The impact of curative treatment on hyperglycemia in patients with Cushing syndrome

Context Hyperglycemia is a common complication of Cushing syndrome (CS). Objective We aimed to determine the impact of curative procedure on hyperglycemia and its management in patients with CS. Design Retrospective longitudinal cohort study, 2000-2019. Setting Referral center. Patients Adults with endogenous CS and hyperglycemia. Main outcome measure Hemoglobin A1c (HbA1c), intensity of hyperglycemia therapy, improvement of hyperglycemia. Results In 174 patients with CS (pituitary in 106, ectopic in 25, adrenal in 43), baseline median HbA1c was 6.9% (range 4.9-13.1), with 41 (24%) patients not on any therapy for hyperglycemia, 93 (52%) on oral medications, and 64 (37%) on insulin (median daily units of 58, range 10-360). Following CS remission, at the end of follow up (median 10.5 months), 37 (21%) patients demonstrated resolution of hyperglycemia, 82 (47%) demonstrated improvement, and 55 (32%) had no change or worsening in hyperglycemia. At the end of follow up, HbA1c decreased by 0.84% (p < 0.0001) and daily insulin dose decreased by a mean of 30 units, p < 0.0001. Biochemical hypercortisolism severity score (severe vs moderate/mild: Odds ratio (OR) of 2.4 (95%CI of 1.1-4.9)), and CS subtype (nonadrenal vs adrenal: OR of 2.9 (95%CI 1.3-6.4)), but not type of hyperglycemia (diabetes vs prediabetes: OR of 2.1 (0.9-4.9)) were associated with hyperglycemia improvement at the end of follow up. Conclusion Two thirds of patients with CS and hyperglycemia demonstrate resolution or improvement of hyperglycemia after a curative procedure. Close monitoring during CS recovery is needed to assure appropriate therapy modification.

Interprofessional Continuous Glucose Monitoring for Underserved Adults with Type 2 Diabetes on Insulin or Secretagogues

Background: Literature describing continuous glucose monitoring for underserved patients, including those with type 2 diabetes or at risk for hypoglycemia, is lacking. Methods: An interprofessional internal medicine residency team implemented a blinded CGM service for underserved adults with type 2 diabetes with at-goal glycated hemoglobin (A1C) taking insulin or secretagogues. Results: The 2-week blinded CGM service (N=44) significantly reduced time in hypoglycemia (<70 mg/dL) by 4.1% (P=0.0038). Time-in-target-range increased significantly (4.31%, P=0.025). Body weight, number of medications, and daily insulin dose decreased significantly. Overall, A1C remained stable, indicating no worsening of diabetes control associated with the service. Conclusions: The interprofessional blinded CGM service influenced improved glycemic control in this vulnerable population.

Is diabetic ketoacidosis a good predictor of 5-year metabolic control in children with newly diagnosed type 1 diabetes?

Background The study aimed to evaluate whether the presence of DKA at diabetes diagnosis was associated with poorer metabolic control during a 5-year follow-up. Methods The study included children treated due to newly diagnosed T1D complicated with DKA between 2010 and 2014 with a complete 5-year follow-up. In every case we performed individual matching for age, gender and BMI with a person without DKA (nDKA) on recognition. We collected data regarding treatment modality, HbA1C, total daily insulin dose, basal insulin and BMI-SDS. Results 85 children at the median age of 7.93 years had DKA at diabetes diagnosis. The median pH was 7.19.Continuous subcutaneous insulin infusion (CSII) was used in 87% of participants in each group. No differences in HbA1C level (7,3%vs7,2%;p = .413) were noted after 5 years of disease duration. The severity of ketoacidosis exerted no significant effect on HbA1C. The method of insulin delivery at baseline was significantly associated with HbA1C levels after 5 years of observation, βCSII = − 1.46,95%CI[− 2.01 to − 0.92],p < .001. Conclusions The presence of DKA at diabetes diagnosis is not associated with deteriorated long-term metabolic control in children using modern technologies. The early implementation of CSII into diabetes treatment may change the effect of DKA and lead to a long-term HbA1C improvement.

