Guía colombiana de práctica clínica para el tratamiento de la diabetes mellitus tipo 2: falla al tratamiento inicial / Colombian Clinical Practice Guideline for Treatment of Type 2 Diabetes Mellitus: First Line Treatment Failure

Introducción: Existen diferentes opciones de manejo para pacientes con diabetes mellitus tipo 2 (DMT2) que ya iniciaron tratamiento farmacológico con metformina y no han alcanzado metas de control glucémico. Resulta prioritario definir pautas para escoger la mejor opción en estos pacientes, así como en aquellos que no han tenido un control óptimo con la combinación de dos medicamentos. Objetivo: Definir cuál es antidiabético de elección, entre sulfonilureas, tiazolidinedionas, inhibidores de DPP-4, agonista del receptor de GLP-1 o insulina basal, como segunda y tercera líneas de manejo en pacientes con DMT2. Métodos: Se elaboró la guía de práctica clínica, siguiendo los lineamientos de la guía metodológica del Ministerio de Salud y Protección Social colombiano. Se revisó la evidencia disponible de forma sistemática y se formularon las recomendaciones utilizando la metodología GRADE. Conclusiones: En pacientes con DMT2 y falla terapéutica al manejo con metformina como monoterapia (HbA1C > 7 %) se recomienda como primera opción adicionar un inhibidor DPP-4, como segunda opción adicionar inhibidor SGLT2 o sulfonilureas con bajo riesgo de hipoglucemia y como tercera opción agregar insulina basal a los pacientes que con la combinación de dos fármacos fallen en alcanzar su meta de HbA1C. Si la falla terapéutica se asocia con un IMC persistentemente ≥ 30, se sugiere la adición de un agonista de GLP-1 por el potencial beneficio sobre la reducción de peso.

Introduction: There are different options to treat type 2 diabetes (DMT2) patients who began treatment with metformin and have not reached therapeutic golds. It is imperative to define rules to choose the best option, in these patients, as in those who have not achieved an optimal control under combined therapy. Aim: To define the best option between sulfonylureas, thiazolidinediones, DPP4 inhibitors, GLP-1 agonist or basal insulin, as second or third line treatment, in patients with DMT2 who have not reached therapeutic golds with metformin or combined therapy. Methods: A clinical practice guide has been developed following the broad outline of the methodological guide from the Colombian Ministry of Health and Social Welfare, with the aim of systematically gathering scientific evidence and formulating recommendations using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) methodology. Conclusions: In patients with DMT2 who did not reach their therapeutic goal with metformin as a monotherapy (Hb1Ac <7%), addition of a second oral antidiabetic medication is recommended. it is recommended as a first step to add a DPP-4 inhibitor. It is suggested to add a SGLT2 inhibitor or a sulfonylurea having low risk of hypoglycemia as acceptable options. It is suggested to add basal insulin as a third antidiabetic medication if the combination of two pharmacological treatments does not enable the patient to reach and maintain the HbA1c goal. It is suggested to add a GLP-1 agonist if therapeutic failure appears in patients who remain obese (BMI ≥30 kg/m²), considering its potential to reduce weight.

Enfoque epidemiológico de las características clínico-terapéuticas de la sífilis congénita (2000-2010) / Epidemiological approach of therapeutic clinical features of congenital syphilis (2000-2010)

Objetivos: Describir el enfoque epidemiológico de las características clínico-terapéuticas de la sífilis congénita en el Hospital Daniel Alcides Carrión del Callao con la finalidad de conocer el resultado de la evolución de la enfermedad. Material y métodos: Estudio de diseño retrospectivo y metodología observacional, transversal y descriptiva en 28 HC de RN con sífilis congénita, admitidos en la UCI neonatal entre el 2000 al 2010. La ficha de datos validada fue el instrumento principal de estudio. Resultados: La edad materna promedio de las madres de RN con SC, fue de 25.5±4.5 años y convivientes (65.40 por ciento), analfabetas / primaria (76.90 por ciento), sexoservidoras (48 por ciento), sin CPN (67.30 por ciento), primigestas (57.90 por ciento), EG pretérmino (40.40 por ciento), con VDRL reactivo (67.30 por ciento), con tratamiento (32.70 por ciento), sexo masculino de los RN (81.55 por ciento), AEG (60.70 por ciento), AEG (32.15 por ciento), RN anormales (92.85 por ciento), con hepatoesplenomegalia (32.15 por ciento), prematuridad (39.30 por ciento), anemia (14.30 por ciento). Con VDRL 32-52 dilusiones (71.45 por ciento) y 1-8 (28.55 por ciento), VDRL en LCR reactivo (39.4 por ciento), no reactivo (14.30 por ciento). Con leucocitos (75 por ciento), anemias (25 por ciento), periostitis (32.15 por ciento). Tratamiento con PG sódica (46.40 por ciento), PG + benzatímica (14.30 por ciento), PG + Clemizol (14.30 por ciento), fallecidos (25 por ciento), sobrevivientes (75 por ciento). Conclusiones: La Sífilis Congénita es una infección reconocida desde la antigüedad, pero a pesar de ello, actualmente su diagnóstico es complicado, debido a los hallazgos clínicos inespecíficos que también son encontrados en otras enfermedades infecciosas intrauterinas. El manejo de la enfermedad en el recién nacido de una madre con sífilis se basa primordialmente en la historia materna por sífilis y su tratamiento. Es indiscutible la importancia de la serología como ayuda...

