Glucagon-like peptide-1 receptor agonists as a possible intervention to delay the onset of type 1 diabetes: A new horizon

Type 1 diabetes (T1D) is a chronic autoimmune condition that destroys insulin-producing beta cells in the pancreas, leading to insulin deficiency and hyper-glycemia. The management of T1D primarily focuses on exogenous insulin replacement to control blood glucose levels. However, this approach does not address the underlying autoimmune process or prevent the progressive loss of beta cells. Recent research has explored the potential of glucagon-like peptide-1 receptor agonists (GLP-1RAs) as a novel intervention to modify the disease course and delay the onset of T1D. GLP-1RAs are medications initially developed for treating type 2 diabetes. They exert their effects by enhancing glucose-dependent insulin secretion, suppressing glucagon secretion, and slowing gastric emptying. Emerging evidence suggests that GLP-1RAs may also benefit the treatment of newly diagnosed patients with T1D. This article aims to highlight the potential of GLP-1RAs as an intervention to delay the onset of T1D, possibly through their potential immunomodulatory and anti-inflammatory effects and preservation of beta-cells. This article aims to explore the potential of shifting the paradigm of T1D management from reactive insulin replacement to proactive disease modification, which should open new avenues for preventing and treating T1D, improving the quality of life and long-term outcomes for individuals at risk of T1D.

'Post-Close' Femoral Arterial Haemostasis at Endovascular Aneurysm Repair using a Dedicated Large-Bore Vascular Closure Device: A Prospective Real-World Audit

PURPOSE

Percutaneous access for endovascular aneurysm repair (EVAR) is commonplace, with its attendant benefits. The combination of continued reduction in device profile and evolution of vascular closure device (VCD) design drives successful and safe percutaneous EVAR. A new such VCD is the MANTA Large-Bore Closure Device designed in two iterations for closure of arterial defects from 10 to 25F. We present a prospective audit of 131 large-bore femoral closures using an 'all-comers' approach to device selection.

MATERIALS AND METHODS

One hundred and thirty-one large-bore femoral arterial defects were analysed. Both 14F and 18F MANTA VCDs were deployed in this series as per instructions for use. Primary objectives were technical success, particularly successful deployment, and haemostasis achieved. Failures were denoted as failure to deploy; failure to achieve haemostasis was denoted as active bleeding, haematoma, or pseudoaneurysm formation requiring intervention. Later complications assessed were vessel occlusion/thrombosis or stenosis.

RESULTS

Seventy-six patients (65 males and 11 females, age 75.2 ± 8.7 years) underwent a range of procedures including EVAR (n = 66), TEVAR (n = 2), and reinterventions (n = 8) requiring large-bore percutaneous femoral arterial access in 131 groins. Of these, the 14F MANTA VCD was used in 61 closures (defects ranging from 12 to 18F) and the 18F in 70 closures (defects ranging from 16 to 24F). Deployments achieved successful haemostasis in 120 (91.6%), and failures occurred in 11(8.4%) groins.

CONCLUSIONS

This study indicates that a post-close approach using the novel MANTA Large-Bore Closure Device can be undertaken successfully to close a range of large-bore femoral arterial defects at EVAR/TEVAR with an acceptable rate of complications.

Suicide Attempt With Levothyroxine Overdose

Symptoms of levothyroxine overdose may vary depending on age, metabolism, etc. There are no specific guidelines for treating levothyroxine poisoning. Here, we present the case of a 69-year-old man with a history of panhypopituitarism, hypertension, and end-stage renal disease who attempted suicide by ingesting 60 tablets of 150 µg levothyroxine (9 mg). Upon presentation to the emergency room, he was asymptomatic despite the free thyroxine level above the range of the assay. During the hospital stay, he developed sinus tachycardia, which was controlled with propranolol. Mild elevations in liver enzymes were also noted. He received stress-dose steroids; hemodialysis was performed a day earlier, and cholestyramine was administered. Thyroid hormone levels started to improve by day seven and finally normalized in 20 days, after which the home dose of levothyroxine was resumed. The human body has several mechanisms to compensate for levothyroxine toxicity, including the conversion of excess levothyroxine to inactive reverse triiodothyronine, increased binding to thyroid-binding globulin, and hepatic metabolism. This case shows that it is possible to have no symptoms even with an overdose of up to 9 mg a day of levothyroxine. Signs and symptoms of levothyroxine toxicity may not appear for several days after ingestion, and, therefore, close observation preferably on a telemetry floor is recommended until the thyroid hormone levels start to decrease. Effective treatment options include beta-blockers preferably propranolol, early gastric lavage, cholestyramine, and glucocorticoids. While hemodialysis has a limited role, antithyroid drugs and activated charcoal are ineffective.

LBSUN213 An Investigation Into The Effects Of Dapagliflozin On Ketogenesis In Type 1 Diabetes

Background

Treatment with sodium-glucose transporter (SGLT)-2 inhibitors in patients with type 1 diabetes (T1DM) is associated with increased ketogenesis and diabetic ketoacidosis (DKA). The exact relationship between SGLT-2 inhibitors use in T1DM and ketogenesis is not fully understood.

Patients and Methods

In this single center, randomized, double blind and placebo-controlled trial 70 patients with established T1DM were randomized into placebo, dapagliflozin (SGLT-2 inhibitor) alone, exenatide/Bydureon (short and long-term acting GLP-1 RA, respectively) alone or with dapagliflozin and exenatide/Bydureon (triple therapy) groups in addition to routine insulin treatment (titrated in all groups to reduce risk of hypoglycemia). Patients were tested acutely (single dose before and after 12 weeks of treatment) under extended fasting and insulinopenic conditions (stress conditions) and under basal fasting conditions during 12 weeks treatment period.

Results

At end of 12 weeks treatment, glycemic indices improved significantly compared to baseline in the dapagliflozin and Bydureon alone groups and improved significantly compared to placebo in the triple therapy group (HbA1c: -0.9±0.1%, p<0. 001). Weight loss was significant (p<0. 001) in all active treatment groups. Ketones (beta-hydroxybutyrate, BHB) increased significantly in blood (0.21±0. 04 to 1.57±0.21 mM) and urine under acute stress conditions in control group at baseline and at 12 weeks visits. The magnitude of this increase was reduced following a single dose of dapagliflozin or exenatide at baseline visit (average of 1.16±0.17 mM) but was further increased following a single dose in the dapagliflozin receiving groups at 12 weeks visit (average of 1.83±0.28 mM). Under acute testing conditions, single dose of dapagliflozin treatment was associated with reduced urinary BHB clearance at baseline and 12 weeks visits. After 12 weeks of treatment and under basal conditions, ketone levels in blood and urine were not significantly altered following dapagliflozin or Bydureon alone but were significantly higher in the triple therapy group (0.22±0. 04 to 0.42±0. 07 mM in blood). At 12 weeks of treatment, dapagliflozin was associated with increased glucagon and lipolysis (increased FFAs) while Bydureon was associated with decreased glucagon and lipolysis. During the 12 weeks there were no episode of DKA or hypoglycemia (<55mg/dl).

