.6%, P = 0.684), or congenital anomalies (7.4% compared with 5.6%, P = 0.582) in neonates exposed to gliclazide compared with metformin. Conclusions: The use of gliclazide during pregnancy was not associated with increased maternal hospitalization or neonatal adverse outcomes in comparison with the use of metformin in pregnancy; however, the limited number of exposed pregnancies is a key limitation.
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Affiliation(s)
- Erin Kelty
- Centre for Health Services Research, School of Population and Global Health, the University of Western Australia, Crawley, Australia
| | | | - Andrea Atkinson
- King Edward Memorial Hospital for Women, Perth, Western Australia, Australia
| | - David B Preen
- Centre for Health Services Research, School of Population and Global Health, the University of Western Australia, Crawley, Australia
| | - Alys Havard
- Centre for Big Data Research in Health, UNSW Sydney, Sydney, Australia
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Abstract
In addition to the common types of diabetes mellitus, two major monogenic diabetes forms exist. Maturity-onset diabetes of the young (MODY) represents a heterogenous group of monogenic, autosomal dominant diseases. MODY accounts for 1-2% of all diabetes cases, and it is not just underdiagnosed but often misdiagnosed to type 1 or type 2 diabetes. More than a dozen MODY genes have been identified to date, and their molecular classification is of great importance in the correct treatment decision and in the judgment of the prognosis. The most prevalent subtypes are HNF1A, GCK, and HNF4A. Genetic testing for MODY has changed recently due to the technological advancements, as contrary to the sequential testing performed in the past, nowadays all MODY genes can be tested simultaneously by next-generation sequencing. The other major group of monogenic diabetes is neonatal diabetes mellitus which can be transient or permanent, and often the diabetes is a part of a syndrome. It is a severe monogenic disease appearing in the first 6 months of life. The hyperglycemia usually requires insulin. There are two forms, permanent neonatal diabetes mellitus (PNDM) and transient neonatal diabetes mellitus (TNDM). In TNDM, the diabetes usually reverts within several months but might relapse later in life. The incidence of NDM is 1:100,000-1:400,000 live births, and PNDM accounts for half of the cases. Most commonly, neonatal diabetes is caused by mutations in KCNJ11 and ABCC8 genes encoding the ATP-dependent potassium channel of the β cell. Neonatal diabetes has experienced a quick and successful transition into the clinical practice since the discovery of the molecular background. In case of both genetic diabetes groups, recent guidelines recommend genetic testing.
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Affiliation(s)
- Zsolt Gaál
- 4th Department of Medicine, Jósa András Teaching Hospital, Nyíregyháza, Hungary
| | - István Balogh
- Division of Clinical Genetics, Department of Laboratory Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary.
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Abstract
PURPOSE OF REVIEW Monogenic diabetes accounts for 1-2% of all diabetes cases, but is frequently misdiagnosed as type 1, type 2, or gestational diabetes. Accurate genetic diagnosis directs management, such as no pharmacologic treatment for GCK-MODY, low-dose sulfonylureas for HNF1A-MODY and HNF4A-MODY, and high-dose sulfonylureas for KATP channel-related diabetes. While diabetes treatment is defined for the most common causes of monogenic diabetes, pregnancy poses a challenge to management. Here, we discuss the key issues in pregnancy affected by monogenic diabetes. RECENT FINDINGS General recommendations for pregnancy affected by GCK-MODY determine need for maternal insulin treatment based on fetal mutation status. However, a recent study suggests macrosomia and miscarriage rates may be increased with this strategy. Recent demonstration of transplacental transfer of sulfonylureas also raises questions as to when insulin should be initiated in sulfonylurea-responsive forms of monogenic diabetes. Pregnancy represents a challenge in management of monogenic diabetes, where factors of maternal glycemic control, fetal mutation status, and transplacental transfer of medication must all be taken into consideration. Guidelines for pregnancy affected by monogenic diabetes will benefit from large, prospective studies to better define the need for and timing of initiation of insulin treatment.
