Efficacy and Safety of Empagliflozin in Patients with Type 2 Diabetes Mellitus Fasting During Ramadan: A Real-World Study from Bangladesh

AIM

In Bangladesh, there is a large population of Muslims with type 2 diabetes mellitus (T2DM) who fast during Ramadan. Changes in the pattern of meal and fluid intake during this long-fasting hours may increase the risk of hypoglycaemia, hyperglycaemia, and dehydration. Our key point of focus was to evaluate the efficacy and safety of Empagliflozin, a sodium-glucose co transporter 2 inhibitor (SGLT2i), in patients with T2DM while fasting during Ramadan.

METHODS

This was a 24-weeks, multi-centre, open-label, two-arm parallel-group study. In this prospective type of observational study, we enrolled patients taking Empagliflozin and Metformin with or without a DPP-4 inhibitor in one group (n = 274) and a parallel group (n = 219) who were treated with Metformin with or without a DPP-4 inhibitor. The primary endpoint of this study was HbA1c reduction, weight loss and the number of reported or symptomatic hypoglycemic events. In secondary endpoints, we evaluated the changes from baseline in blood pressure, estimated glomerular filtration rate (eGFR), serum creatinine, and serum electrolyte, the proportion of volume depletion (≥1 event) and incidence of other adverse events (AEs) of interest potentially related to SGLT2 inhibitor.

RESULTS

During Ramadan, HbA1c reduction was significant in Empagliflozin arm (-0.49% vs -0.12%); [p < 0.001]. From before to the end of the study, significant weight reduction was seen in the Empagliflozin arm (-1.4 kg vs -0.09 kg); [p < 0.001]. We observed no significant increase in the incidence of hypoglycemia (0.7% vs 0.4%, p = 0.267) and volume depletion (2.6% vs 1.8%; p = 0.55) in both arm. All these milder forms events did not require any hospital admission. There was no report of serious adverse events or any discontinuation, or reduction of prescribed doses of empagliflozin during Ramadan.

CONCLUSION

Empagliflozin is efficacious and safe for treating adults with T2DM during Ramadan.

Bangladesh Endocrine Society (BES) Position Statement for Management of Diabetes and Other Endocrine Diseases in Patients with COVID-19

BACKGROUND

The year 2020 witnessed a largely unprecedented pandemic of coronavirus disease (COVID-19), caused by SARS COV-2. Many people with COVID-19 have comorbidities, including diabetes, hypertension and cardiovascular diseases, which are significantly associated with worse outcomes. Moreover, COVID-19 itself is allied with deteriorating hyperglycemia. Therefore, Bangladesh Endocrine Society has formulated some practical recommendations for management of diabetes and other endocrine diseases in patients with COVID-19 for use in both primary and specialist care settings.

OBJECTIVE

The objective of the article is to develop a guideline to protect the vulnerable group with utmost preference - the elderly and those with comorbid conditions. Therefore, to ensure the adequate protective measures and timely treatment for COVID-19 patients with diabetes, other endocrine diseases or any other comorbidities.

CONSIDERING AND MONITORING ISSUES

The risk of a fatal outcome from COVID-19 may be up to 50% higher in patients with diabetes than in non-diabetics.Patients with diabetes and COVID had CFR 7.3-9.2%, compared with 0.9-1.4% in patients without comorbidities.Diabetic ketoacidosis may be one of the causes of mortality in COVID-19.There is wide fluctuation of blood glucose in these patients, probably due to irregular diet, reduced exercise, increased glucocorticoids secretion, and use of glucocorticoids. HbA1c should be <7.0% for the majority of the patients, this target may be relaxed in appropriate clinical settings.More emphasis should be given on day-to-day blood glucose levels. Hypoglycemia (<3.9 mmol/l) must be avoided.Frequent monitoring of blood glucose is needed in critically ill patients.

CONCLUSION

The fight against COVID-19 has been proven to be a challenging one. Therefore, all healthcare personnel should make the best use of updated knowledge and skills to ensure adequate protective measures and timely treatment for COVID-19 patients with diabetes, other endocrine diseases or any other comorbidities.