Conclusions

Adjunct therapies treatment in T1DM results in significant improvements in glycemia and HbA1c. Dapagliflozin treatment increases lipolysis and glucagon while reduces urinary excretion of BHB. This may contribute to the increased blood ketone levels following extended treatment with dapagliflozin. However, the magnitude of this increase in ketones is significantly below DKA ketones levels which indicates that other DKA triggering factors play a more significant role.

Presentation: Sunday, June 12, 2022 12:30 p.m. - 2:30 p.m.

Improving the residual risk of renal and cardiovascular outcomes in diabetic kidney disease: A review of pathophysiology, mechanisms, and evidence from recent trials

Based on global estimates, almost 10% of adults have diabetes, of whom 40% are estimated to also have chronic kidney disease (CKD). Almost 2 decades ago, treatments targeting the renin-angiotensin system (RAS) were shown to slow the progression of kidney disease. More recently, studies have reported the additive benefits of antihyperglycaemic sodium-glucose co-transporter-2 inhibitors in combination with RAS inhibitors on both CKD progression and cardiovascular outcomes. However, these recent data also showed that patients continue to progress to kidney failure or die from kidney- or cardiovascular-related causes. Therefore, new agents are needed to address this continuing risk. Overactivation of the mineralocorticoid (MR) receptor contributes to kidney inflammation and fibrosis, suggesting that it is an appropriate treatment target in patients with diabetes and CKD. Novel, selective non-steroidal MR antagonists are being studied in these patients, and the results of two large recently completed clinical trials have shown that one such treatment, finerenone, significantly reduces CKD progression and cardiovascular events compared with standard of care. This review summarizes the pathogenic mechanisms of CKD in type 2 diabetes and examines the potential benefit of novel disease-modifying agents that target inflammatory and fibrotic factors in these patients.

1430 Mid-Term Outcomes After Endovascular Repair of Popliteal Artery Aneurysms Demonstrate Satisfactory Patency Rates and Safety of Stent-Grafts

Aim

Popliteal artery aneurysms (PAAs) are increasingly treated via an endovascular approach. We present mid-term outcomes of popliteal endovascular aneurysm repair (PEVAR) from a single centre.

Method

A retrospective analysis of a prospective database of consecutive patients who underwent either elective or emergency PEVAR in a single regional vascular centre from January 2010 to August 2020. The patients underwent placement of a heparin-bonded stent-graft (Viabahn Endoprosthesis, WL Gore and Associates, Flagstaff, USA) for PAA >20mm or complications: thromboembolism, rupture or popliteal vein thrombosis. Patency and stent-graft related complications were assessed.

Results

A total of 64 PAAs (mean size 36.8±13.4mm) were treated in 56 patients (mean age 75±10.7 years, 54 (96%) male). Median follow-up was 29.5 months (IQR 36.75). 30-day mortality was 0%. Technical success rate of stent-graft insertion was 100%. 1-year and 5-year primary patency was 83% and 67% respectively; primary-assisted patency at these time points was 86% and 72%, and the corresponding secondary patency was 89% and 75%. 61 out of 64 treated limbs had >1 vessel runoff. The most frequently occurring complication was stent-graft occlusion which affected 11 (17%) limbs. Stent-graft fracture occurred in 1 patient, resulting in endoleak.

Conclusions

Viabahn Endoprosthesis can be used successfully in treatment of PAA with acceptable short- and mid-term patency rates. One in five patients in this cohort required a reintervention, with most complications occurring in the first year postoperatively. Stent-graft fracture occurred only in one patient demonstrating that PEVAR is a safe option for PAA management in the intermediate term.

Dapagliflozin reduces systolic blood pressure and modulates vasoactive factors

AIM

To investigate the mechanisms underlying improvements in blood pressure (BP) and congestive heart failure outcomes following treatment with dapagliflozin, a sodium-glucose co-transporter-2 inhibitor.

RESEARCH DESIGN AND METHODS

A total of 52 patients with type 2 diabetes (T2D) with an HbA1c of less than 8% participated in this prospective, double-blind and placebo-controlled study. Patients were randomized (1:1) to either dapagliflozin 10 mg daily or placebo for 12 weeks. Half the patients were also monitored for 6 h following their first dose for acute effects on BP. Blood and urine samples were collected and levels of angiotensinogen, angiotensin II, renin, aldosterone, endothelin-1, atrial natriuretic peptide (ANP), brain natriuretic peptide, cyclic adenosine monophosphate, cyclic guanosine monophosphate (cGMP) and neprilysin were measured. The expression of angiotensin-converting enzyme, guanylate cyclase and phosphodiesterase 5 (PDE5) was measured in circulating mononuclear cells (MNC).

RESULTS

A total of 24 and 23 patients receiving dapagliflozin and placebo, respectively, completed the 12-week study. Systolic BP decreased significantly, compared with placebo, both after single-dose (by 7 ± 3 mmHg) and 12-week (by 7 ± 2 mmHg) treatment with dapagliflozin. Dapagliflozin suppressed angiotensin II and angiotensinogen (by 10.5 ± 2.1 and 1.45 ± 0.42 μg/mL, respectively) and increased ANP and cGMP (by 34 ± 11 and 29 ± 11 pmol/mL, respectively) compared with the placebo group. cGMP levels also increased acutely following a single dose of dapagliflozin. Dapagliflozin also suppressed PDE5 expression by 26% ± 11% in MNC. There were no changes observed in the other vasoactive mediators investigated.

CONCLUSIONS

Dapagliflozin administration in T2D resulted in both acute and chronic reduction in systolic BP, a reduction in vasoconstrictors and an increase in vasodilators. These changes may potentially contribute to its antihypertensive effects and its benefits in congestive cardiac failure.

Liraglutide hospital discharge trial: A randomized controlled trial comparing the safety and efficacy of liraglutide versus insulin glargine for the management of patients with type 2 diabetes after hospital discharge

AIM

To compare a glucagon-like peptide-1 receptor agonist with basal insulin at hospital discharge in patients with uncontrolled type 2 diabetes in a randomized clinical trial.

METHODS

A total of 273 patients with glycated haemoglobin (HbA1c) 7%-10% (53-86 mol/mol) were randomized to liraglutide (n = 136) or insulin glargine (n = 137) at hospital discharge. The primary endpoint was difference in HbA1c at 12 and 26 weeks. Secondary endpoints included hypoglycaemia, changes in body weight, and achievement of HbA1c <7% (53 mmol/mol) without hypoglycaemia or weight gain.