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Affiliation(s)
- Laura T Dickens
- Department of Medicine, Section of Adult and Pediatric Endocrinology, Diabetes, and Metabolism, University of Chicago, 5841 S. Maryland Ave., MC 1027, Chicago, IL, 60637, USA.
| | - Rochelle N Naylor
- Department of Medicine, Section of Adult and Pediatric Endocrinology, Diabetes, and Metabolism, University of Chicago, 5841 S. Maryland Ave., MC 1027, Chicago, IL, 60637, USA
- Department of Pediatrics, Section of Adult and Pediatric Endocrinology, Diabetes, and Metabolism, University of Chicago, Chicago, IL, USA
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Shepherd M, Brook AJ, Chakera AJ, Hattersley AT. Management of sulfonylurea-treated monogenic diabetes in pregnancy: implications of placental glibenclamide transfer. Diabet Med 2017; 34:1332-1339. [PMID: 28556992 PMCID: PMC5612398 DOI: 10.1111/dme.13388] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/25/2017] [Indexed: 01/05/2023]
Abstract
The optimum treatment for HNF1A/HNF4A maturity-onset diabetes of the young and ATP-sensitive potassium (KATP ) channel neonatal diabetes, outside pregnancy, is sulfonylureas, but there is little evidence regarding the most appropriate treatment during pregnancy. Glibenclamide has been widely used in the treatment of gestational diabetes, but recent data have established that glibenclamide crosses the placenta and increases risk of macrosomia and neonatal hypoglycaemia. This raises questions about its use in pregnancy. We review the available evidence and make recommendations for the management of monogenic diabetes in pregnancy. Due to the risk of stimulating increased insulin secretion in utero, we recommend that in women with HNF1A/ HNF4A maturity-onset diabetes of the young, those with good glycaemic control who are on a sulfonylurea per conception either transfer to insulin before conception (at the risk of a short-term deterioration of glycaemic control) or continue with sulfonylurea (glibenclamide) treatment in the first trimester and transfer to insulin in the second trimester. Early delivery is needed if the fetus inherits an HNF4A mutation from either parent because increased insulin secretion results in ~800-g weight gain in utero, and prolonged severe neonatal hypoglycaemia can occur post-delivery. If the fetus inherits a KATP neonatal diabetes mutation from their mother they have greatly reduced insulin secretion in utero that reduces fetal growth by ~900 g. Treating the mother with glibenclamide in the third trimester treats the affected fetus in utero, normalising fetal growth, but is not desirable, especially in the high doses used in this condition, if the fetus is unaffected. Prospective studies of pregnancy in monogenic diabetes are needed.
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Affiliation(s)
- M. Shepherd
- Institute of Biomedical and Clinical ScienceUniversity of Exeter Medical SchoolExeterUK
- Exeter NIHR Clinical Research FacilityRoyal Devon and Exeter NHS Foundation TrustExeterUK
| | - A. J. Brook
- Institute of Biomedical and Clinical ScienceUniversity of Exeter Medical SchoolExeterUK
- Lancashire Women and Newborn CentreBurnley General Hospital, East Lancashire NHS Hospitals TrustBurnleyUK
- University of ManchesterManchesterUK
| | - A. J. Chakera
- Institute of Biomedical and Clinical ScienceUniversity of Exeter Medical SchoolExeterUK
- Royal Sussex County Hospital, Brighton and Sussex University HospitalsBrightonUK
| | - A. T. Hattersley
- Institute of Biomedical and Clinical ScienceUniversity of Exeter Medical SchoolExeterUK
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Ashcroft FM, Puljung MC, Vedovato N. Neonatal Diabetes and the K ATP Channel: From Mutation to Therapy. Trends Endocrinol Metab 2017; 28:377-387. [PMID: 28262438 PMCID: PMC5582192 DOI: 10.1016/j.tem.2017.02.003] [Citation(s) in RCA: 62] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2016] [Revised: 01/30/2017] [Accepted: 02/01/2017] [Indexed: 12/25/2022]
Abstract
Activating mutations in one of the two subunits of the ATP-sensitive potassium (KATP) channel cause neonatal diabetes (ND). This may be either transient or permanent and, in approximately 20% of patients, is associated with neurodevelopmental delay. In most patients, switching from insulin to oral sulfonylurea therapy improves glycemic control and ameliorates some of the neurological disabilities. Here, we review how KATP channel mutations lead to the varied clinical phenotype, how sulfonylureas exert their therapeutic effects, and why their efficacy varies with individual mutations.
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Affiliation(s)
- Frances M Ashcroft
- Henry Wellcome Centre for Gene Function, Department of Physiology, Anatomy and Genetics, University of Oxford, OX1 3PT, UK.