Metabolic Syndrome in Type 1 Diabetics: Prevalence and Clinicobiological Features

Background: Because of the world obesity epidemic, some type 1 diabetics exhibit clinical-biological features of metabolic syndrome. Few studies have investigated the association between this syndrome and this type of diabetes. Aim: To estimate the prevalence of metabolic syndrome in type 1 diabetics and to study the relationship between this syndrome and the clinical-biological profile of these patients. Methods: We carried out a cross-sectional study, involving type 1 diabetics, monitored at the National Institute of Nutrition in Tunis. All of these patients underwent a clinical examination and laboratory workup. Results: We included 150 patients. The mean age of the patients was 31.25 ± 10.3 years. Women represented 54% of the patients. Abdominal obesity was found in 61.7% of women and 14.5% of men. The metabolic syndrome was found in 30.7% of patients, with a female predominance (48.1% vs. 10.1% in men, p <0.001). Comparing the two groups with and without metabolic syndrome, the latter was significantly correlated with sedentary lifestyle, daily insulin dose, hypertriglyceridemia, hypoHDL-cholesterolemia and arterial hypertension, but not correlated with the age of the patients, the duration of diabetes or the glycemic control. Conclusion: This work reveals a high prevalence of metabolic syndrome in type 1 diabetics in whom it seems relevant to look for the components of this syndrome, each considered to be a cardiovascular risk factor in its own right.

The association between overweight/obesity and double diabetes in adults with type 1 diabetes; a cross-sectional study

Background Double Diabetes (DD), type 1 diabetes (T1DM) + insulin resistance (IR), is associated with increased risk of micro/macro-vascular complications and mortality. Obesity can contribute to the development of DD. This study explored the prevalence of overweight/obesity and their association with DD in adults with T1DM. Methods Cross-sectional study of consecutive adults with T1DM attending diabetes clinics in a secondary care hospital (January-November 2019). Estimated glucose disposal rate (eGDR) was used as a marker of IR, and an eGDR < 8 was used to identify individuals with DD. Results One hundred seven adults with T1DM were included; female/male: 51/56; age [median (inter-quartile range): 30.0 (23–51) years]; BMI 25.4 (22.8–30.0) kg/m2. Overweight/obesity prevalence was 57/107 (53.3 %) [overweight: 30/107 (28 %); obesity: 27/107 (25.2 %)]. Compared to those with normal BMI, individuals with T1DM and overweight/obesity had longer diabetes duration; higher total daily insulin dose; and higher DD prevalence: 48/57 (84.2 %) vs. 14/50 (28 %) (p < 0.01); with similar HbA1c. BMI correlated with total daily insulin dose (rho = 0.55; p < 0.01). Individuals with DD were older, had longer duration of diabetes, higher HbA1c, and more adverse lipid profile and microalbuminuria compared to those without DD. Conclusions Overweight/obesity is very common in adults with T1DM, and is associated with double diabetes. BMI is positively associated with total insulin dose. Double diabetes is associated with adverse cardiovascular risk profile and is also common in lean individuals with T1DM. Further research is needed to examine the impact of overweight/obesity in people with T1DM and whether weight loss in this population can improve diabetes-related outcomes.

Pregnancy in Diabetics: Clinicobiological Features and Evolution

Background: The association between diabetes and pregnancy is a real public health problem due to the inherent maternal and fetal complications.Aims: To study the clinical and biological features of diabetic pregnancies.Methods: We conducted a retrospective descriptive study including pregnant diabetic women followed at the National Institute of Nutrition of Tunis.Results: We included 100 patients with a mean age of 32.87±5.3 years. In preconception, 63.6% of patients were overweight and had poorly balanced diabetes (HbA1c> 7%). The mean weight gain throughout the pregnancy was 8.62 ± 5.39 kg. Pregnancy was planned in 18% of cases.Significant improvement in HbA1c was observed in the second trimester. The average daily insulin dose increased from 0.68 u/kg/day in the first trimester to 0.87 u/kg/day in the third trimester (p <0.001). Full term delivery occurred in 72% of cases.The majority (93.3%) of our patients gave birth by caesarean section. Macrosomia was observed in 24% of cases. The main neonatal complications were neonatal respiratory distress and hypoglycemia in 26.7% and 20.5% of cases, respectively. Five newborns had deformities.Conclusion: Diabetic pregnancy is associated with an increased risk of maternal and fetal complications. An action on modifiable factors, before conception, could significantly improve its prognosis.

Bariatric Surgery Outcomes in Patients with Latent Autoimmune Diabetes of the Adult

Bariatric surgery is a very effective treatment for obesity-associated type 2 diabetes. However, the benefits of bariatric surgery in patients with obesity and autoimmune diabetes, such as type 1 diabetes and latent autoimmune diabetes in adults (LADA), are controversial. We report 3 female patients with obesity and LADA who underwent laparoscopic Roux-en-Y gastric bypass &#x3e;10 years ago. The patients were diagnosed with LADA both 1 and 9 years before (<i>n</i> = 2) or 11 years after the surgery (<i>n</i> = 1). Patients preoperative body mass index ranged from 36 to 47 kg/m² and improved to 23–37 kg/m² in the last follow-up visit, 10–15 years after surgery. Daily insulin dose also decreased from an average of 0.68 to 0.45 IU/kg in those patients treated with insulin before bariatric surgery. Only one patient developed diabetes-related target organ damage. This study shows that patients with LADA depict remarkable reduction of body weight and insulin requirements over long-term after bariatric surgery. So, LADA should not be considered a contraindication for bariatric surgery yet should only be recommended for patients with concomitant obesity with the primary aim of achieving sustained weight loss.

