Experiencia con insulina degludec en pacientes diabéticos Tipo 1 del Hospital San Juan de Dios Santiago / Experience with degludec insulin in Type 1 diabetic patients at the San Juan de Dios Hospital

OBJECTIVE: To study the efficacy and safety of degludec insulin in Type 1 diabetic patients. PATIENTS AND METHOD: In a prospective study, 230 type 1 diabetics patients, average aged 34 years age and 14 years of diagnosis of diabetes and treated with two doses of insulin glargine U-100, were changed to degludec. Patients had glycosylated hemoglobins (HbA1c) greater than 10 percent. Results were recorded at 3 and 6 months with parameters clinical, biochemical, insulin requirements per kilogram of weight (U/kg/wt) and hypoglycemia. Capillary glycemia was evaluated three times a day and the dose of insulin degludec every two weeks. The statistical analysis used was average and rank, standard deviation, normal Swilk test, categorical Chi2 and continuous ANOVA or Kwallis, and p < 0.05. A psychological survey was conducted to evaluate satisfaction with the new treatment. RESULTS: Fasting blood glucose decreased from 253 (range 243-270) at 180 mg/dl (172-240) at 3 months and at 156 (137-180) at 6 months after the change insulin (p < 0.05). HbA1c, initially 10.6 percent (10.4-12.2) decreased to 8.7 percent (9.3-10.1) and 8.3 percent (8.7-9.7) at 3 and 6 months, respectively (p < 0.05). There was a decrease in basal insulin requirements from 0.7 to 0.4 U/kg/60 percent reduction in hypoglycaemia; both mild and moderate and severe. Isolated nocturnal hypoglycaemias were recorded in only 4 patients in this group. CONCLUSION: Six months of treatment with degludec insulin reduces fasting blood glucose, glycosylated hemoglobin and hypoglycemia, both mild and moderate severe and nocturnal, which makes this new ultra-long acting basal insulin a safe and effective tool for the management of type 1 diabetics patients

Disfunción sexual en la mujer diabética pre y postmenopáusica / Sexual dysfunction in women with diabetes in pre and postmenopausic state

Objective: female sexual dysfunction (FSD) in diabetic women, is a topic poorly studied. The aim of this study is to determine the prevalence of FSD in typ1 1 and typ2 diabetic patients (T1D and T2D) compared with non diabetic controls. Patients and Method: interview under written consent 24 diabetic patients attended at Diabetes Unit of the San Juan de Dios Hospital and 24 healthy controls. Inclusion criteria: diagnosis of diabetes mellitus over one year, age 18-75 years old and stable partner for over a year. Exclusion criteria: antidepressants treatment. The validated survey by Rosen et al. was applied. Female Sexual Function Index (FSFI), of 19 questions that assess 6 areas of sexual function: desire, lubrication, excitement, orgasm, satisfaction and pain. A total score of 26.55 or less diagnosed DSF. In diabetic patients the metabolic control, lipid profile, creatinine and glycated hemoglobin A1c (HbA1c) was recorded. Statistical analysis was performed using median, range and Mann Whitney test. Percentages of sexual dysfunction was analysed by chi². It was considered significant at p < 0.05. Results: the results of the FSFI survey were divided and related to menopause. In premenopausal diabetic group (n = 11), the average score was 31.1 versus 32.5 in controls (NS) and in postmenopausal diabetic group (n = 13) the average score was 23,1 versus 28,5 (p = 0.05). The overall frequency of DSF in premenopausal diabetic women was 27.3 percent and 6.3 percent in controls (NS), in postmenopausal reached 69.2 percent and25.0 percent in controls (p = 0.01 ). Conclusion: in diabetic patients sexual dysfunction was more frequent than in controls; in premenopausal women the most affected area is the excitement and in postmenopausal women was lubrication.

