BackgroundClinical inertia is related to the difficulty of achieving and maintaining optimal glycemic control. It has been extensively studied the delay of the period to insulin introduction in type 2 diabetes mellitus (T2DM) patients. This study aims to evaluate clinical inertia of insulin treatment intensification in a group of T2DM patients followed at a tertiary public Diabetes Center with limited pharmacologic armamentarium (Metformin, Sulphonylurea and Human Insulin).MethodsThis is a real life retrospective record based study with T2DM patients. Demographic, clinical and laboratory characteristics were reviewed. Clinical inertia was considered when the patients did not achieve the individualized glycemic goals and there were no changes on insulin daily dose in the period.ResultsWe studied 323 T2DM patients on insulin therapy (plus Metformin and or Sulphonylurea) for a period of 2 years. The insulin daily dose did not change in the period and the glycated hemoglobin (A1c) ranged from 8.8 + 1.8% to 8.7 ± 1.7% (basal vs 1st year; ns) and to 8.5 ± 1.8% (basal vs 2nd year; p = 0.035). The clinical inertia prevalence was 65.8% (basal), 61.9% (after 1 year) and 58.2% (after 2 years; basal vs 1st year vs 2nd year; ns). In a subgroup of 100 patients, we also studied the first 2 years after insulin introduction. The insulin daily dose ranged from 0.22 ± 0.12 to 0.32 ± 0.24 IU/kg of body weight/day (basal vs 1st year; p < 0.001) and to 0.39 ± 0.26 IU/kg of body weight/day (basal vs 2nd year; p < 0.05). The A1c ranged from 9.6 + 2.1% to 8.6 + 2% (basal vs 1st year; p < 0.001) and to 8.7 + 1.7% (1st year vs 2nd year; ns). The clinical inertia prevalence was 78.5% (at the moment of insulin therapy introduction), 56.2% (after 1 year; p = 0.001) and 62.2% (after 2 years; ns).ConclusionClinical inertia prevalence ranged from 56.2 to 78.5% at different moments of the insulin therapy (first 2 years and long term) of T2DM patients followed at a tertiary public Diabetes Center from an upper-middle income country with limited pharmacologic armamentarium.Electronic supplementary materialThe online version of this article (10.1186/s13098-018-0382-x) contains supplementary material, which is available to authorized users.
Expressões como "diabetes é uma doença vascular, o paciente com diabetes é um coronariopata em potencial, pacientes com diabetes têm o mesmo risco em desenvolver um evento cardiovascular quando comparados com não-diabéti-cos que já tiveram um infarto do miocárdio" têm sido comumente utilizadas e cada vez mais difundidas. Realmente tem sido recomendado que os pacientes com diabetes tipo 2 sejam considerados portadores de doença coronariana e como tal devam ser tratados, incluindo, por exemplo, metas mais rígidas de controle de colesterol e suas frações e dos níveis pressóricos (prevenção secundária).A causa maior das internações hospitalares de pacientes com diabetes é em razão da doença cardiovascular. A elevada taxa de morbidade e mortalidade nesses pacientes é, sem dúvida, também conseqüência de manifestações de doença cardiovascular. O infarto do miocárdio e o acidente vascular cerebral são as principais causas de morte dos pacientes com diabetes (1-4). Especialistas em cardiologia têm cada vez mais se envolvido no tratamento do diabetes. Por outro lado, endocrinologistas têm também se envolvido mais e mais em estudos sobre a patogênese da aterosclerose, tentando compreender melhor as relações entre, por exemplo, resistência à insulina, adipoquinas, inflamação e desenvolvimento da doença coronariana.Sociedades médicas, como a American Diabetes Association, têm lançado diretrizes para o diagnóstico de doença coronariana em pacientes portadores de diabetes (5,6). Em excelente revisão, Young e col. (7) discutem quais pacientes com diabetes devem ser avaliados. É óbvio que possam existir barreiras econômicas. Um estudo recente realizado no Centro de Diabetes da Universidade Federal de São Paulo (8) demonstrou que a avaliação cardiovascular em um centro universitário está aquém do mínimo necessário. Apesar disso, a maioria dos endocrinologistas, quando existe disponibilidade para tal, tem-se empenhado mais nesse tipo de avaliação. A solicitação do eletrocardiograma de esforço, do ecodopplercardiograma, da cintilografia do miocárdio, da tomografia computadorizada de coronárias e de outros testes cardiológicos tem-se tornado mais freqüente no consultório do endocrinologista.Esse fato demonstra uma mudança de paradigma e expressa que absolutamente não devemos ser "glucocêntricos" ao extremo, mas entender que o desfecho final de qualquer tratamento para diabetes deve ter como objetivo a prevenção da doença cardiovascular. Contudo, e supreendentemente, nenhum agente oral demonstrou, até o momento, atuar na prevenção de eventos cardiovasculares. Atualmente, discute-se mais a segurança de tais agentes em termos de doença cardiovascular do que propriamente a proteção.A importância do tema diabetes e doença cardiovascular pode ser demonstrada pela recente edição dos Arquivos Brasileiros de Endocrinologia e Metabolismo, órgão oficial da Sociedade Brasileira de Endocrinologia e Metabolismo com um número especial dedicado ao tema (9).