RESULTS

The between-group difference in HbA1c at 12 weeks and 26 weeks was -0.28% (95% CI -0.64, 0.09), and at 26 weeks it was -0.55%, (95% CI -1.01, -0.09) in favour of liraglutide. Liraglutide treatment resulted in a lower frequency of hypoglycaemia <3.9 mmol/L (13% vs 23%; P = 0.04), but there was no difference in the rate of clinically significant hypoglycaemia <3.0 mmol/L. Compared to insulin glargine, liraglutide treatment was associated with greater weight loss at 26 weeks (-4.7 ± 7.7 kg vs -0.6 ± 11.5 kg; P < 0.001), and the proportion of patients with HbA1c <7% (53 mmol/mol) without hypoglycaemia was 48% versus 33% (P = 0.05) at 12 weeks and 45% versus 33% (P = 0.14) at 26 weeks in liraglutide versus insulin glargine. The proportion of patients with HbA1c <7% (53 mmol/mol) without hypoglycaemia and no weight gain was higher with liraglutide at 12 (41% vs 24%, P = 0.005) and 26 weeks (39% vs 22%; P = 0.014). The incidence of gastrointestinal adverse events was higher with liraglutide than with insulin glargine (P < 0.001).

CONCLUSION

Compared to insulin glargine, treatment with liraglutide at hospital discharge resulted in better glycaemic control and greater weight loss, but increased gastrointestinal adverse events.

The side effects of immune checkpoint inhibitor therapy on the endocrine system

Immune checkpoint inhibitors (ICIs) are a relatively newer class of drugs approved for the treatment of malignancies such as melanoma, renal, bladder and lung cancer. Immune-related adverse events (IrAEs) involving the endocrine system are a common side effect of these drugs. The spectrum of endocrine adverse events varies by the drug class. Cytotoxic T-lymphocyte–associated antigen-4 inhibitors commonly cause hypophysitis/hypopituitarism, whereas the incidence of thyroid disease is higher with programmed cell death (PD)-1/ ligand (PD-L) protein 1 inhibitors. The focus of this review is to describe the individual endocrinopathies with their possible mechanisms, signs and symptoms, clinical assessment and disease management. Multiple mechanisms of IrAEs have been described in literature including type II/IV hypersensitivity reactions and development of autoantibodies. Patients with pre-existing autoimmune endocrine diseases can have disease exacerbation following ICI therapy rather than de novo IrAEs. Most of the endocrinopathies are relatively mild, and timely hormone replacement therapy allows continuation of ICIs. However, involvement of the pituitary–adrenal axis could be life-threatening if not recognized. Corticosteroids are helpful when the pituitary–adrenal axis is involved. In cases of severe endocrine toxicity (grade 3/4), ICIs should be temporarily discontinued and can be restarted after adequate hormonal therapy. Endocrinologists and general internists need to be vigilant and maintain a high degree of awareness for these adverse events.

Confirmed Hypoglycemia Without Whipple Triad: A Rare Case of Hyper-Warburgism

Spontaneous hypoglycemia in nondiabetic patients poses a diagnostic challenge. Hypoglycemia in malignancy has several etiologies; an extremely rare mechanism is the Warburg effect causing excess lactate production and avid glucose consumption. We describe the clinical course of a 52-year-old man admitted for chest wall mass and severe but asymptomatic hypoglycemia. Laboratory workup was obtained for insulin vs noninsulin-mediated hypoglycemia, and biopsy of the chest wall mass and ¹⁸F-fluorodeoxyglucose positron emission tomography/computed tomography (¹⁸F-FDG-PET/CT) scan were performed. D10 infusion and intravenous/oral steroids started for severe hypoglycemia. Chemotherapy was initiated after biopsy, and blood glucose (BG) and lactate levels followed with clinical response in tumor size and changes in PET/CT. Investigations were significant for venous BG in the 40s (Ademolus Classification of Hypoglycemia grade 2 hypoglycemia), plasma insulin of less than 2 µU/mL (2-20 µU/mL), C-peptide of 0.2 ng/mL (0.8-6.0 ng/mL), insulin-like growth factor 2 (IGF-2) of 113 ng/mL (333-967 ng/mL), serum lactate of 16 mmol/L (0.5-2 mmol/L), and albumin of 2.3 g/dL (3.4-5.4 g/dL). Biopsy showed diffuse large B-cell lymphoma, and PET revealed highly FDG-avid disease in the chest, abdomen, and pelvis, but no FDG uptake was seen in the brain. Hypoglycemia and lactic acidosis improved remarkably after chemotherapy. PET/CT at 4 weeks showed complete metabolic response with reappearance of physiological FDG uptake in the brain. Noninsulin-mediated hypoglycemia was likely due to the combination of profound malnutrition and rapid glucose use by cancer cells. The patient presented with exaggerated Warburg effect (hyper-Warburgism), evident by extreme glucose consumption, severe lactic acidosis, and large tumor burden on PET/CT. Absence of cognitive symptoms was probably due to use of lactate by the brain. Chemotherapy corrected these abnormalities rapidly, and must be instituted in a timely manner.

Liraglutide treatment in overweight and obese patients with type 1 diabetes: A 26-week randomized controlled trial; mechanisms of weight loss

AIM

To investigate the effects of liraglutide treatment on glycaemic control and adipose tissue metabolism in overweight and obese people with type 1 diabetes (T1DM).

RESEARCH DESIGN AND METHODS

A total of 84 adult overweight and obese patients with T1DM, with no detectable C-peptide, were randomized (1:1) to either placebo or 1.8 mg/d liraglutide for 6 months. Blood samples were collected at 0, 12 and 26 weeks. Subcutaneous adipose tissue biopsies, a high-calorie high-fat meal challenge test, continuous glucose monitoring, dual-energy X-ray absorptiometry and MRI were performed before and at the end of treatment.

RESULTS

In all, 37 and 27 patients who received liraglutide and placebo, respectively, completed the study. Glycated haemoglobin fell by 0.41 ± 0.18% (4.5±1.4 mmol/mol) from baseline after liraglutide treatment (P = 0.001), and by 0.29 ± 0.19% (3.1±2.0 mmol/mol) compared to placebo (P = 0.1). There was no increase in hypoglycaemia, while the time spent in normal glycaemia increased (P = 0.015) and time spent in hyperglycaemia decreased (P = 0.019). Body weight fell significantly in the liraglutide group, mostly in the form of fat mass loss (including visceral fat), with no change in lean mass. Systolic blood pressure (SBP) also fell after liraglutide treatment. Liraglutide also caused a significant increase in the expression of adipose tissue triglyceride lipase, carnitine palmitoyl transferase-1, peroxisome proliferator-activated receptor (PPAR)α, PPARδ, uncoupling protein-2 and type 2 iodothyronine deiodinase in the adipose tissue.

CONCLUSIONS

Liraglutide improves glycaemia, reduces adiposity and SBP. Liraglutide also stimulates mechanisms involved with an increase in lipid oxidation and thermogenesis, while conserving lean body mass.

MON-359 Hollow Bones: A Case Report of Immobilization Osteoporosis in a Young Female

Abstract

Introduction:

Osteoporosis is defined as decreased bone strength due to reduced bone mineral density (BMD) and/or abnormal bone architecture leading to bone fragility and increased risk of pathologic fractures. Typically a disease of post-menopausal females, osteoporosis is uncommon in the young. We present a case of a 34-year-old woman, who was diagnosed with severe osteoporosis in the setting of prolonged immobilization.