| | - Michael C Puljung
- Henry Wellcome Centre for Gene Function, Department of Physiology, Anatomy and Genetics, University of Oxford, OX1 3PT, UK
| | - Natascia Vedovato
- Henry Wellcome Centre for Gene Function, Department of Physiology, Anatomy and Genetics, University of Oxford, OX1 3PT, UK
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Simmons D. Safety considerations with pharmacological treatment of gestational diabetes mellitus. Drug Saf 2015; 38:65-78. [PMID: 25542297 DOI: 10.1007/s40264-014-0253-9] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
The number of women with gestational diabetes mellitus (GDM: diabetes first diagnosed in pregnancy) continues to grow, as do the associated risks of antenatal and postnatal complications and the chance of future diabetes and obesity in both mother and offspring. Recent randomised controlled trials have demonstrated clear benefits for intensive management of GDM using lifestyle modification, self blood glucose monitoring, close clinical supervision and, where glycaemia remains inadequately controlled, insulin therapy. More recently, metformin and glibenclamide have been shown to adequately reduce hyperglycaemia as part of a stepped approach to GDM management, with a switch to insulin therapy where necessary. Other oral medications have not been shown to be safe in pregnancy. Human insulin therapy is safe within the limits of hypoglycaemia and weight gain. Most insulin analogues are also now considered safe for use in pregnancy (insulin lispro, aspart and detemir). Metformin therapy is oral, and therefore preferred to insulin, but is associated with more gastrointestinal adverse effects, although not hypoglycaemia or weight gain. Conversely, glibenclamide is also an oral therapy but is associated with hypoglycaemia and weight gain. However, metformin crosses the placenta and it remains unclear whether glibenclamide crosses the placenta or not: long-term risks have not been shown, and are thought to be minimal, but further studies are needed. Metformin is seen by some as the treatment of choice where weight gain is an issue, providing that the unanswered questions over the long-term safety of oral agents have been discussed.
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Affiliation(s)
- David Simmons
- Wolfson Diabetes and Endocrinology Clinic, Institute of Metabolic Science, Cambridge University Hospitals NHS Foundation Trust, Addenbrookes Hospital, Cambridge, CB2 2QQ, UK,
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Myngheer N, Allegaert K, Hattersley A, McDonald T, Kramer H, Ashcroft FM, Verhaeghe J, Mathieu C, Casteels K. Fetal macrosomia and neonatal hyperinsulinemic hypoglycemia associated with transplacental transfer of sulfonylurea in a mother with KCNJ11-related neonatal diabetes. Diabetes Care 2014; 37:3333-5. [PMID: 25231897 PMCID: PMC5894804 DOI: 10.2337/dc14-1247] [Citation(s) in RCA: 17] [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: 02/03/2023]
Abstract
OBJECTIVE Sulfonylureas (SUs) are effective at controlling glycemia in permanent neonatal diabetes mellitus (PNDM) caused by KCNJ11 (Kir6.2) mutations. RESEARCH DESIGN AND METHODS We report the case of a woman with PNDM who continued high doses of glibenclamide (85 mg/day) during her pregnancy. The baby was born preterm, and presented with macrosomia and severe hyperinsulinemic hypoglycemia requiring high-rate intravenous glucose infusion. RESULTS Postnatal genetic testing excluded a KCNJ11 mutation in the baby. Glibenclamide was detected in both the baby's blood and the maternal milk. CONCLUSIONS We hypothesize that high doses of glibenclamide in the mother led to transplacental passage of the drug and overstimulation of fetal β-cells, which resulted in severe hyperinsulinemic hypoglycemia in the neonate (who did not carry the mutation) and contributed to fetal macrosomia. We suggest that glibenclamide (and other SUs) should be avoided in mothers with PNDM if the baby does not carry the mutation or if prenatal screening has not been performed, while glibenclamide may be beneficial when the fetus is a PNDM carrier.
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Affiliation(s)
- Nele Myngheer
- Department of Endocrinology, University Hospitals Leuven, Leuven, Belgium
| | - Karel Allegaert
- Neonatal Intensive Care Unit, University Hospitals Leuven, Leuven, Belgium Department of Development and Regeneration, KU Leuven, Leuven, Belgium
| | | | - Tim McDonald
- University of Exeter Medical School, Exeter, U.K
| | - Holger Kramer
- University Laboratory of Physiology, Oxford, Oxford, U.K
| | | | - Johan Verhaeghe
- Department of Obstetrics/Gynaecology, University Hospitals Leuven, Leuven, Belgium
| | - Chantal Mathieu
- Department of Endocrinology, University Hospitals Leuven, Leuven, Belgium Department of Clinical and Experimental Medicine, KU Leuven, Leuven, Belgium
| | - Kristina Casteels
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium Department of Pediatrics, University Hospitals Leuven, Leuven, Belgium
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Affiliation(s)
- Shivani Misra
- From the Department of Metabolic Medicine, Imperial Healthcare NHS Trust, London, U.K.; and the
| | - Anne Dornhorst
- Department of Medicine, Imperial College Healthcare NHS Trust, London, U.K
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