Diabetes mellitus with resistance to insulin administered subcutaneously or intramuscularly (DRIASM) is a rare syndrome and is usually treated with continuous intravenous insulin infusion. We present here two cases of DRIASM in 16 and 18 years female patients that were submitted to pancreas transplantation alone (PTA). Both were diagnosed with type 1 diabetes as young children and had labile glycemic control with recurrent episodes of diabetic ketoacidosis. They had prolonged periods of hospitalization and complications related to their central venous access. Exocrine and endocrine drainages were in the bladder and systemic, respectively. Both presented immediate graft function. In patient 1, enteric conversion was necessary due to reflux pancreatitis. Patient 2 developed mild postoperative hyperglycemia in spite of having normal pancreas allograft biopsy and that was attributed to her immunosuppressive regimen. Patient 1 died 9 months after PTA from septic shock related to pneumonia. In 8 months of follow-up, Patient 2 presented optimal glycemic control without the use of antidiabetic agents. In conclusion, PTA may be an alternative treatment for DRIASM patients.
Our data has shown the variability and limitations on boarding diagnosing of DAC in university environment patients and point us the necessity of constructing defined and directed directives for the peculiarities of the Brazilian population and health system.
Studies on head injury-induced pituitary dysfunction are limited in number and conflicting results have been reported. To further clarify this issue, 29 consecutive patients (24 males), with severe (n = 21) or moderate (n = 8) head trauma, having a mean age of 37 ± 17 years were investigated in the immediate post-trauma period. All patients required mechanical ventilatory support for 8-55 days and were enrolled in the study within a few days before ICU discharge. Basal hormonal assessment included measurement of cortisol, corticotropin, free thyroxine (fT4), thyrotropin (TSH), testosterone (T) in men, estradiol (E2) in women, prolactin (PRL), and growth hormone (GH). Cortisol and GH levels were measured also after stimulation with 100 µg human corticotropin releasing hormone (hCRH) and 100 µg growth hormone releasing hormone (GHRH), respectively. Cortisol hyporesponsiveness was considered when peak cortisol concentration was less than 20 µg/dl following hCRH. TSH deficiency was diagnosed when a subnormal serum fT4 level was associated with a normal or low TSH. Hypogonadism was considered when T (males) or E2 (women) were below the local reference ranges, in the presence of normal PRL levels. Severe or partial GH deficiencies were defined as a peak GH below 3 µg/l or between 3 and 5 µg/l, respectively, after stimulation with GHRH. Twenty-one subnormal responses were found in 15 of the 29 patients (52%) tested; seven (24%) had hypogonadism, seven (24%) had cortisol hyporesponsiveness, five (17%) had hypothyroidism, and two patients (7%) had partial GH deficiency. These preliminary results suggest that a certain degree of hypopituitarism occurs in more than 50% of patients with moderate or severe head injury in the immediate post-trauma period, with cortisol hyporesponsiveness and hypogonadism being most common. Further studies are required to elucidate the pathogenesis of these abnormalities and to investigate whether they affect long-term morbidity. P2 Cortisol reserve in head trauma victims: evaluation with the low-dose (1 µ µg) corticotropin (ACTH) stimulation test
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