Clinical Case:

A 34-year-old woman was admitted for treatment of bacteremia in the setting of IV drug use and right hip septic arthritis leading to femoral head osteonecrosis requiring a long course of antibiotic treatment and resulting in prolonged immobilization. She was readmitted 2 months later with septic shock and bilateral septic arthritis needing right hip replacement for source control. She developed multiple contractures of lower extremities due to prolonged immobility and was immobile for a total of 11 months despite significant physical therapy (PT) involvement. A few months into her hospital stay, she developed acute onset right ankle pain with no falls or trauma. Xrays showed right tibial metaphyseal fracture and severe demineralization of bones of lower extremities. History and physical exam showed no signs/symptoms of malabsorption, hyperthyroidism or Cushing’s syndrome. Laboratory evaluation showed calcium (Ca) of 11.8 mg/dL (8.5–10.4), parathyroid hormone (PTH) &lt; 3 ng/dL (12–72), C-telopeptide (Ctx) 1806 pg/ml (60–650) and normal phosphate, TSH, prolactin, 25-hydroxy and 1,25-dihydroxy vitamin D levels. PTHrP (parathyroid hormone related peptide) was &lt; 2 pmol/L. 24-hour urine Ca was 414 mg (50–150). Serum and urine protein electrophoresis showed no monoclonal spike. Gonadal profile showed estrogen 42 pg/dL, FSH 1 mU /mL, LSH 0.1 mU /mL. DEXA scan showed severe osteoporosis with T-score of -3.2 at both the left femoral neck and lumbar spine. Osteoporosis and hypercalcemia were attributed to protracted immobilization. Therapy was initiated with alendronate 70 mg weekly along with vitamin D. Teriparatide was not used due to high serum Ca. Repeat labs at 6 months showed good response to alendronate with Ca 9.6, PTH 58, 24 hr urine Ca 96 and Ctx 1092. Mobilization of patient and regular PT were performed.

Conclusion:

Osteoporosis in a young adult is a rare entity and demands evaluation for secondary causes. An important and overlooked cause of bone loss is immobility and decreased load development on bones. Bone is a piezoelectric material and immobilization causes negative bone turnover. Early physical mobility and weight bearing is the most effective method of reducing bone loss. Teriparatide, due to anabolic effects has an advantage over bisphosphonates. Romosozumab (anti-sclerostin antibody) and whole body vibration are also being studied for disuse osteoporosis. Calcium and vitamin D supplementation are essential.

SAT-131 Asymptomatic Severe Hypoglycemia with Lactic Acidosis in a Case of Non-Hodgkin’s Lymphoma - an Unusual Phenomenon of Hyper-Warburgism

INTRODUCTION

Hypoglycemia in malignancy is well known with several etiologies; impaired liver function, insulin receptor autoantibodies, production of insulin-like substance by malignant cells or large tumor burden. Another possible mechanism is the Warburg effect where metabolism shifts towards glycolytic pathways over oxidative phosphorylation even under aerobic conditions leading to excess lactate production. This leads to glucose consumption due to shunting of glucose away from normal cells to cancer cells. Very few cases of lactic acidosis and severe hypoglycemia in Non-Hodgkin’s Lymphoma have been described in the literature. We report such an unusual case here.

CASE DISCUSSION

A 52-year-old, African-American male was admitted for severe malnutrition with 80 lb. weight loss, severe hypoglycemia and progressively increasing right chest wall mass. On arrival, he had no classic symptoms of hypoglycemia. Physical exam revealed persistent tachycardia, white patches on oral mucosa and posterior tongue, and an indurated mass on right chest wall with extensive swelling of right upper limb. Lab work was significant for blood glucose (BG) of 41 mg/dL (60–100), lactate 16 mmol/L (0.5 to 2), anion gap 26 mEq/L (3–10), albumin 2.3 g/dL (3.4 to 5.4) and normal renal and liver function tests. Fingerstick sugar readings were persistently in the 20s with no response to multiple boluses of dextrose and glucagon. He was started on dextrose 5% (D5) drip and intravenous solumedrol. Solumedrol was weaned off and D5 titrated down to investigate causes of hypoglycemia. BG dropped to 39 and corresponding labs showed insulin level of < 2 mcUnit/mL (2–20), C-peptide of 0.2 ng/mL (0.8–6.0) and ketone level of 0.2 mmol/L (<0.4). IGF-1 and IGF-2 were both low at 26 ng/mL (61–200) and 113 ng/mL (333–967) respectively. A CT torso with contrast showed bilateral pleural effusions, moderate pericardial effusions and a large ill-defined heterogeneous mass along anterior chest wall. He underwent ultrasound guided biopsy of the chest wall mass and diagnosed with diffuse large B-cell lymphoma. He also tested positive for HIV/AIDS and Hepatitis C. PET scan showed diffuse FDG (fluorodeoxyglucose) uptake consistent with advanced disease. He was started on chemotherapy and lactate and BG normalized soon after 1^st cycle.

CONCLUSION

In our case; suppressed insulin, low C-peptide and IGF-2 levels indicate non-insulin mediated hypoglycemia due to rapid glucose utilization by cancer cells. Severe hypoglycemia with lack of neuroglycopenic symptoms suggests use of lactate (rather than glucose) as an alternative metabolic fuel for brain, thus preserving its function. Our patient presented with an exaggerated Warburg effect (hyper-Warburgism) as evident by extreme glucose consumption, severe lactic acidosis and large tumor burden on FDG/PET. Chemotherapy must be instituted timely to correct these abnormalities.

Dapagliflozin Suppresses Hepcidin And Increases Erythropoiesis

CONTEXT

Dapagliflozin and other SGLT2 inhibitors are known to increase hematocrit, possibly due to its diuretic effects and hemoconcentration.

OBJECTIVE

Since type 2 diabetes is a proinflammatory state and since hepcidin, a known suppressor of erythropoiesis, is increased in proinflammatory states, we investigated the possibility that dapagliflozin suppresses hepcidin concentrations and thus increases erythropoiesis.

DESIGN

Prospective, randomized, and placebo-controlled study.

SETTING

Single endocrinology center.

PATIENTS

Fifty-two obese type 2 diabetes patients.

INTERVENTION

Patients were randomized (1:1) to either dapagliflozin (10 mg daily) or placebo for 12 weeks. Blood samples were collected before and after treatments and serum, plasma, and mononuclear cells (MNC) were prepared.

MAIN OUTCOME MEASURE

Hepcidin and other hematopoietic factors.

