Diabetic Gastroparesis: A Review

Subthreshold activation of the melanocortin system causes generalized sensitization to anorectic agents in mice

The melanocortin-3 receptor (MC3R) regulates GABA release from agouti-related protein (AgRP) nerve terminals and thus tonically suppresses multiple circuits involved in feeding behavior and energy homeostasis. Here, we examined the role of the MC3R and the melanocortin system in regulating the response to various anorexigenic agents. The genetic deletion or pharmacological inhibition of the MC3R, or subthreshold doses of an MC4R agonist, improved the dose responsiveness to glucagon-like peptide 1 (GLP1) agonists, as assayed by inhibition of food intake and weight loss. An enhanced anorectic response to the acute satiety factors peptide YY (PYY3-36) and cholecystokinin (CCK) and the long-term adipostatic factor leptin demonstrated that increased sensitivity to anorectic agents was a generalized result of MC3R antagonism. We observed enhanced neuronal activation in multiple hypothalamic nuclei using Fos IHC following low-dose liraglutide in MC3R-KO mice (Mc3r-/-), supporting the hypothesis that the MC3R is a negative regulator of circuits that control multiple aspects of feeding behavior. The enhanced anorectic response in Mc3r-/- mice after administration of GLP1 analogs was also independent of the incretin effects and malaise induced by GLP1 receptor (GLP1R) analogs, suggesting that MC3R antagonists or MC4R agonists may have value in enhancing the dose-response range of obesity therapeutics.

Association Between Treatment Adherence and Continuous Glucose Monitoring Outcomes in People With Diabetes Using Smart Insulin Pens in a Real-World Setting

OBJECTIVE

To evaluate the association of insulin injection adherence, smart insulin pen engagement, and glycemic control using real-world data from 16 countries from adults self-administering basal insulin degludec and bolus insulin with a smart insulin pen (NovoPen 6 or NovoPen Echo Plus) alongside continuous glucose monitoring (CGM).

RESEARCH DESIGN AND METHODS

Data were aggregated over 14-day periods. Treatment adherence was defined according to the number of missed basal and missed bolus insulin doses and smart pen engagement according to the number of days with data uploads.

RESULTS

Data from 3,945 adults, including 25,157 14-day periods with ≥70% CGM coverage, were analyzed. On average, 0.2 basal and 6.0 bolus insulin doses were missed over 14 days. The estimated probability of missing at least one basal insulin dose over a 14-day period was 17.6% (95% CI 16.5, 18.7). Missing one basal or bolus insulin dose per 14 days was associated with a significant decrease in percentage of time with glucose levels in range (TIR) (3.9-10.0 mmol/L), of -2.8% (95% CI -3.7, -1.8) and -1.7% (-1.8, -1.6), respectively; therefore, missing two basal or four bolus doses would decrease TIR by >5%. Smart pen engagement was associated positively with glycemic outcomes.

CONCLUSIONS

This combined analysis of real-world smart pen and CGM data showed that missing two basal or four bolus insulin doses over a 14-day period would be associated with a clinically relevant decrease in TIR. Smart insulin pens provide valuable insights into treatment injection behaviors.

Pathogenesis and management of diabetic gastroparesis: An updated clinically oriented review

BACKGROUND AND AIMS

Diabetic gastroparesis (DGp) is a common and preventable complication of uncontrolled diabetes mellitus (D.M.) and significantly affects the Quality of Life of patients. Diagnosis and management present as a clinical challenge due to the disease's complexity and limited effective therapeutic options. This review aims to comprehensively outline the pathogenesis, diagnosis, and management of diabetic gastroparesis, evaluating evolving approaches to guide clinicians and provide future recommendations.

METHODS

A literature review was conducted on scholarly databases of PubMed, Google Scholar, Scopus and Web of Science encompassing published articles, gray literature and relevant clinical guidelines. Data were synthesized and analyzed to provide a comprehensive overview of diabetic gastroparesis, focusing on pathogenesis, diagnosis, and management.

RESULTS

The review intricately explores the pathogenesis contributing to diabetic gastroparesis, emphasizing autonomic neuropathy, oxidative stress, inflammation, hormonal dysregulation, microbiota alterations, and gastrointestinal neuropathy. Primary management strategies are underscored, including lifestyle modifications, symptom relief, and glycemic control. The discussion encompasses pharmacological and surgical options, highlighting the importance of a multidisciplinary approach involving various healthcare professionals for comprehensive patient care.

CONCLUSION

This review offers a thorough understanding of pathogenesis, diagnosis, and management of diabetic gastroparesis, underlining evolving approaches for clinicians. A multidisciplinary approach is crucial to address both the physical and mental health aspects of diabetes and its complications.