Objectives: To describe the epidemiological approach of clinical and therapeutic features of congenital syphilis in the Hospital Daniel Alcides Carrion in Callao in order to know the result of the evolution of the disease. Material and Methods: Study design and methodology retrospective observational, transversal and descriptive RN HC 28 with congenital syphilis, admitted to the NICU between 2000 and 2010. The validated data sheet was the main instrument of study. Results: The average maternal age of mothers of infants with SC, was 25.5+/-4.5 years and cohabiting (65.40 per cent), illiterate / primary (76.90 per cent), sex workers (48 per cent) without CPN (67.30 per cent), primiparous (57.90 per cent), EG preterm (40.40 per cent) with reactive VDRL (67.30 per cent), with treatment (32.70 per cent), male newborns (81.55 per cent), AEG (60.70 per cent), AEG (32.15 per cent), abnormal RN (92.85 per cent), with hepatosplenomegaly (32.15 per cent), prematurity (39.30 per cent), anemia (14.30 per cent). With 32-52 VDRL dilutions (71.45 per cent) and 1-8 (28.55 per cent), reactive CSF VDRL (39.4 per cent), non-reactive (14.30 per cent). Leukocyte (75 per cent), anemia (25 per cent), periostitis (32.15 per cent).Treatment with sodium PG (46.40 per cent), PG + benzathimic (14.30 per cent), PG + clemizole (14.30 per cent), deaths (25 per cent), survivors (75 per cent). Conclusions: Syphilis is an infection known since antiquity, but nevertheless, its current diagnosis is complicated by nonspecific clinical findings are also found in other intrauterine infectious diseases. The management of the disease in the newborn of a mother with syphilis is based primarily on maternal history of syphilis and treatment. It is undeniable the importance of serology as a diagnostic aid because despite its specificity is sensitive and useful in our environment. The most important measure is prevention of Congenital syphilis identify infected pregnant women, ensuring appropriate...

Cortical, brainstem and autonomic nervous system dysfunction in infants with post-hemorrhagic hydrocephalus

OBJECTIVE: The aim of this study was to evaluate the degree of central and autonomic dysfunction by means of electroencephalographic (EEG) and cardio-pneumographic recording (CPGR) in infants with Post-Hemorrhagic Hydrocephalus (PHH). METHODS: Nineteen infants with PHH were studied, born from October 1998 to January 2000. Clinical diagnosis was confirmed by cephalic perimeter measurement and ultrasonographic study. Eight channel bipolar EEG and CPGR were performed after sleep deprivation, EEG features studied were: Temporal organization, symmetry, synchrony, frequency of normal and abnormal patterns. CPGR features studied were: Frequency of apnea and temporal organization by means of beat to beat variability. RESULTS: Averages of birth's age and weight, Apgar scores at one and five minutes, and cephalic perimeter showed lower values in PHH infants. PHH infants showed abnormalities in EEG and CPGR such as: Higher discontinuous activity (63), asymmetry (73), asynchrony (89), abnormal EEG patterns (89), apnea (26) and absence of heart rate variability (63). CONCLUSIONS: EEG and CPGR recordings are a useful tools in the examination of infants with PHH. These findings suggest cortical-subcortical, and brainstem dysfunction with severe encephalopathy and autonomic nervous dysfunction related to ventricular dilatation in infants with PHH.