RESULTS

Following dapagliflozin treatment, there was a significant fall in HbA1c and a significant increase in hemoglobin concentration and hematocrit. Dapagliflozin treatment significantly reduced circulating hepcidin and ferritin concentrations while causing a significant increase in levels of the hepcidin inhibitor, erythroferrone, and a transient increase in erythropoietin. Additionally, dapagliflozin increased plasma transferrin levels and expression of transferrin receptors 1 and 2 in MNC, while there was no change in the expression of the iron cellular transporter, ferroportin. Dapagliflozin treatment also caused a decrease in hypoxia-induced factor-1α expression in MNC while it increased the expression of its inhibitor, prolyl hydroxylase-2. There were no significant changes in any of these indices in the placebo group.

CONCLUSIONS

We conclude that dapagliflozin increases erythropoiesis and hematocrit through mechanisms that involve the suppression of hepcidin and the modulation of other iron regulatory proteins.

Testosterone Increases the Expression and Phosphorylation of AMP Kinase α in Men With Hypogonadism and Type 2 Diabetes

CONTEXT

Adenosine 5'-monophosphate-activated protein kinase-α (AMPKα) is a mediator of exercise-induced glucose uptake in skeletal muscle.

OBJECTIVE

We evaluated whether AMPKα expression and phosphorylation are reduced in skeletal muscle and adipose tissue of patients with hypogonadotropic hypogonadism (HH), and whether testosterone replacement therapy results in restoration of the expression and phosphorylation of AMPKα.

DESIGN

This is a secondary analysis of a previously completed trial that showed an insulin-sensitizing effect of testosterone therapy in men with type 2 diabetes and HH.

SETTING

Clinical research center at university.

PATIENTS

Thirty-two men with HH and 32 eugonadal men were compared at baseline.

INTERVENTIONS

Men with HH were treated with intramuscular injections of testosterone or placebo every 2 weeks for 22 weeks. Quadriceps muscle biopsies and subcutaneous abdominal fat biopsies were obtained before and after 4-hour euglycemic hyperinsulinemic clamp, prior to and after testosterone or placebo therapy.

OUTCOME MEASURES AND RESULTS

mRNA expression of AMPKα in hypogonadal men was lower by 37% in adipose tissue and 29% in skeletal muscle, respectively, compared with levels in eugonadal men, while phosphorylated AMPKα was lower by 22% and 28%, respectively. Following testosterone replacement, the expression of AMPKα did not alter in the fasting state but increased markedly by 41% and 46% in adipose tissue and muscle, respectively, after the clamp. In contrast, phosphorylated AMPKα increased by 69% in muscle after testosterone therapy but did not change following the clamp.

CONCLUSIONS

Testosterone modulates the expression of AMPKα and phosphorylated AMPKα. These effects may contribute to the improved insulin sensitivity following testosterone therapy.

Acute effects of insulin on skeletal muscle growth and differentiation genes in men with type 2 diabetes

AIMS

Insulin has anabolic effects on skeletal muscle. However, there is limited understanding of the molecular mechanisms underlying this effect in humans. We evaluated whether the skeletal muscle expression of satellite cell activator fibroblast growth factor 2 (FGF2) and muscle growth and differentiation factors are modulated acutely by insulin during euglycemic-hyperinsulinemic clamp (EHC).

DESIGN AND METHODS

This is a secondary investigation and analysis of samples obtained from a previously completed trial investigating the effect of testosterone replacement in males with hypogonadotropic hypogonadism and type 2 diabetes. Twenty men with type 2 diabetes underwent quadriceps muscle biopsies before and after 4 h of EHC.

RESULTS

The infusion of insulin during EHC raised the expression of myogenic growth factors, myogenin (by 72 ± 20%) and myogenin differentiation protein (MyoD; by 81 ± 22%). Insulin reduced the expression of muscle hypertrophy suppressor, myogenic regulatory factor 4 (MRF4) by 34 ± 14%. In addition, there was an increase in expression of FGF receptor 2, but not FGF2, following EHC. The expression of myostatin did not change.

CONCLUSIONS

Insulin has an acute potent effect on expression of genes that can stimulate muscle differentiation and growth.

Ultrasound Assisted On-Table Management of Type III Endoleak at Endovascular Repair of Isolated Giant Common Iliac Aneurysm

Objectives

This report presents the endovascular treatment of a large isolated common iliac artery aneurysm, focusing on the use of on table ultrasonography to characterise and treat an early endoleak that could not be defined by angiography alone.

Report

A 58 year old man presented with an asymptomatic, large (13cm) left common iliac artery aneurysm (LCIAA) whilst being investigated for change in bowel habit. This was treated successfully via a percutaneous approach using left internal iliac embolisation followed by endovascular aneurysm repair (EVAR) with deployment of an aorto-uni-iliac converter system from the LCIA origin to the external iliac artery. A non-characterised endoleak at the end of the procedure was shown to be a type IIIb endoleak by application of immediate on table ultrasonography, allowing immediate supplementary targeted stent graft deployment to cover the leaking segment.

Discussion

The patient was discharged uneventfully and will remain on follow up. On table ultrasonography allowed both localisation and characterisation of an immediate intra-procedural endoleak and confirmed cessation of the endoleak with supplementary stent grafting and thrombosis within the sac.

Conclusions

Isolated CIAA is rare, and endovascular therapy is appropriate for them, given that open surgery, whilst feasible, carries a high morbidity and mortality risk. Application of on-table ultrasound allows definition and targeted treatment of endoleaks, reducing the need for further intervention at a later stage, and thus also reducing the risk of continued pressurisation of the large sac post-EVAR till the next surveillance episode.

•

Isolated common iliac artery aneurysms (CIAAs) are very rare.

•

They can be asymptomatic but have a high risk of rupture.

•

Open repair is high risk and associated with high morbidity/mortality.

•

This paper highlights successful endovascular repair of a giant isolated CIAA.

•

On table ultrasound helps immediately to characterise and treat endoleaks at EVAR.

Increase in Osteocalcin Following Testosterone Therapy in Men With Type 2 Diabetes and Subnormal Free Testosterone

Context

One-third of men with type 2 diabetes have subnormal free testosterone concentrations. We evaluated the following: (i) whether bone mineral density (BMD) and bone strength are affected by gonadal status in type 2 diabetes and (ii) the effect of testosterone replacement on markers of osteoblast and osteoclast activity.

Design

This is a secondary analysis of a previously completed, randomized, placebo-controlled trial. Ninety-four men with type 2 diabetes were recruited; 44 had subnormal free testosterone concentrations. Men with subnormal free testosterone concentrations were randomized to receive intramuscular injections of testosterone or placebo every 2 weeks for 22 weeks. Dual energy X-ray absorptiometry scans were performed at baseline and at 23 weeks.

Results

Men with subnormal free testosterone had similar BMD compared with men with normal free testosterone. However, bone strength indices were lower in men with subnormal free testosterone. BMD was related to free estradiol concentrations (r = 0.37, P = 0.004 at hip), whereas bone strength was related to free testosterone concentrations (r = 0.41, P < 0.001). Testosterone replacement increased osteocalcin concentrations [mean change (95% CI), 3.52 (0.45, 6.59), P = 0.008]. C-Terminal telopeptide (CTx) concentrations also increased at 15 weeks but reverted to baseline following that. There were no changes in other bone turnover markers or BMD.