Glucagon-Like Peptide-1 Receptor Agonists During Electroconvulsive Therapy: Case Report With Evolving Concerns and Management Considerations

ABSTRACT

Glucagon-like peptide-1 receptor agonists are an emerging class of medications transforming the management of diabetes mellitus and obesity, two highly prevalent and chronic medical conditions associated with significant morbidity and posing serious public health concerns. Although generally well tolerated and relatively safe to use, case reports of patients taking these medications while undergoing elective procedures with general anesthesia describe a potential heightened risk of regurgitation and pulmonary aspiration of gastric contents, deriving from the delayed gastric emptying effect of these agents. Based on increased recognition of this risk, the American Society of Anesthesiologists convened a task force to review available data, resulting in the promulgation of a new procedural management guideline for patients on these drugs and undergoing elective procedures with general anesthesia. However, this guideline pertains mostly to procedures and situations that are distinct from electroconvulsive therapy (ECT). This case report describes the experience of a patient on semaglutide, a glucagon-like peptide-1 receptor agonist for obesity, undergoing ECT, provides a general overview of this novel drug class, identifies issues specific to ECT management, and suggests potential adaptations to patient care over different phases of ECT practice.

Inhibition of the melanocortin-3 receptor (MC3R) causes generalized sensitization to anorectic agents

The melanocortin-3 receptor (MC3R) acts presynaptically to regulate GABA release from agouti-related protein (AgRP) nerve terminals and thus may be a negative regulator of multiple circuits involved in feeding behavior and energy homeostasis. Here, we examined the role of MC3R in regulating the response to various anorexigenic agents. Our findings reveal that genetic deletion or pharmacological inhibition of MC3R improves the dose responsiveness to Glucagon-like peptide 1 (GLP1) agonists, as assayed by inhibition of food intake and weight loss. An enhanced anorectic response to other agents, including the acute satiety factors peptide YY (PYY3-36) and cholecystokinin (CCK) and the long-term adipostatic factor, leptin, demonstrated that increased sensitivity to anorectic agents is a generalized result of MC3R antagonism. Enhanced neuronal activation in multiple nuclei, including ARH, VMH, and DMH, was observed using Fos immunohistochemistry following low-dose liraglutide in MC3R knockout mice (Mc3r-/-), supporting the hypothesis that the MC3R is a negative regulator of circuits regulating multiple aspects of feeding behavior. The enhanced anorectic response in Mc3r -/- mice after administration of GLP1 analogs was also independent of the incretin effects and malaise induced by GLP1R analogs, suggesting that MC3R antagonists may have value in enhancing the dose-response range of obesity therapeutics.

A Type 2 Diabetes Mellitus Patient With Severe Diabetic Gastroparesis Successfully Treated With Intravenous Erythromycin

Gastroparesis, characterized by a decrease in gastric emptying, can lead to worsened diabetes control and a reduced quality of life. The patient was a 32-year-old male with type 2 diabetes. He was initially admitted for control of diabetes, and two months later, he was readmitted due to nausea and vomiting. He showed resistance to various drugs, including antiemetics, and an upper gastrointestinal endoscopy revealed significant gastric residue, leading to a diagnosis of gastroparesis. We administered intravenous erythromycin. After three days of treatment, the vomiting resolved. Gastroparesis is challenging to manage, and there are limited effective treatment options. We experienced a case of diabetic gastroparesis with severe vomiting and loss of appetite that responded remarkably well to intravenous erythromycin treatment. Intravenous administration of erythromycin may be a potentially effective treatment for gastroparesis.

Frequency of Gastroparesis Symptoms in Patients With Type-2 Diabetes Mellitus at a Tertiary Care Hospital in Pakistan

Background Gastroparesis symptoms seem to affect many diabetes mellitus patients. Pakistan has a high prevalence of diabetes, with an estimated 33 million people living with the condition. This study aimed to investigate the frequency of gastroparesis symptoms in patients with type-2 diabetes mellitus (T2DM). Methods This cross-sectional study was conducted from April to May 2022 in the outpatient Department of Medicine at the University College of Medicine and Dentistry, Lahore, Pakistan. Patients of both genders aged between 18 and 75 years and having T2DM were analysed. Data regarding demographic information, medical history, BMI assessment, and symptoms related to gastroparesis, as measured by the Gastroparesis Cardinal Symptoms Index (GCSI) were collected at the time of enrolment. For gastroparesis, a diagnostic cutoff of ≥1.90 was considered as per GCSI. Results Of a total of 148 T2DM patients, 85 (57.4%) were females. The mean age was calculated to be 54.0±11.3 years, ranging between 23 and 75 years. There were 134 (90.5%) patients who were using metformin. The most common symptom was fullness, reported by 66 (44.6%), while nausea, bloating, early satiety, retching, and vomiting were noted in 61 (41.2%), 59 (39.9%), 55 (37.2%), 39 (26.4%), and 22 (14.9%) patients, respectively. The frequency of gastroparesis was found in 17 (11.5%) T2DM patients. Stratification of gastroparesis revealed a significant association with female gender (82.4% vs. 54.2%, p=0.0272). Conclusion The study found a high frequency of gastroparesis symptoms in patients with T2DM. Nausea and bloating were the most commonly reported symptoms, while vomiting was the least common. The prevalence of gastroparesis was significantly higher in the female gender.