Spontaneous hypoglycemia: a review

Spontaneous hypoglycemia is an important entity that may affect multiple organs. The differential diagnosis is broad in individuals with hypoglycemia in the absence of diabetes mellitus. Multiple etiologies may be present concurrently. Drugs, critical illnesses, hormone deficiencies, and non-islet cell tumors should be considered in those who are ill or taking medications. In apparently healthy individuals, endogenous hyperinsulinism due to insulinoma, functional β-cell disorders, or insulin autoimmune conditions are possible, as are accidental, surreptitious or factitious causes of hypoglycemia. Investigations should be guided by clinical scenario. Irrespective of the exact cause of the spontaneous hypoglycemia, treatment consists of correcting the glycemic state and preventing recurrence by alleviating underlying pathology. This review discusses the causes, diagnosis and management of spontaneous hypoglycemia. IMC J Med Sci 2019; 13(1): 001

Hyperprolactinemia: A Systematic Review of Diagnosis and Management

Hyperprolactinemia is a common endocrine disorder that can be associated with significant morbidity. It can result from a number of causes, including use of medication, hypothyroidism and pituitary disorders. Depending on the cause and consequences of hyperprolactinemia, selected patients require treatment considering the underlying cause, age sex, and reproductive status. We describe a systematic review of hyperprolactinemia, including microadenomas and macroadenomas, in various clinical settings, with emphasis on newer diagnostic strategies and the role of various therapeutic options, including treatment with selective dopamine agonists. Through this review, we aimed to compare efficacy and adverse effects of medications, surgery and radiotherapy in the treatment of hyperprolactinemia.Delta Med Col J. Jan 2018 6(2): 90-101

Neck Circumference as a Marker of Overweight and Obesity and Cutoff Values for Bangladeshi Adults

OBJECTIVE

There are several methods of assessing overweight and obesity. Several studies conducted in different populations indicate that neck circumference (NC) can be used as a simple measure of overweight and obesity. This study was conducted to evaluate NC as a marker of overweight and obesity and to determine respective cutoff values for Bangladeshi male and female participants.

RESEARCH DESIGN/MATERIALS AND METHODS

This cross-sectional observational study was conducted with during July 2013-June 2014 among randomly selected 871 Bangladeshi participants (male = 496 [56.9%], female = 375 [43.1%], aged >18 years) who visited Outpatient Department of United Hospital, Bangladesh Institute of Research and Rehabilitation in Diabetes, Endocrine and Metabolic disorders, primary health-care centers located in Dhaka, Savar, Gazipur. NC of participants was taken in centimeter to the nearest 1 mm, using plastic tape measure. Main outcome included NC, waist circumferences (WC), body mass index (BMI), and waist: hip ratio (WHR).

RESULTS

Pearson's correlation coefficients indicated a significant association between NC and height (men, r = 0.33; women, r = 0.28; P < 0.0001), weight (men, r = 0.61; women, r = 0.55; P < 0.0001), BMI (men, r = 0.51; women, r = 0.41; P < 0.0001), WC (men, r = 0.61; women, r = 0.46; P < 0.0001), hip circumference (men, r = 0.61; women, r = 0.44; P < 0.0001), WHR (men, r = 0.22; women, r = 0.18; P < 0.0001). Receiver operating characteristic curve analysis showed that NC ≥34.75 cm in men (area under curve [AUC]: 0.77; P < 0.001) and ≥31.75 cm in women (AUC: 0.62; P < 0.001) were the best cutoff value for BMI ≥23 (overweight). NC ≥35.25 cm in men (AUC: 0.82; P < 0.001) and NC ≥34.25 cm in women (AUC: 0.76; P < 0.001) were the best cutoff value for BMI ≥27.5 (obesity). NC ≥35.25 cm in male (AUC: 0.83; P < 0.001) and NC ≥31.25 cm in women (AUC: 0.65; P < 0.001) were the best cutoff value for WC >90 cm in men and > 80 cm in women, respectively. NC ≥34.45 cm in male (AUC: 0.59; P = 0.001) and NC ≥31.25 cm in women (AUC: 0.66; P = 0.008) were the best cutoff value for WHR >0.9 in men and >0.8 in women, respectively.