Conclusion

We conclude that testosterone replacement resulted in an increase in osteocalcin and a transient increase in CTx, indicating an increase in osteoblastic activity and transient increase in bone breakdown. Therefore, a major action of testosterone is to increase bone turnover in men with type 2 diabetes.

Effect of Testosterone on FGF2, MRF4, and Myostatin in Hypogonadotropic Hypogonadism: Relevance to Muscle Growth

CONTEXT

Fibroblast growth factor (FGF)2 is an important stimulatory modulator of satellite cells in skeletal muscle. Satellite cells play a cardinal role in muscle growth and repair.

OBJECTIVE

We evaluated whether skeletal muscle expression of FGF2 and muscle growth and differentiation factors are reduced in patients with hypogonadotropic hypogonadism (HH) and whether testosterone replacement therapy results in their restoration.

DESIGN

This is a secondary analysis of a previously completed trial of testosterone replacement in men with type 2 diabetes and HH.

SETTING

Clinical Research Center at a university.

PATIENTS

Twenty-two men with HH and 20 eugonadal men were compared at baseline.

INTERVENTIONS

Twelve men with HH were treated with intramuscular injections of 250 mg testosterone every 2 weeks for 22 weeks, and 10 men received placebo injections. Quadriceps muscle biopsies and blood samples were obtained before and after testosterone therapy.

OUTCOME MEASURES AND RESULTS

The expression of FGF2 and FGF receptor (FGFR)2 in skeletal muscle of men with HH was significantly lower than that in eugonadal men by 57% and 39%, respectively (P < 0.05). After 22 weeks of testosterone, the expression of FGF2 increased, whereas that of myogenic regulatory factor (MRF)4 and myostatin decreased significantly. There was no change in expression of FGFR2, myogenin, or myogenic differentiation protein in the skeletal muscle. Plasma FGF2 and IGF-1 concentrations increased after testosterone therapy.

CONCLUSIONS

These data show that testosterone is a major modulator of FGF2, MRF4, and myostatin expression in skeletal muscle. These effects may contribute to the increase in muscle mass after testosterone therapy.

OR14-2 Liraglutide Treatment in Overweight and Obese Patients with Type 1 Diabetes: A 26 weeks Randomized Controlled Trial

We have previously demonstrated that a 12-week addition of liraglutide to insulin therapy in patients with type 1 diabetes (T1D) results in an improvement in glycemic control, weight loss and a reduction in systolic blood pressure (SBP). We have now conducted a 6 month randomized study investigating effects of liraglutide in overweight and obese patients with T1DM. All patients had T1D for at least one year, were on insulin therapy and had no detectable c-peptide in plasma (mean BMI: 31.2±1.1kg/m², mean HbA1c: 7.85±0.19%, mean age: 46.1±1.7 years, mean age of T1D diagnosis: 18.5±2.2 years). Twenty seven and 37 patients (out of total of 85 randomized patients) who received placebo or 1.8mg Liraglutide, respectively, for 26 weeks completed the study. Continuous glucose monitoring (CGM) was performed for 2 weeks before and at end of treatment. At the end of 26 weeks treatment with liraglutide, HbA1c fell significantly by 0.41±0.18% (p=0.001 vs baseline) from 7.96±0.19 to 7.55±0.18%. Placebo adjusted fall in HbA1c was 0.34±0.14 (p= 0.037) at 12 weeks and 0.29±0.19% (p=0.1) at 26 weeks. Placebo adjusted weekly average blood glucose fell by 14±5mg/dl (p=0.069 vs placebo) from 182±7 to 166±6mg/dl (p=0.021 vs baseline) and fasting weekly glucose fell by 11±9mg/dl (p=0.086 vs placebo) from 175±8 to 159±11mg/dl (p=0.032 vs baseline). There was no significant change in percent time spent in hypoglycemic range while the percent time spent in normal range (70-160mg/dl) increased significantly by 7±2% (from 44±3% to 51±2%, p=0.015) and time spent in hyperglycemic range (>160mg/dl) decreased by 8±3% (from 52±4 to 44±4%, p=0.019). There was also a concurrent fall in total and bolus insulin doses. Weight fell by 4.6±0.8kg (placebo adjusted, p=0.001) in the liraglutide group mostly in the form of fat mass loss (3.2±0.6kg, p=0.01 vs placebo) with no change in lean mass as measured by DEXA. Placebo corrected SBP also fell following liraglutide treatment by 5±3mmHg (p=0.076) from 125±3 to 120±3mmHg (p=0.023 vs baseline) with no change in diastolic BP. We conclude that the addition of liraglutide to insulin treatment in obese and overweight patients with type 1 diabetes improves indices of glycemia, body weight and blood pressure without additional risk of hypoglycemia.

Targeting inflammation to reduce ASCVD in type 2 diabetes

ASCVD is the leading cause of mortality in T2DM. Inflammation appears to be pivotal in the genesis of ASCVD. As T2DM is also a pro-inflammatory state, our aim was to determine the benefit of anti-inflammatory strategies on ASCVD in T2DM. PubMed searches were conducted using the keywords of T2DM, ASCVD, Inflammation and clinical trials. Our data review suggests that the Mediterranean diet, GLP1 receptor agonists and a monoclonal antibody against IL-1 reduces ASCVD events in T2DM. The former 2 therapies appear to be safe. Anti-IL-1 therapy resulted in an increase mortality from infections. We conclude that only the Mediterranean diet and GLP1 receptor agonists can be safely incorporated into mainstay therapy for patients with T2DM to reduce ASCVD. Further studies are required with respect to biologics targeting Inflammation to establish benefit to risk ratio.

Exenatide Increases IL-1RA Concentration and Induces Nrf-2‒Keap-1‒Regulated Antioxidant Enzymes: Relevance to β-Cell Function

PURPOSE

We previously demonstrated the anti-inflammatory and antioxidant effects of exenatide. We now hypothesized that exenatide also increases the plasma concentration of interleukin-1 receptor antagonist (IL-1RA), an endogenous anti-inflammatory protein, and modulates the nuclear factor erythroid 2‒related factor‒Kelchlike ECH-associated protein 1‒antioxidant response element (Nrf-2‒Keap-1‒ARE) system to induce key antioxidant enzymes to suppress inflammatory and oxidative stress.

METHODS

Twenty-four patients with obesity and type 2 diabetes receiving combined oral and insulin therapy were randomly assigned to receive either exenatide 10 μg or placebo twice a day for 12 weeks.

RESULTS

Exenatide increased IL-1RA concentration by 61% (from 318 ± 53 to 456 ± 88 pg/mL; P < 0.05). Exenatide treatment also suppressed Keap-1 protein (P < 0.05) and increased messenger RNA expression of NQO-1, glutathione S-transferase PI, heme oxygenase-1, and p21 and increased NAD(P)H dehydrogenase [quinone] 1 protein (P < 0.05) in mononuclear cells.

