„Chronicky nekompenzovatelných pacientů“ s diabetes mellitus (DM) 1. typu, kteří se po mnoho let pohybují v pásmu neuspokojivé kompenzace z důvodu „vysoké lability diabetu“, maximální snahy zabránění hypoglykemii pro předchozí těžké hypoglykemii, nepřijetí nemoci, iracionální obavy z podání bolusu kvůli případné hypoglykemii, pozdě aplikovaných bolusů a přemrštěných korekčních dávek, přejedených hypoglykemií apod., je v našich ambulancích jistě celá řada. Mnohdy máme tyto pacienty již zařazené v sekci „nic nefunguje, opakované edukace neúspěšné, rekondice s efektem pouze krátkodobým“. Tato práce popisuje kazuistiky 10 pacientů, u kterých se po dlouhých letech neoptimální, či spíše tragické kompenzace diabetu podařilo díky převedení léčby na hybridní uzavřenou smyčku dosáhnout až zázračného, leč dlouhodobého zlepšení. Jedenáctá kazuistika ukazuje skutečnost, že zlepšení není jisté u všech pacientů, zvláště pokud je překážkou psychické nastavení osobnosti.
In our outpatient clinics, there are many “chronically uncompensable patients” with type 1 diabetes mellitus who have been in the zone of unsatisfactory compensation for many years due to “high diabetes lability”, maximal efforts to avoid hypoglycaemia due to previous severe hypoglycaemia, non-acceptance of the disease, irrational fear of bolus administration due to possible hypoglycaemia, late bolus administrations and exaggerated correction doses, overeaten hypoglycaemia, etc. Often, we have these patients already classified in the “nothing works, repeated education unsuccessful, reconditioning with only short-term effect” section. This article presents the case reports of 10 patients in whom, after many years of suboptimal (or rather tragic) diabetes control, a miraculous, but long-term improvement was achieved by switching to a hybrid closed-loop treatment.
BACKGROUND: Successful conversion from insulin therapy to glucagon-like peptide 1 receptor agonist (GLP-1RA) with basal insulin in well-controlled patients has already been demonstrated. However, the data concerning individuals with poor glycaemic control are scarce. The aim of this work was to assess the success rate of insulin therapy to liraglutide transition in poorly controlled diabetes in a real-world clinical setting and to define predictors of success. We are the first to present the method of a fasting test as a way to identify the patients at higher risk of failure after treatment de-intensification. METHODS: The retrospective observational study analyzed data of 62 poorly controlled obese diabetic patients on high-dose insulin therapy, who were subjected to a 72 h fasting test during hospitalization and subsequently switched to liraglutide ± basal insulin therapy. During the fasting, all antidiabetic treatment was discontinued. Patients were classified as responders if they remained on GLP-1RA treatment after 12 months. Non-responders restarted the basal-bolus insulin (BBI) regimen. Development of glycated hemoglobin (HbA1c) and body weight in both groups, alongside with parameters associated with the higher risk of return to the BBI regimen, were analyzed. RESULTS: A total of 71% of patients were switched successfully (=responders). Responders had more significant improvement in HbA1c (-6.4 ± 19.7 vs. -3.4 ± 22.9 mmol/mol) and weight loss (-4.6 ± 7.1 vs. -2.5 ± 4.0). Statistically significant difference between groups was found in initial HbA1c (75.6 ± 17.9 vs. 90.5 ± 23.6; p = 0.04), total daily dose of insulin (67.6 ± 36.4 vs. 90.8 ± 32.4; p = 0.02), and mean glycaemia during the fasting test (6.9 ± 1.7 vs. 8.6 ± 2.2 mmol/L; p < 0.01). CONCLUSIONS: This study confirms that therapy de-intensification in poorly controlled patients with a BBI regimen is possible. Higher baseline HbA1c, total daily insulin dose, and mean glucose during fasting test are negative predictive factors of successful therapy de-escalation.
- Publication type
- Journal Article MeSH
Fyzická aktivita by měla být běžnou součástí dne každého člověka, pacientů s diabetem nevyjímaje. Realita je bohužel odlišná, doporučení České diabetologické společnosti, tedy provádění fyzické aktivity alespoň 150 minut týdně, splňuje jen velmi málo našich pacientů. Někteří pacienti udávají jako důvod, proč pravidelně nesportují, obtížný management svého diabetu, se zvýšením množství hypoglykemií i hyperglykemií. Přínosem pro tyto pacienty může být kromě pečlivé edukace i inzulínová pumpa Medtronic MiniMed 780G s algoritmem SmartGuard. Uvedené kazuistiky ukazují efektivitu této pumpy u dvou pacientek s diabetes mellitus 1. typu (DM) při běhu půlmaratonu.