Diabetes Mellitus tipo 2 con tendencia a la cetosis: Caso clínico / Ketosis prone type 2 diabetes (KPD)

Ketosis prone type 2 diabetes (KPD) is presently a well-defined clinical entity, characterized by a debut with severe hyperglycemia and ketoacidosis similar to the presenting form of Type 1 diabetes mellitus (DM1). However, it appears in subjects with Type 2 diabetes mellitus (DM2) phenotype. This situation is caused by an acute, reversible dysfunction of the beta cell in individuals with insulin resistance. Once the acute stage subsides, patients behave as having a DM2 and do not require insulin treatment. They should be kept on a diet and oral hypoglycemic drugs due to their susceptibility to have recurrent acute ketotic decompensations.

Metformina asociada a insulinoterapia en pacientes diabéticos tipo 1 / Metformin associated with insulin therapy in type 1 diabetic patients

In patients with diabetes type 1 (T1D) glycemic control remains suboptimal, despite the availability of new insulin analogues and continuous infusion systems. Metformin may be a complementary therapy regarding to intensified insulin therapy since a significant percentage of T1D have insulin resistance (IR). Objective: To analyze the clinical, anthropometric and metabolic effects of the combination of metformin to insulin therapy in T1D patients. Subjects and Method: 34 T1D patients, 15 men and 19 women, mean age 41 years (range 20-64) metformin 850 mg / day was associated for 6 months (group 1) and retrospectively evaluated 18 T1D, 9 men and 9 women, age average 34 years (range 17-58), who received metformin for 36 months (group 2). It was recorded before and after treatment with metformin: nutritional status, waist circumference, index waist / hip, glucose fasting, glycosylated hemoglobin (HbA1c), HDL cholesterol, triglycerides, systolic and diastolic blood pressure (BP), glucose uptake (UG) and insulin dose (U/kg). Statistical analyses. Clinical and biochemical parameters were expressed as median, range or percentage (percent). For the statistical significance were used chi2and Fisher exact and Mann Whitney test; and was established as significant at p <0.05. Results: In group 1 significantly decreased waist circumference in men and women and improved fasting glucose, HbA1c, systolic blood pressure and triglycerides. In group 2, waist circumference and systolic blood pressure was also reduced. Conclusion: In T1D patients with clinical signs of IR the association of metformin to insulin therapy may be useful.

Alteraciones hematológicas en la diabetes mellitus / Blood disorders in diabetes mellitus

Although it has been treated in a limited way the relationship between diabetes and hematopoietic system, there is evidence demonstrating thedeleterious effect of hyperglycemia on the three cell lines: red blood cells, white cells and platelets. Different forms of anemia associated with hyperglycemia are analyzed and erythrocyte alterations observed in diabetes. In chronic decompensated patients have been demonstrated alterationsof monocytes, lymphocytes and polymorphonuclear particularly, with decreased chemotaxis, adherence, phagocytosis and opsonization. Hyperglycemia determines a prothrombotic state by platelet hyperreactivity, which is a marker of inflammation...

Diabéticos tipo 1 portadores de síndrome metabólico: cuantificación de la resistencia a la insulina / Type 1 diabetics patients carriers of metabolic syndrome: quantification of insulin resistance

The presence of insulin resistance (IR) has been indirectly assessed in Type 1 Diabetics (T1DM) through the detection of Metabolic Syndrome (MS), by applying criteria for Type 2 Diabetics(T2DM). In the EDC study (the Pittsburg Epidemiology of Diabetes Complications) a formula applicable to T1DM was validated, quantifying IR through the glucose uptake (GU) employing the usual clinical and laboratory parameters, in patients with HbA1c < 11.4 percent. Objectives: To determine in T1DM whether there exists a relationship between the presence of MS according to the Modified NCEP/ATPIII criteria and IR quantification through assessment of the glucose uptake or GU. Patients and Method: The modified NCEP/ATPIII criteria were applied to 150 T1DM patients, and those with more than 3 altered parameters were classified as MS carriers. IR was quantified through the glucose uptake (GU), applying the formula for Estimated Glucose Disposal Rate (GDR-EDC). Results: 26.6 percent of the T1DM (40 patients) complied with the modified NCEP/ATPIII criteria. When the formula for GU was applied (31 patient), 90.3 percent of the T1DM showed insulin resistance (GU value < 8.77). And when applied to 124 patients (T1DM with and without MS and HbA1c < 11,4 percent) 75 percent showed IR...