CONCLUSIONS

Because IL-1RA protects, maintains, and stimulates β-cell function in humans and Nrf-2‒Keap-1‒ARE protects β cells in animals with experimental diabetes, these actions of exenatide may contribute to a potential protective effect on β cells in diabetes.

Diminished androgen and estrogen receptors and aromatase levels in hypogonadal diabetic men: reversal with testosterone

AIMS

One-third of males with type 2 diabetes (T2DM) have hypogonadism, characterized by low total and free testosterone concentrations. We hypothesized that this condition is associated with a compensatory increase in the expression of androgen receptors (AR) and that testosterone replacement reverses these changes. We also measured estrogen receptor and aromatase expression.

MATERIALS AND METHODS

This is a randomized double-blind placebo-controlled trial. Thirty-two hypogonadal and 32 eugonadal men with T2DM were recruited. Hypogonadal men were randomized to receive intramuscular testosterone or saline every 2 weeks for 22 weeks. We measured AR, ERα and aromatase expression in peripheral blood mononuclear cells (MNC), adipose tissue and skeletal muscle in hypogonadal and eugonadal males with T2DM at baseline and after 22 weeks of treatment in those with hypogonadism.

RESULTS

The mRNA expression of AR, ERα (ESR1) and aromatase in adipose tissue from hypogonadal men was significantly lower as compared to eugonadal men, and it increased significantly to levels comparable to those in eugonadal patients with T2DM following testosterone treatment. AR mRNA expression was also significantly lower in MNC from hypogonadal patients compared to eugonadal T2DM patients. Testosterone administration in hypogonadal patients also restored AR mRNA and nuclear extract protein levels from MNC to that in eugonadal patients. In the skeletal muscle, AR mRNA and protein expression are lower in men with hypogonadism. Testosterone treatment restored AR expression levels to that comparable to levels in eugonadal men.

CONCLUSIONS

We conclude that, contrary to our hypothesis, the expression of AR, ERα and aromatase is significantly diminished in hypogonadal men as compared to eugonadal men with type 2 diabetes. Following testosterone replacement, there is a reversal of these deficits.

Incretins: Beyond type 2 diabetes

While the use of incretins, including GLP-1 receptor agonists and PDD-IV inhibitors, is well established in the treatment of type 2 diabetes, many other aspects of these agents are yet to be discovered and utilized for their potential clinical benefit. These include the potential role of GLP-1 receptor agonists in the induction of weight loss, blood pressure reduction, anti-inflammatory and nephro- and cardio-protective actions. Their potential benefit in type 1 diabetes is also being investigated. This review will attempt to comprehensively describe novel discoveries in the field of incretin pathophysiology and pharmacology beyond their classical role in the treatment of type 2 diabetes.

Liraglutide acutely suppresses glucagon, lipolysis and ketogenesis in type 1 diabetes

In view of the occurrence of diabetic ketoacidosis associated with the use of sodium-glucose transport protein-2 inhibitors in patients with type 1 diabetes (T1DM) and the relative absence of this complication in patients treated with liraglutide in spite of reductions in insulin doses, we investigated the effect of liraglutide on ketogenesis. Twenty-six patients with inadequately controlled T1DM were randomly divided into 2 groups of 13 patients each. After an overnight fast, patients were injected, subcutaneously, with either liraglutide 1.8 mg or with placebo. They were maintained on their basal insulin infusion and were followed up in our clinical research unit for 5 hours. The patients injected with placebo maintained their glucose and glucagon concentrations without an increase, but there was a significant increase in free fatty acids (FFA), acetoacetate and β-hydoxybutyrate concentrations. In contrast, liraglutide significantly reduced the increase in FFA, and totally prevented the increase in acetoacetate and β-hydroxybutyrate concentrations while suppressing glucagon and ghrelin concentrations. Thus, a single dose of liraglutide is acutely inhibitory to ketogenesis.

Sodium-glucose co-transporter 2 inhibitors for type 2 diabetes mellitus: An overview for the primary care physician

AIMS

Sodium-glucose co-transporter type 2 (SGLT2) inhibitors are a new class of anti-hyperglycaemic agents in type 2 diabetes mellitus (T2DM). This review examines their mechanism of action and provides an overview of safety and efficacy from the main studies of SGLT2 inhibitors marketed in the United States and Europe, namely, canagliflozin, dapagliflozin and empagliflozin.

METHODS

We searched the PubMed database to identify relevant publications on the mechanism of action of SGLT2 inhibitors and clinical trial reports.

RESULTS

Clinical trials in patients with T2DM have shown significant improvements in glycaemic control vs placebo with canagliflozin, dapagliflozin and empagliflozin: patients were more likely to reach target glycated haemoglobin levels compared with patients receiving placebo. All SGLT2 inhibitors also led to modest reductions in body weight and blood pressure vs placebo. Generally, all agents were well tolerated, with the most common adverse events with this class being genital mycotic infections and urinary tract infections. Hypoglycaemia was reported at rates similar to those seen with placebo, except when SGLT2 inhibitors were given in combination with insulin or an insulin secretagogue. Long-term outcome data are available only for empagliflozin: in the EMPA-REG OUTCOME study, empagliflozin demonstrated reduced risk of the composite end-point of 3-point major adverse cardiovascular events (cardiovascular death, non-fatal myocardial infarction or non-fatal stroke), primarily because of a significant reduction in cardiovascular mortality.

CONCLUSIONS

SGLT2 inhibitors are an exciting addition to the list of available agents for T2DM, and may be suitable for various types of patients who need additional glycaemic control.

Exenatide induces an increase in vasodilatory and a decrease in vasoconstrictive mediators

In view of the known vasodilatory effects of glucagon-like peptide-1 and exenatide, we investigated the effects of exenatide on vasoactive factors. We analysed blood samples and mononuclear cells (MNCs) from a previous study, collected after a single dose and 12 weeks of exenatide or placebo treatment in a series of 24 patients with type 2 diabetes mellitus. After exenatide treatment, plasma concentrations of atrial natriuretic peptide, cyclic guanyl monophosphate (cGMP) and cyclic adenyl monophosphate increased significantly at 12 weeks. Plasma cGMP and adenylate cyclase expression in MNCs increased significantly after a single dose. Angiotensinogen concentration fell significantly 2 hours after a single dose and at 12 weeks, while renin and angiotensin II levels fell significantly only after a single dose and not after 12 weeks of treatment. Exenatide also suppressed the plasma concentration of transforming growth factor-β and the expression of P311 in MNCs at 12 weeks. Thus, exenatide induces an increase in a series of vasodilators, while suppressing the renin-angiotensin system. These changes may contribute to the overall vasodilatory effect of exenatide.

Antiinflammatory and ROS Suppressive Effects of the Addition of Fiber to a High-Fat High-Calorie Meal

BACKGROUND

Fiber intake is associated with a reduction in the occurrence of cardiovascular events and diabetes.