Physical activity should be a regular part of every person’s day, including patients with diabetes. Unfortunately, the reality is different. Very few of our patients meet the recommendations of the Czech Diabetes Society, i.e. physical activity of at least 150 minutes per week. Some patients state that the reason why they do not exercise regularly is the difficult management of their diabetes, with an increase in the number of hypoglycaemias and hyperglycaemias. In addition to careful education, the Medtronic MiniMed 780G insulin pump with the SmartGuard algorithm can be of benefit to these patients. The following case reports show the effectiveness of this pump in two patients with type 1 diabetes mellitus while running a half-marathon.
- Keywords
- MiniMed 780G,
- MeSH
- Diabetes Mellitus, Type 1 * drug therapy MeSH
- Adult MeSH
- Insulin Infusion Systems * MeSH
- Continuous Glucose Monitoring MeSH
- Middle Aged MeSH
- Humans MeSH
- Marathon Running MeSH
- Motor Activity MeSH
- Check Tag
- Adult MeSH
- Middle Aged MeSH
- Humans MeSH
- Female MeSH
- Publication type
- Case Reports MeSH
Cílem článku je ukázat, že je možné za pomoci třídenního testu hladověním zjednodušit a zefektivnit léčbu i u diabetiků obecně považovaných za „beznadějné“. Dvě kazuistiky ukazují pacienty s dlouholetým trváním diabetes mellitus 2. typu, s chronickou dekompenzací i přes léčbu intenzifikovaným inzulínovým režimem (IIR) ve vysokých dávkách. Pomocí testu hladověním jsme ověřili dostatečnou reziduální sekreci inzulínu a převodem na fixní kombinaci GLP-1 analoga s bazálním inzulínem zlepšili jejich kompenzaci, ale i další parametry a zejména pak kvalitu života.
The aim of the article is to show that with the help of a three-day fasting test, it is possible to simplify the treatment and make it more efficient even in diabetics generally considered to be “hopeless”. Two case reports show patients with long-standing type 2 diabetes mellitus and with chronic decompensation despite the treatment with high-dose intensive insulin regimen (IIR). Using the fasting test, we verified sufficient residual insulin secretion, and by switching to a fixed combination of GLP-1 analogue and basal insulin, we improved not only their compensation but also other parameters and especially the quality of life.
- MeSH
- Diabetes Mellitus, Type 2 * therapy MeSH
- Glucagon-Like Peptide 1 analogs & derivatives therapeutic use MeSH
- Insulin analogs & derivatives therapeutic use MeSH
- Drug Therapy, Combination methods MeSH
- Middle Aged MeSH
- Humans MeSH
- Fasting metabolism MeSH
- Aged MeSH
- Check Tag
- Middle Aged MeSH
- Humans MeSH
- Male MeSH
- Aged MeSH
- Female MeSH
- Publication type
- Case Reports MeSH
- Keywords
- inzulínová pumpa,
- MeSH
- Biomedical Technology classification instrumentation MeSH
- Diabetes Mellitus, Type 2 * drug therapy blood prevention & control MeSH
- Insulin Resistance MeSH
- Insulin Infusion Systems * classification MeSH
- Humans MeSH
- Patient Selection MeSH
- Check Tag
- Humans MeSH
- Publication type
- Research Support, Non-U.S. Gov't MeSH
- Review MeSH
- Geographicals
- Czech Republic MeSH
- Publication type
- Meeting Abstract MeSH
- Publication type
- Meeting Abstract MeSH
Glifloziny jsou a budou v naší společnosti čím dál hojněji využívaným léčivem. Opakovaně byly doloženy jejich výhody jak v léčbě diabetu, tak ve snížení kardiovaskulární a renální morbidity a mortality. V klinické praxi však musíme myslet i na možné nežádoucí účinky, zejména pak na riziko vývoje diabetické ketoacidózy. Kazuistika popisuje případ rozvoje této komplikace u pacientky s diabetes mellitus 2. typu, ke které došlo i přes včasné vysazení gliflozinu dva dny před zahájením lačnění. Důležitým mechanismem se přitom ukázala být protrahovaná glykosurie po vysazení gliflozinu, kterou jsme pozorovali v celkové době osmi dní, a to i přes normoglykemii u pacientky. Tento efekt může v rizikových situacích vést přes sníženou sekreci inzulínu a stimulaci ketogeneze k rozvoji euglykemické ketoacidózy. V popisu případu chceme upozornit na nutnost včasného vysazení léčiva před rizikovými situacemi a na fakt, že se s rozvojem euglykemické diabetické ketoacidózy můžeme setkat i s odstupem několika dnů po vysazení gliflozinu. V tomto smyslu je třeba edukovat i pacienta a zdravotnický personál a poučit je o nutnosti kontroly ketolátek v krvi v situaci rozvoje klinických obtíží, a to i přes normoglykemii a přes fakt, že riziková medikace je již několik dnů vysazena.