Diabetic gastroparesis: clinical features, diagnosis and management

Diabetic gastroparesis carries a heavy burden on people with diabetes and the healthcare system. It remains underdiagnosed and represents challenges to treat. This article reviews the epidemiology, pathophysiology, clinical features, diagnosis and treatment of diabetic gastroparesis. The disorder is characterized by delayed gastric emptying without evidence of mechanical gastric outflow obstruction. It presents with upper gastrointestinal (GI) symptoms such as nausea, vomiting, early satiety, postprandial fullness, upper abdominal discomfort and or bloating. As the prevalence of diabetes has been growing over the last few decades, we would expect an increased incidence of delayed gastric emptying in poorly controlled diabetes and perhaps in line with the increasing use of medications that act on the GI tract such as incretin-based therapy. The disease results from multiple reversible and irreversible mechanisms. Diagnosing diabetic gastroparesis requires careful history, examination and investigations to exclude other disorders that could mimic its clinical presentation. Treatment involves a wide variety of options starting with optimization of glycaemic control, stopping any offending medications and lifestyle modifications followed by the introduction of medical therapeutics such as prokinetics. Then, surgical interventions are considered in refractory cases.

T2DB: A Web Database for Long Non-Coding RNA Genes in Type II Diabetes

Type II diabetes (T2D) is a growing health problem worldwide due to increased levels of obesity and can lead to other life-threatening diseases, such as cardiovascular and kidney diseases. As the number of individuals diagnosed with T2D rises, there is an urgent need to understand the pathogenesis of the disease in order to prevent further harm to the body caused by elevated blood glucose levels. Recent advances in long non-coding RNA (lncRNA) research may provide insights into the pathogenesis of T2D. Although lncRNAs can be readily detected in RNA sequencing (RNA-seq) data, most published datasets of T2D patients compared to healthy donors focus only on protein-coding genes, leaving lncRNAs to be undiscovered and understudied. To address this knowledge gap, we performed a secondary analysis of published RNA-seq data of T2D patients and of patients with related health complications to systematically analyze the expression changes of lncRNA genes in relation to the protein-coding genes. Since immune cells play important roles in T2D, we conducted loss-of-function experiments to provide functional data on the T2D-related lncRNA USP30-AS1, using an in vitro model of pro-inflammatory macrophage activation. To facilitate lncRNA research in T2D, we developed a web application, T2DB, to provide a one-stop-shop for expression profiling of protein-coding and lncRNA genes in T2D patients compared to healthy donors or subjects without T2D.

Diabetes-Related Gastroparesis in the Acute Care Setting: A Case Report

Diabetes-related gastroparesis is a challenging complication of diabetes that often results in flares of intractable vomiting and recurrent hospitalizations. Currently, there is no standard of care or guidelines for the management of diabetes-related gastroparesis in the acute care setting, leading to inconsistent and suboptimal care for these patients. Consequently, patients with diabetes-related gastroparesis may have prolonged inpatient lengths of stay and frequent readmissions affecting their overall health and well-being. Successful management of diabetes-related gastroparesis requires a coordinated multimodal approach to address the different components of an acute flare, including nausea and vomiting, pain, constipation, nutrition, and dysglycemia. This case report demonstrates how the development and implementation of an acute care diabetes-related gastroparesis treatment protocol demonstrates efficacy and promise for better quality of care for this population.

Early Gastrointestinal Neuropathy Assessed by Wireless Motility Capsules in Adolescents with Type 1 Diabetes

BACKGROUND

To assess the prevalence of objective signs of gastrointestinal (GI) autonomic neuropathy (AN) in adolescents with type 1 diabetes (T1D). In addition, to investigate associations between objective GI findings and self-reported symptoms or other findings of AN.

METHODS

Fifty adolescents with T1D and 20 healthy adolescents were examined with a wireless motility capsule to assess the total and regional GI transit times and motility index. GI symptoms were evaluated with the GI Symptom Rating Scale questionnaire. AN was evaluated with cardiovascular and quantitative sudomotor axon reflex tests.

RESULTS

There was no difference in GI transit times in adolescents with T1D and healthy controls. Adolescents with T1D had a higher colonic motility index and peak pressure than the controls, and GI symptoms were associated with low gastric and colonic motility index (all p < 0.05). Abnormal gastric motility was associated with the duration of T1D, while a low colonic motility index was inversely associated with "time in target range" for blood glucose (all p < 0.01). No associations were found between signs of GI neuropathy and other measures of AN.