CONCLUSION

NC measurement is a simple, convenient, inexpensive screening measure to identify overweight and obese participants. Men with NC ≥34.75 cm and women with NC ≥31.75 cm are to be considered overweight while men with NC ≥35.25 cm and women with NC ≥34.25 cm are to be considered obese. NC ≥35.25 cm in male and NC ≥31.25 cm in women were the best cutoff value for abdominal obesity.

Obesity: A Review of Pathogenesis and Management Strategies in Adult

Obesity is a chronic metabolic disease characterized by an increase of body fat stores. It is a gateway to ill health, and has become one of the leading causes of disability and death, affecting not only adults but also children and adolescents worldwide. Obesity is a major risk factor for cancer, cardiovascular, metabolic, and respiratory disorders. This presents an ever increasing social and economic burden to individuals, families and the healthcare system. Preventing obesity is the optimal long-term population strategy. A comprehensive history, physical examination and laboratory assessment relevant to the patient’s obesity should be obtained. Appropriate goals of weight management emphasize realistic weight loss to achieve a reduction in health risks and should include promotion of weight loss, maintenance and prevention of weight regain. Management of co-morbidities and improving quality of life of obese patients are also included in treatment aims.Treatment should be based on good clinical care, and evidence-based interventions; should focus on realistic goals and lifelong multidisciplinary management. A comprehensive obesity management can only be accomplished by a multidisciplinary obesity management team. We conclude that physicians have a responsibility to recognize obesity as a disease and help obese patients with appropriate prevention and treatment. This review addresses the current therapeutic options in the treatment of obesity, focusing on pathogenesis, lifestyle changes, medications, and surgery. It also presents a suggested algorithm for the clinician assessing and managing obese patients.Delta Med Col J. Jan 2017 5(1): 35-48

Safe and pragmatic use of sodium-glucose co-transporter 2 inhibitors in type 2 diabetes mellitus: South Asian Federation of Endocrine Societies consensus statement

Diabetes prevalence shows a continuous increasing trend in South Asia. Although well-established treatment modalities exist for type 2 diabetes mellitus (T2DM) management, they are limited by their side effect profile. Sodium-glucose co-transporter 2 inhibitors (SGLT2i) with their novel insulin-independent renal action provide improved glycemic control, supplemented by reduction in weight and blood pressure, and cardiovascular safety. Based on the clinical outcomes with SGLT2i in patients with T2DM, treatment strategies that make a "good clinical sense" are desirable. Considering the peculiar lifestyle, body types, dietary patterns (long duration religious fasts), and the hot climate of the South Asian population, a unanimous decision was taken to design specific, customized guidelines for T2DM treatment strategies in these regions. The panel met for a discussion three times so as to get a consensus for the guidelines, and only unanimous consensus was included. After careful consideration of the quality and strength of the available evidence, the executive summary of this consensus statement was developed based on the American Association of Clinical Endocrinologists/American College of Endocrinology protocol.

Hirsutism - Evaluation and Treatment

Hirsutism is a distressing clinical condition seen in adult female patients. The cause is mainly hyperandrogenism, which may be ovarian or adrenal. The most common pathological cause is usually polycystic ovary syndrome. It may be part of a rare metabolic syndrome, drug induced, or just idiopathic. It requires in depth clinical evaluation and investigation for treatment. Serum testosterone measurements are not needed in many cases. Hirsutism has a huge psychosocial impact, especially in the young females. This article reviews the current evaluation guidelines and management of hirsutism.Delta Med Col J. Jan 2016 4(1): 35-44