Consenso elaborado por la Sociedad Chilena de Endocrinología y Diabetes sobre resistencia a la insulina(RI) y síndrome metabólico (SM): aspectos clínicos y terapéuticos / Chilean society of endocrinology and diabetes consensus on clinical and therapeutic aspects of insulin resistance and metabolic syndrome

Background: The concept insulin resistance as the basis for a series of metabolic alterations and diseases was introduced by Gerald Reaven in 1988, when he described a cluster of alterations that named syndrome X. Aim: To review and discuss the present information about insulin resistance (IR) and metabolic syndrome (MS). Material and methods: The IR concept is defined,the affected metabolic ways, its consequences and relationship with different diseases are presented. The importance of central obesity with its metabolic, inflammatory and prothrombotic consequences playing a key role in cardiovascular risk, is discussed. The cluster of factors focused on cardiovascular disease and eventually diabetes is named MS. Several definitions of MS are analyzed and compared. A proposition is made about the definition to be used in the Chilean population. Differences between IR syndrome and MS are discussed. Diagnostic methods of IR and MS are presented, recommendations are made about their usefulness and reliability. Non pharmacological and pharmacological treatments of IR and MS are analyzed. Other related diseases, such as polycystic ovary syndrome, non alcoholic steatohepatitis and sleep apnea are discussed. Conclusions. Until further studies are made to define a local waist circumference cut-off associated with high risk, the ATPIII MS definition is preferred. A clinical approach is recommended for diagnosis. A search for all components of the MS is important. There is no evidence about the benefits of MS treatment on the prevention of cardiovascular diseases or diabetes. Evidence supports the use of lifestyle changes and some drugs, such as metformin on the prevention of diabetes in prediabetic states.

Pie diabético / Diabetic foot

Las personas con diabetes presentan en su vida un riesgo de desarrollar úlceras estimado en un 15 a 25 por ciento, las úlceras involucran riesgo de graves complicaciones, situación favorecida por la neuropatía ya sea motora, autonómica y/o sensitiva, el aumento de la presión plantar y el trauma repetido. Una vez que la úlcera se produce, se favorece su mala evolución si hay enfermedad vascular periférica asociada, más alteraciones inmunológicas secundarias a la diabetes y alteraciones del apoyo. Su manejo debe ser realizado por un equipo multidisciplinario dirigido a tratar todos sus componentes tanto locales como sistémicos. Debe optimizarse el control metabólico y la condición general del paciente. Es fundamental la prevención en la población expuesta a través de la educación, indicación de zapatos adecuados, y cuidados podológico.

¿Es posible la prevención de la diabetes tipo 2? / Is it possible to prevent diabetes type 2?

La diabetes tipo 2 (DM2) es una enfermedad que presenta un explosivo aumento de la incidencia, prevalencia y mortalidad, constituyendo un problema de salud pública. Actualmente se conoce su patogenia, constituida por un doble mecanismo: aumento de la resistencia insulínica y disminución progresiva de la secreción de insulina. Además, se ha establecido que la DM2 evoluciona precedida por un período de intolerancia a la glucosa, que dura años, lo que hace posible intervenir en esa etapa para frenar la aparición de la diabetes. Existen múltiples investigaciones en los últimos años, con resultados consistentes en demostrar la factibilidad en prevenir o retardar la DM2 con cambios de estilo de vida –disminución de peso, aumento de la actividad física, cambios dietarios- en sujetos intolerantes a la glucosa, de diversas etnias. El uso exclusivo de fármacos insulino-sensibilizadores ha mostrado ser menos efectivos que los cambios de estilo de vida; actualmente están en desarrollo estudios que combinan ambas medidas terapéuticas, los que darán respuesta a esta interrogante.

