The basal to total insulin ratio in outpatients with diabetes on basal-bolus regimen

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.

Correction to: The basal to total insulin ratio in outpatients with diabetes on basal-bolus regimen

[This corrects the article DOI: 10.1007/s40200-018-0358-2.].

Long-term follow-up of patients with hyperthyroidism due to Graves' disease treated with methimazole. Comparison of usual treatment schedule with drug discontinuation vs continuous treatment with low methimazole doses: a retrospective study

Antithyroid drugs may be proposed as the firstline therapy for hyperthyroidism due to Graves' disease since some patients undergo prolonged remission after drug withdrawal. On the other hand, some studies, though controversial, indicated that methimazole (MMI) has some immunomodulating activity. We retrospectively analyzed 384 consecutive patients newly diagnosed with Graves' disease in the years 1990-2002 to ascertain whether long-term therapy with low doses of MMI may prevent relapse of thyrotoxicosis. Two hundred and forty-nine patients were included in our study. The date of reduction of MMI dose to 5 mg/day was considered time 0 for survival analysis. In 121 MMI was discontinued in less than 15 months after time 0 (group D), while in the remaining 128 a daily MMI 2.5-5 mg dose was maintained (group M). One hundred and thirty-five patients were excluded for inadequate response to MMI, relapse of thyrotoxicosis that could be related to an improper withdrawal or reduction of MMI, inadequate or too short followup, iodide contamination, steroid or interferon therapy, pregnancy or post-partum. D and M groups did not differ for clinical and hormonal parameters except age, which was lower in D (p=0.019). Age > vs < 35 yr was relevant in survival analysis; therefore patients were divided in 2 groups according to this age cut-off. In younger patients relapse of thyrotoxicosis occurred in 15 patients of group D 2.4-39.6 months (median 19.0) after time 0, and 8 M after 5.9-40.0 (21.3) months, while 14 D and 5 M maintained euthyroidism until the end of the observation after 31.8-95.3 (56.6) months and 30.4-62.1 (46.5) months, respectively. Survival analysis indicated that the risk of relapse was similar in group D and M. In older patients relapse of thyrotoxicosis occurred in 40 patients of group D after 8.2-65.8 (25.4) months and 29 M after 5.8-62.5 (22.4) months, while 52 D and 86 M maintained euthyroidism until the end of the observation, 20.1-168.0 (46.7) months and 24.1-117.4 (53.4) months respectively. Survival analysis indicated that the risk of relapse was increased in group D. Therefore long-term treatment with low doses of MMI seems to prevent relapse in Graves' disease in patients above 35 yr of age. This should be confirmed in a prospective study.

Reduced serum levels of dehydroepiandrosterone sulphate in adrenal incidentalomas: a marker of adrenocortical tumour

BACKGROUND AND OBJECTIVE

Reduced serum levels of dehydroepiandrosterone sulphate (DHEAS) have been shown in patients with Cushing's syndrome resulting from adrenocortical adenoma, in contrast with normal DHEAS levels in patients with Cushing's disease. The aim of this study was to verify whether patients with incidentally discovered adrenocortical adenomas also have reduced levels of DHEAS.

DESIGN

Evaluation of serum DHEAS, serum and urinary cortisol, plasma ACTH and low dose dexamethasone suppression test in patients with adrenal incidentaloma and Cushing's syndrome.

PATIENTS

Thirty-two patients with adrenal incidentaloma and, as controls, 17 patients with overt Cushing's syndrome, were studied.

RESULTS

Serum DHEAS levels lower than normal were found in 21/24 (87.5%) patients with adrenocortical incidentaloma, but in only 1/8 patients with a mass of non-adrenocortical origin. This patient had massive bilateral metastatic infiltration of both adrenal glands and primary adrenal failure. The prevalence of low DHEAS levels in the two groups was significantly different (P = 0.0001). In patients with adrenocortical incidentaloma, the prevalence of low DHEAS levels was significantly higher (P = 0.0001) than that found for some hormonal alterations indicating pre-clinical hypercortisolism (high urinary cortisol, unsuppressed serum cortisol after low dose dexamethasone administration and low plasma ACTH). Low DHEAS levels were found in all patients with Cushing's syndrome due to adrenocortical adenoma but in none of those with Cushing's disease.

CONCLUSIONS

Our results indicate that the finding of low DHEAS levels can be considered a marker of the adrenocortical origin of an adrenal incidentaloma, provided adrenal failure has been excluded.