Is Diabetic Ketoacidosis A Good Predictor Of 5-Year Metabolic Control in Children with Newly Diagnosed Type 1 Diabetes?

Purpose: The study aimed to evaluate whether the presence of DKA at diabetes diagnosis was associated with poorer metabolic control during a 5-year follow-up.Methods: The study included children treated due to newly diagnosed T1D complicated with DKA between 2010-2014 with a complete 5-year follow-up. In every case we performed individual matching for age, gender and BMI with a person without DKA (nDKA) on recognition. We collected data regarding treatment modality, HbA1C, total daily insulin dose, basal insulin and BMI-SDS.Results: 85 children at the median age of 7.93 years had DKA at diabetes diagnosis. The median pH was 7.19.Continuous subcutaneous insulin infusion (CSII) was used in 87% of participants in each group. No differences in HbA1C level (7,3%vs7,2%;p=.413) were noted after 5 years of disease duration. The severity of ketoacidosis exerted no significant effect on HbA1C. The method of insulin delivery at baseline was significantly associated with HbA1C levels after 5 years of observation, βCSII=-1.46,95%CI[-2.01 to -0.92],p<.001.Conclusions: The presence of DKA at diabetes diagnosis is not associated with deteriorated long-term metabolic control in children using modern technologies. The early implementation of CSII into diabetes treatment may change the effect of DKA and lead to a long-term HbA1C improvement.

Severe hyperglycemia and insulin resistance in patients with SARS-CoV-2 infection: a report of two cases

Background Severe insulin resistance is an uncommon finding in patients with type 2 diabetes but is often associated with difficult to managing blood glucose. While severe insulin resistance is most frequently seen in the setting of medication side effects or rare genetic conditions, this report of two cases highlights the presence of severe insulin resistance in the setting of severe COVID-19 and explores how this may contribute to the poor prognosis of patients with diabetes who become infected with SARS-CoV-2. Case presentation Here we present the cases of two African-American women with pre-existing type 2 diabetes who developed severe COVID-19 requiring mechanical ventilation and concurrent severe insulin resistance with total daily insulin dose requirements of greater than 5 unit/kg. Both patients received aggressive insulin infusion and subcutaneous insulin therapy to obtain adequate glucose management. As their COVID-19 clinical course improved, their severe insulin resistance improved as well. Conclusions The association between critical illness and hyperglycemia is well documented in the literature, however severe insulin resistance is not commonly identified and may represent a unique clinical feature of the interaction between SARS-CoV-2 infection and type 2 diabetes.

Evaluation of GLP-1 Receptor Agonists in Combination With Multiple Daily Insulin Injections for Type 2 Diabetes

Objective: To assess the available literature evaluating the efficacy and safety of glucagon-like peptide-1 receptor agonists (GLP-1 RAs) with multiple daily insulin injections (MDII). Data Sources: A literature search of MEDLINE and Embase was performed (2004 to May 2020) using the following search terms: glucagon-like 1 receptor agonist, liraglutide, albiglutide, dulaglutide, exenatide, semaglutide, diabetes mellitus, and prandial insulin or bolus insulin. Additional references were obtained from cross-referencing the bibliographies of selected articles. Study Selection and Data Extraction: All information obtained from the searches were reviewed. All relevant trials are included in this review. Data Synthesis: Eight studies met criteria for inclusion. The addition of a GLP-1 RA to multiple daily insulin injections was associated with a reduction in A1c in 7 out of 8 studies, and weight loss in 5 studies. In studies that allowed insulin adjustment after the addition of GLP-1 RA, the average total daily insulin dose was reduced in 3 studies. When evaluated, hypoglycemia frequency or other adverse events were not increased when GLP-1 RAs were added to MDII. Relevance to Patient Care and Clinical Practice: Guidelines do not offer recommendations regarding the use of GLP-1 RAs in combination with MDII regimens. This review evaluates current studies demonstrating efficacy and safety considerations of this combination. Conclusions: While some studies did demonstrate an improvement in A1c and reduction in insulin doses without increased hypoglycemia, larger randomized controlled trials are needed to adequately assess the benefit and safety of GLP-1 RAs in combination with MDII.