OBJECTIVE

To investigate whether the addition of fiber to a high-fat, high-calorie (HFHC) meal prevents proinflammatory changes induced by the HFHC meal.

DESIGN

Ten normal fasting subjects consumed an HFHC meal with or without an additional 30 g of insoluble dietary fiber on 2 separate visits. Blood samples were collected over 5 hours, and mononuclear cells (MNCs) were isolated.

RESULTS

Fiber addition to the HFHC meal significantly lowered glucose excursion in the first 90 minutes and increased insulin and C-peptide secretion throughout the 5-hour follow-up period compared with the meal alone. The HFHC meal induced increases in lipopolysaccharide (LPS) concentrations, MNC reactive oxygen species generation, and the expression of interleukin (IL)-1β, tumor necrosis factor α (TNF-α), Toll-like receptor (TLR)-4, and CD14. The addition of fiber prevented an increase in LPS and significantly reduced the increases in ROS generation and the expression of IL-1β, TNF-α, TLR-4, and CD14. In addition, the meal increased Suppressor of cytokine signaling (SOCS)-3 and protein tyrosine phosphatase 1B (PTP-1B) messenger RNA and protein levels, which were inhibited when fiber was added.

CONCLUSIONS

The addition of fiber to a proinflammatory HFHC meal had beneficial anti-inflammatory and metabolic effects. Thus, the fiber content of the American Heart Association meal may contribute to its noninflammatory nature. If these actions of dietary fiber are sustained following long-term intake, they may contribute to fiber's known benefits in the prevention of insulin resistance, type 2 diabetes, and atherosclerosis.

Ilioprofunda Endobypass Can Successfully Treat a Post-Operative Femoral Pseudo-Aneurysm

INTRODUCTION

A 75-year-old male patient with significant cardiopulmonary comorbidity presented with a 70-mm left femoral pseudoaneurysm 6 years after aortobifemoral bypass (and prior femoral endarterectomy).

REPORT

As the left superficial femoral artery was occluded, an ilioprofunda endobypass was undertaken following extraperitoneal exposure of the left limb of the bypass graft with subsequent deployment of four Viabahn endoprostheses via the left limb into the proximal left deep femoral artery with successful exclusion of the pseudoaneurysm. The endografts remain patent at 6 months with regression noted in the pseudoaneurysm itself.

DISCUSSION

Post-operative femoral pseudoaneurysm following anastomotic dehiscence has traditionally been treated by open surgical repair. Re-re-do open femoral vascular surgery has a high complication rate. Scarring and potential graft infection may necessitate ligation of involved arteries and extra-anatomic bypasses with an attendant risk of limb loss. Although the common femoral artery is conventionally contraindicated for endograft deployment because of the perceived high risk of stent fracture in a highly mobile zone, an endobypass can avoid the potential complications of open revision groin surgery in an unfit, high-risk patient.

Effect of testosterone on hepcidin, ferroportin, ferritin and iron binding capacity in patients with hypogonadotropic hypogonadism and type 2 diabetes

CONTEXT

As the syndrome of hypogonadotropic hypogonadism (HH) is associated with anaemia and the administration of testosterone restores haematocrit to normal, we investigated the potential underlying mechanisms.

DESIGN

Randomized, double-blind, placebo-controlled trial.

METHODS

We measured basal serum concentrations of erythropoietin, iron, iron binding capacity, transferrin (saturated and unsaturated), ferritin and hepcidin and the expression of ferroportin and transferrin receptor (TR) in peripheral blood mononuclear cells (MNC) of 94 men with type 2 diabetes. Forty-four men had HH (defined as subnormal free testosterone along with low or normal LH concentrations) while 50 were eugonadal. Men with HH were randomized to testosterone or placebo treatment every 2 weeks for 15 weeks. Blood samples were collected at baseline, 3 and 15 weeks after starting treatment. Twenty men in testosterone group and 14 men in placebo group completed the study.

RESULTS

Haematocrit levels were lower in men with HH (41·1 ± 3·9% vs 43·8 ± 3·4%, P = 0·001). There were no differences in plasma concentrations of hepcidin, ferritin, erythropoietin, transferrin or iron, or in the expression of ferroportin or TR in MNC among HH and eugonadal men. Haematocrit increased to 45·3 ± 4·5%, hepcidin decreased by 28 ± 7% and erythropoietin increased by 21 ± 7% after testosterone therapy (P < 0·05). There was no significant change in ferritin concentrations, but transferrin concentration increased while transferrin saturation and iron concentrations decreased (P < 0·05). Ferroportin and TR mRNA expression in MNC increased by 70 ± 13% and 43 ± 10%, respectively (P < 0·01), after testosterone therapy.

CONCLUSIONS

The increase in haematocrit following testosterone therapy is associated with an increase in erythropoietin, the suppression of hepcidin, and an increase in the expression of ferroportin and TR.

Dapagliflozin as Additional Treatment to Liraglutide and Insulin in Patients With Type 1 Diabetes

CONTEXT

It is imperative that novel approaches to treatment of type 1 diabetes (T1D) are devised.

OBJECTIVE

The objective of the study was to investigate whether addition of dapagliflozin to insulin and liraglutide results in a significant reduction in glycemia and body weight.

DESIGN

This was a randomized clinical trial.

SETTING

The study was conducted at a single academic medical center.

PARTICIPANTS

Participants included T1D patients on liraglutide therapy for at least last 6 months.

INTERVENTION

Thirty T1D patients were randomized (in 2:1 ratio) to receive either dapagliflozin 10 mg or placebo daily for 12 weeks.

MAIN OUTCOME MEASURE

Change in mean glycated hemoglobin after 12 weeks of dapagliflozin when compared with placebo was measured.

RESULTS

In the dapagliflozin group, glycated hemoglobin fell by 0.66% ± 0.08% from 7.8% ± 0.21% (P < .01 vs placebo), whereas it did not change significantly in the placebo group from 7.40% ± 0.20% to 7.30% ± 0.20%. The body weight fell by1.9 ± 0.54kg (P < .05 vs placebo). There was no additional hypoglycemia (blood glucose < 3.88 mmol/L; P = .52 vs placebo). In the dapagliflozin group, there were significant increases in the plasma concentrations of glucagon by 35% ± 13% (P < .05), hormone-sensitive lipase by 29% ± 11% (P < .05), free fatty acids by 74% ± 32% (P < .05), acetoacetate by 67% ± 34% (P < .05), and β-hydroxybutyrate by 254% ± 81% (P < .05). Urinary ketone levels also increased significantly (P < .05). None of these changes was observed in the placebo group. Two patients in the dapagliflozin group developed diabetic ketoacidosis.

CONCLUSIONS

Addition of dapagliflozin to insulin and liraglutide in patients with T1D results in a significant improvement in glycemia and weight loss while increasing ketosis. If it is decided to use this approach, then it must be used only by a knowledgeable patient along with an endocrinologist who is well versed with it.