Gliflozins are and will be an increasingly widely used medicine in our society. Their benefits in the treatment of diabetes and in the reduction of cardiovascular and renal morbidity and mortality have been repeatedly demonstrated. However, in clinical practice, we must also think about possible side effects, especially the risk of developing diabetic ketoacidosis. The case report describes a case of development of this complication in a patient with type 2 diabetes mellitus, which occurred despite early discontinuation of gliflozin two days before the start of fasting. Prolonged glycosuria after discontinuation of gliflozin, which we observed over a total of eight days, proved to be an important mechanism, despite the patient’s normoglycaemia. This effect may lead to the development of euglycaemic ketoacidosis through reduced insulin secretion and stimulation of ketogenesis in high-risk situations. In this case, we want to draw attention to the need for early discontinuation of the drug before risky situations and the fact that the development of euglycaemic diabetic ketoacidosis can be encountered several days after discontinuation of gliflozin. In this sense, it is necessary to educate the patient and medical staff and instruct them on the need to control ketone bodies in the blood in a situation of developing clinical difficulties, despite normoglycaemia and the fact that risk medication has been discontinued for several days.
- MeSH
- Blood Chemical Analysis methods MeSH
- Diabetes Mellitus, Type 2 drug therapy complications MeSH
- Diabetic Ketoacidosis diagnosis etiology prevention & control MeSH
- Sodium-Glucose Transporter 2 Inhibitors * administration & dosage adverse effects MeSH
- Glycosuria diagnosis MeSH
- Ketone Bodies urine MeSH
- Humans MeSH
- Drug-Related Side Effects and Adverse Reactions MeSH
- Treatment Outcome MeSH
- Check Tag
- Humans MeSH
- Female MeSH
- Publication type
- Case Reports MeSH
AIM: To assess the safety and efficacy of the short-acting glucagon-like peptide-1 receptor agonist exenatide on a population of patients with type 2 diabetes (T2D) mostly treated with continuous subcutaneous insulin injection (CSII). MATERIALS AND METHODS: A phase 2/3, multicentre, randomized, parallel-group, double-blind, placebo-controlled, 6-month trial was conducted. Patients were randomized to receive subcutaneous (SC) injections of exenatide (10 μg BID) or matched placebo. RESULTS: A total of 46 patients with T2D and elevated HbA1c were randomized (42% of the planned sample size): exenatide (n = 28) and placebo (n = 18). CSII treatment was used by 75% and 89% of patients of the exenatide and placebo groups, respectively. At 6 months, the change in HbA1c was -0.62% ± 0.94% and 0.08% ± 0.81% in the exenatide and placebo groups, respectively (difference, -0.70%; 95% CI [-1.24%; -0.15%], P = .014); body weight and body mass index decreased in the exenatide group (-2.55 ± 3.25 kg and -1.00 ± 1.31 kg/m2 ) and increased in the placebo group (1.29 ± 2.82 kg and 0.46 ± 1.16 kg/m2 ) (observed difference, -3.85 and -1.45, respectively, both P < .001); the postdinner capillary blood glucose value was lower in the exenatide group compared with the placebo group (162.4 ± 80.5 vs. 259.1 ± 94.4 mg/dL, respectively; observed difference, -96.7, P < .01). Hypoglycaemic risk, quality of life and overall safety were not different between the groups, apart from the expected occurrence of digestive effects in the exenatide group. CONCLUSIONS: Although we failed to reach our planned sample size, the addition of exenatide treatment 10 μg BID SC in T2D patients with uncontrolled HbA1c despite an intensified insulin regimen, resulted in a significant reduction of HbA1c and body weight with a good overall safety profile and acceptance.
- MeSH
- Diabetes Mellitus, Type 2 * drug therapy MeSH
- Double-Blind Method MeSH
- Exenatide MeSH
- Glycated Hemoglobin analysis MeSH
- Hypoglycemic Agents adverse effects MeSH
- Insulin MeSH
- Blood Glucose MeSH
- Quality of Life MeSH
- Humans MeSH
- Treatment Outcome MeSH
- Venoms adverse effects MeSH
- Check Tag
- Humans MeSH
- Publication type
- Journal Article MeSH
- Multicenter Study MeSH
- Research Support, Non-U.S. Gov't MeSH
- Randomized Controlled Trial MeSH