CONCLUSIONS

Objective signs of GI neuropathy are common in adolescents with T1D and it seems to require early interventions in patients at high risk of developing GI neuropathy.

Cannabinoid Hyperemesis Syndrome in a 23-Year-Old Woman with Uncontrolled Type 1 Diabetes Mellitus

BACKGROUND Patients with type 1 diabetes mellitus may experience gastrointestinal symptoms, including those suggestive of diabetic gastroparesis. Cannabinoid hyperemesis syndrome (CHS) includes nausea, vomiting, and abdominal pain in the setting of chronic cannabinoid use. This report presents a case of CHS in a 23-year-old woman with uncontrolled type 1 diabetes mellitus. CASE REPORT A 23-year-old woman with chronically uncontrolled type 1 diabetes mellitus had been presenting monthly at the emergency department for the last 2 years, for acute bouts of intractable nausea and vomiting, occasionally with abdominal pain. Given her history of uncontrolled diabetes, she had been managed for diabetic gastroparesis with prokinetics. A gastric emptying study 6 months prior to admission was normal, and the patient had had multiple unremarkable abdominal computed tomography imaging scans. On this admission, she benefitted from supportive management with only temporary improvement of symptoms. On further questioning, she reported consistent use of cannabis for the last few years, and regression of acute vomiting with hot baths at home. With counseling, she ceased cannabis for 2 months and was symptom-free during this period. CONCLUSIONS This report has shown the importance of taking a comprehensive drug history in all patients, including in patients with type 1 diabetes, and is a reminder that cannabinoid use can cause severe nausea, vomiting, and abdominal pain in this patient group.

A Comparative Study of Fasting Gastric Volume in Diabetic and Non-diabetic Patients Undergoing Elective Surgeries Using Ultrasonography: A Prospective Observational Study

BACKGROUND

Gastric ultrasound can be used to evaluate the residual gastric volume (GV) and contents before anesthetizing a patient. Autonomic gastropathy in patients with diabetes increases the risk of pulmonary aspiration of gastric contents. Therefore, the present study was conducted to assess the fasting GV among diabetics and healthy individuals using point-of-care (POC) ultrasonography.

MATERIALS AND METHODS

This prospective observational study was conducted in a tertiary care hospital between January 2021 and February 2022. A total of 122 patients included in the study were divided into two groups: group D (n = 61) patients had a history of diabetes mellitus and group C (n = 61) patients were non-diabetics (control). Gastric ultrasound was performed in supine and right lateral decubitus (RLD) positions. The following parameters were measured: duration of fasting, craniocaudal (CC) diameter, anteroposterior (AP) diameter, cross-sectional area (CSA), and GV using CC and AP diameters.

RESULTS

The mean age of the participants was found to be 46.60 ± 13.77 years with 51.6% female patients and 48.4% male patients. Among the patients, there was a significantly higher mean level of CC diameter, AP diameter, and CSA in the supine position in diabetics compared to controls (p < 0.05). Similarly, there was a significantly higher mean level of CC diameter, AP diameter, and CSA in the RLD position in diabetics compared to healthy individuals (p < 0.05). The GV was significantly higher in diabetics (9.96 ± 14.520) compared to healthy individuals (-8.991 ± 20.95; p < 0.05).

CONCLUSION

Fasting GV assessed using POC ultrasonography in diabetic individuals was higher when compared to non-diabetics after similar periods of fasting.

Gastrointestinal and Liver Complications in Patients with Diabetes Mellitus-A Review of the Literature

The number of diabetes mellitus patients has increased over the last few years in developing countries, along with obesity and sedentary lifestyle. Besides macroangiopathy and microangiopathy, damage to the nerve fibers of the peripheral nervous system is the most common chronic complication of diabetes. Digestive complications in diabetic patients represent a consequence of diabetic autonomic neuropathy involving the gastrointestinal tract, but unfortunately not always evaluated by diabetologists. Aside from the complications encountered in the digestive tract, patients with diabetes mellitus are prone to developing liver diseases. This review will describe the prevalence of these complications, the modality of diagnosis, and therapeutical solutions in order to reduce the risk of progression of these complications in diabetic subjects.

Trying to stomach multiple myeloma: A case report

We report a case of a 51-year-old male with minimal past medical history who presented to his primary care provider with nausea, vomiting and constipation in the outpatient setting. Concomitantly, he was found to have a renal injury, anemia and lytic lesions which were confirmed to be due to multiple myeloma. After further investigation of the gastrointestinal symptoms, he was diagnosed with gastroparesis. This case represents an unusual presentation of gastroparesis, diagnosed at the same time as multiple myeloma, for which there has yet to be a published association. Here we detail the case, review gastric emptying physiology, the diagnostic criteria for gastroparesis and hypothesize the connection if it might have with multiple myeloma.