Adrenal Insufficiency - Aetiology, Diagnosis and Treatment

Adrenal insufficiency is caused by either primary adrenal failure or by hypothalamic-pituitary impairment of the corticotropic axis. Adrenal insufficiency, first codified in 1855 by Thomas Addison, remains relevant in 2014 because of its lethal nature. Though, it is a rare disease but is life threatening when overlooked. Main presenting symptoms such as fatigue, anorexia and weight loss are nonspecific, thus diagnosis is often delayed. The diagnostic work-up is well established but some pitfalls remain. The diagnosis is adequately established by the 250 ?g ACTH (adrenocorticotropic hormone) stimulation test in most cases. Glucocorticoids provide life saving treatment but long-term quality of life is impaired, perhaps because therapy is not given in a physiologic way. Dehydroepiandrosterone-replacement therapy has been introduced that could help to restore quality of life. It may be useful in pubertal girls, but not in adults. Monitoring of glucocorticoid-replacement is difficult due to lack of objective methods of assessment and is therefore largely based on clinical grounds. Thus, long-term management of patients with adrenal insufficiency remains a challenge, requiring an experienced specialist. DOI: http://dx.doi.org/10.3329/dmcj.v3i1.22238 Delta Med Col J. Jan 2015; 3(1): 36-47

Insulin Resistance and Hypogonadism

Backgound: The number of hypogonads is increasing day by day. It may be due to sedentary life style with increased obesity, increased tension or stressed lifestyle among all groups of populations. Visceral obesity is associated with insulin resistance, diabetes mellitus and also with hypogonadism. Objective: This study was carried out to determine the proportion of insulin resistance among male subjects with hypogonadism in different age groups along with status of erectile quality among diabetics and non diabetics. Materials and method: This cross sectional study among 161 adult male subjects aged ? 20 to ? 60 years were purposively selected from Bangladesh Institute of Research and Rehabilitation in Diabetes Endocrine and Metabolic Disorders (BIRDEM), Dhaka, Bangladesh between May 2009 to September 2010. Glycemic status and insulin resistance (by HOMA-R) were done and relevant history were documented. Results: The highest proportion (38.9%) of hypogonadism was in ? 50 years age group whereas highest proportion (39.6%) of the eugonads was in the age group of 40 to 49 years. More than half of the hypogonad subjects had weak erectile quality (54.0%) which were followed by absent erectile quality in 32.7% and 13.3% subjects had normal erectile quality. Among the eugonad subjects 41.7% had normal erectile quality, 41.6% subjects had weak erectile quality and 16.7% subjects had no erectile quality. More than ninety percent of the hypogonad subjects and about 60% of the eugonad subjects had insulin resistance. The average HOMA-R was more in the subjects with hypogonadism with diabetes which was highly significant (p-value < 0.001). Conclusion: Hypogonadism is associated with insulin resistance.DOI: http://dx.doi.org/10.3329/dmcj.v1i1.14968 Delta Med Col J. Jan 2013;1(1):3-7 

Guillain-Barre Syndrome Following Dengue Fever in Adult Patient

Guillain-Barre syndrome is a post infectious ascending, usually demyelinationg polyradiculoneuropathy. Dengue fever as an antecedent infection in GBS is uncommon. A 39-year-old female presented with acute flaccid weakness of both upper and lower limbs which developed in ascending and progressive fashion following a febrile illness of three days. During work-up IgM for dengue virus was found positive. Diagnosis of Guillain-Barre syndrome was made based on neurologic manifestations, the typical CSF findings and pattern of electrophysiological study and exclusion of other pathologies. Patient was treated with intravenous immunoglobulins. During the course of illness, she developed lower motor neuron type trigeminal, facial, glossopharyngeal, vagus and hypoglossal nerve palsy and autonomic involvement. She had significant recovery and was able to talk, eat and walk six weeks later. Dengue is endemic in Bangladesh. Post dengue Guillain- Barre syndrome in adult, as shown in previous reports, should now be considered in the part of spectrum of neurological complications of this infection. DOI: http://dx.doi.org/10.3329/jom.v13i2.12772 J Medicine 2012; 13 : 246-249