[Preclinical left ventricular diastolic dysfunction in insulin-dependent diabetes]

BACKGROUND

Isolated alterations of the left ventricular diastolic function have been described in diabetic insulin-dependent patients (IDDM), even in the absence of old age, hypertension, ischemic heart disease, left ventricular hypertrophy. Such alterations have been associated with microangiopathy but it is not known whether it is reversible or if there is a relation with the way the therapy is given.

METHODS

Fifty-five subjects have been studied, of which 15 were healthy, 30 recently diagnosed IDDM without microangiopathy and 10 IDDM with microangiopathy. All the patients were under 35 years old and did not present risk factors for coronary artery disease, hypertension or autonomic neuropathy. The maximal exercise stress test proved negative. The diastolic function was studied using the results of Doppler echocardiography of the mitral flow and of isovolumetric relaxation time, with continuous and discrete parameters.

RESULTS

The velocity of wave A and E, the relationship between them and their integrals are significantly greater in diabetics with microangiopathy than in those without it and in healthy subjects. There are no significant differences between healthy and diabetic subjects without microangiopathy using continuous parameters. Using discrete parameters diastolic damage is absent in the healthy subjects and is present in 48% of diabetics without microangiopathy and in 90% of those with it.

CONCLUSIONS

Slight preclinical diastolic dysfunction is present in young recently diagnosed IDDM without microangiopathy. More severe dysfunction is present when there is also microangiopathy.

Treatment of allergy to heterologous monocomponent insulin with human semisynthetic insulin. Long-term study

Eight type II (non-insulin-dependent) diabetic subjects (7 women, 1 man, aged 42-61 yr), initially treated with oral hypoglycemic agents and intermittently treated with conventional insulins, were identified as developing allergic reactions to porcine and mixed-species monocomponent insulin. Allergy was systemic (urticaria and nonthrombocytopenic purpura) and local delayed in two subjects and local immediate or biphasic in six subjects. Lipoatrophy was present in two subjects. After treatment with human semisynthetic insulin (Monotard HM and Actrapid HM), systemic allergy disappeared. Local allergy disappeared in five subjects and was reduced in three subjects. No lipoatrophy occurred in new injection areas. The clinical results were accompanied by a significant decrease in serum insulin-specific IgE after 6, 12, 18, 24, 30, and 36 mo. Insulin-specific IgG showed an evident decrease in five of eight patients, but the difference in mean values was not significant after 6, 18, 24, 30, and 36 mo. With one exception, intradermal skin tests were positive to human, bovine, and porcine insulin before and after human insulin treatment.

[Insulin-dependent diabetes and pregnancy. A model of coordinated approach]

A historical account of the relation between diabetes and pregnancy is followed by the presentation of a personal series of 10 insulin-dependent diabetic pregnant women (3 White's class B, 2 class C, 3 class D and 2 class F/R) treated in accordance with a newly applied quarterly and fortnightly protocol. Nearly normal blood sugar (HbA1 maintained around 8% in the second and third trimester) was achieved through home blood glucose self-monitoring, in keeping with the Karen Bruni Centre's educational programme. This includes self-management of intensified insulin treatment in the form of 2-3 injections per day (Monotard MC and HM, Actrapid MC and HM), as well as the use of Novo Pen (100 U/ml Actrapid HM) for supplementary insulinisation. Average insulin initial dose: 0.51 U/Kg/day (range 0.2-0.7); final dose 0.83 U/Kg/day (range 0.6-1.2). Delivery was by caesarean section on obstetric indication: 9 at the 36th week, 1 at the 34th for trisymptomatic gestosis. There were no foetal nor neonatal death. All children were subjected to intensive neonatological care. There were 3 cases of macrosomia and 1 tetralogy of Fallot, which followed a benign course. Despite their absence of statistical value, these data show that optimised multidisciplinary treatment can be of utility in preventing neonatal morbidity and mortality in an insulin-dependent diabetic pregnancy. They also indicate that a coordinated treatment model can equally be put into effect even in a non centralised structure, provided certain facilities exist: in our case, voluntary support on the part of Karen Bruni Diabetic Association, obstetric interest in diabetology and a neonatological background for treatment of the offspring of diabetic mothers. Lastly, this series substantiate the effectiveness of the programme of self-checking and self-management of diabetes in the accomplishment of "optimised" blood glucose control and containment of costly hospitalisation at the time of delivery.

[Education of the diabetic patient: 10-year experience at the Karen Bruni Center]

On the basis of a ten year experience, new behavioural and philosophical approaches to the education of insulin-dependent diabetic patients are proposed by the Karen Bruni Diabetes Center of Turin. Conceptual and methodological revisions of conventional programs should be tried out. Practical difficulties are still restricting an integrated educational treatment of the diabetic persons.