Gluco-lipotoxicidad y sus implicancias en la diabetes mellitus tipo 2 / Glycolipotoxicity and it implications in diabetes mellitus type 2

Se entiende por glucotoxicidad a los daños estructurales y funcionales debidos a la hiperglicemia crónica, que se producen en la célula beta y en los tejidos periféricos donde actúa la insulina; alteraciones que se traducen en una menor secreción y acción de la hormona (insulinorresistencia). La lipotoxicidad se relacionea con daños similares a consecuencia de altos niveles de ácidos grasos libres(AGL), productos del catabolismo de los triglicéridos. Debido a que la elevación permanente de la glucosa y de los AGL interactúan y tiene los mismos efectos deletéreos, se ha acuñado el término de gluco-lipotoxicidad, cuya importancia radica en que sería uno de los factores implicados en la patogénesis de la diabetes tipo 2(DM 2) y en la evolución de ésta al fracaso secundario a las drogas hipoglicemiantes orales. En la actualidad se acepta que la DM 2 se desarrolla en etapas: resistencia a la insulina con normoglicemia, intolerancia a la glucosa y diabetes clínica. Dado que los dos primeros períodos son reversibles, y que el déficit de secreción insulínica es parte de la historia natural de la DM 2, el controlar las glicemias elevadas y la lipólisis exagerada(gluco-lipotoxicidad), permitiría revertir o enlentecer estos procesos

Macroangiopatía en la diabetes mellitus no insulinodependiente / Macroangiopathy in non insulin-dependent diabetes mellitus

La diabetes mellitus cursa con una alta prevalencia de complicaciones macrovasculares, las que afectan principalmente a las arterias coronarias, cerebrales y meimbros inferiores. La lesión ateromatosa que aparece en los diabéticos es desde el punto de vista anátomo-patológico, similar a la observada en individuos no diabéticos y sólo se disntingue por desarrollarse de manera rápida, extensa y precoz. Dada la alta morbilidad y mortalidad provocada por esta patología en los diabéticos no insulinodependiente, es indispensable estudiar los mecanismos que conducen a las complicaciones vasculares, así como la identificación de los marcadores de riesgo, para evitar la aparición y progresión de la macroangiopatía diabética

Microalbuminuria en diabéticos insulinodependientes: prevención de la nefropatía diabética / Microalbuminuria in insulin dependent diabetics: prevention of diabetic nephropathy by angiotensin converting enzyme inhibition

We evaluated the effects of angiotensin converting enzyme inhibition upon the urinary excretion of albumin in 36 insulin dependent normotensive diabetic patients with adeuate metabolic control and no evidence of renal failure. 19 subjects had normal levels of albumin excretion (<30 mg/24h) and 17 showed microalbuminuria from 30 to 300 mg/24 h. Half of the patients were randomly selected ine ach group to receive enalapril, 5 mg/day. A progressive decrease in albumin excretion levels was observed for both enealpril treated subgroups, from 18.9 ñ 8.3 to 8.1 ñ 2.7 mg/24 h (normoalbuminurics) and from 73.1 ñ 25.0 to 40.1 ñ 26.3 mg/24 h (microalbuminurics). In contrast, an increase in albumin excretion from 19.4 ñ 6.8 to 29.4 ñ 14.2 mg/24 h was observed in non treated normoalbuminuric patients. Untreated patients with microalbuminuria remained with stable albumin excretion level (67.4 ñ 39 to 64.8 ñ 23.4 mg/24h. Enalapril treatment was associated to a significant (p < 0.05) decrease in cratinine clearance which remained within normal limits. Blood pressure, Na and K plasma levels and totral proteins remained normal throughout the study. Thus, angiotensin converting enzyme inhibition reduces the urinary excretion of albumin in insulin dependent diabetics with normo or microalbuminuria