[Diabetes and cognitive decline - An often overlooked association]. / Nedsatt kognition och diabetes ­ ett ofta förbisett samband.

In addition to peripheral neuropathy of various manifestations, diabetes is also associated with central neuropathy. This can manifest as premature cognitive decline, although the role of hyperglycemia in this process remains ambiguous. Notwithstanding that the link between diabetes and cognitive decline was discovered 100 years ago, and has important clinical implications, this co-morbidity remains relatively unknown. Recent years have seen research that has clarified cerebral insulin resistance and defective insulin signaling as two putative pathogenic factors behind this cognitive impairment. Recently published studies have shown that physical activity may reverse insulin resistance in the brain as well as improve cognitive impairment and pathological appetite regulation. Pharmacological intervention with e.g. nasal insulin and GLP-1 receptor agonists have also shown promising results, but must be further tested in clinical studies.

GAD-65 antibodies in a case of HNF1A-Maturity-Onset Diabetes of the Young: Double diabetes?

Diabetes classification is not as defined as it used to be. A patient with one type of diabetes can have diagnostic criteria of another type, which may affect the course of the disease. Clinicians need to consider that when dealing with patients who do not fit the exact description of their diagnosed type of diabetes.

Hemiballismus in hyperglycemia.

Diabetes may cause late complications in the CNS but certain lesions may also occur acutely in hyperglycemia. We describe a case of hyperosmolar non-ketotic syndrome and reversible hemichoreic dyskinesia with morphological changes in basal ganglia.

Using adjuvant pharmacotherapy in the treatment of type 1 diabetes.

Introduction: Insulin and its analogues have so far been the only approved treatment for type 1 diabetes in Europe, while in the US, the amylin analog pramlintide is approved for adjuvant use with insulin. However, in clinical practice, various drugs against type 2 diabetes have been used off label with insulin for type 1 diabetes. Recently, the EMA approved the SGLT inhibitors dapagliflozin and sotagliflozin as adjuvant treatments to insulin for type 1 diabetes in adults.Areas covered: This article is a survey of adjuvant treatments used against type 1 diabetes, focusing on SGLT inhibitors.Expert opinion: While GLP-1 R agonists and metformin may reduce weight gain associated with insulin therapy and possibly also confer non-glycemic benefits, only the SGLT inhibitors dapagliflozin and sotagliflozin have been approved in Europe as adjunctive to insulin for type 1 diabetes. Since these drugs act independently of insulin, they are very valuable additions to the armamentarium against type 1 diabetes. However, they should be used judiciously in select patients to mitigate the risk of diabetic ketoacidosis. Patients should be instructed to avoid risk situations and be taught to measure blood ketones themselves.

Prediabetic Dysglycemia: Call for Action.

Different dysglycemic states precede overt type 2 diabetes. Prediabetic dysglycemia also carries an increased cardiovascular risk per se. Prediabetic dysglycemia may be divided into impaired fasting glycemia, impaired glucose tolerance and intermediate hyperglycemia. Mixed forms of these are very common. Dysglycemia develops insidiously for many years and usually produces no symptoms until very late. It is possible to prevent prediabetic dysglycemia from progressing to manifest type 2 diabetes and it can also be made to return to normoglycemia. The importance of lifestyle interventions, pharmacological treatment, surgical treatment and community efforts are discussed.

[Type B insulin resistance syndrome]. / Typ B-insulinresistenssyndrom ­ sällsynt tillstånd med hög mortalitet.

Type B insulin resistance syndrome (TBIRS) is a very rare autoimmune condition with polyclonal autoantibodies directed against the insulin receptor, which results in severe and refractory hyperglycemia and high mortality. Described here is a patient who, within a few months after the onset of an autoimmune type 1 diabetes, increased her insulin requirements more than 20-fold, and despite this having a considerable difficulty maintaining  her P-glucose < 40-60 mmol/L. On suspicion of TBIRS the patient was started on tapering glucocorticoids to overcome the autoimmune insulin receptor blockade, resulting in an immediate and dramatic effect. Within days insulin requirements decreased by 80-90 %, and the P-glucose stabilized around 7-8 mmol/L. The presence of antibodies to the insulin receptor was detected by immunoprecipitation and binding assays. After a 4-month remission on low maintenance dose prednisolone the patient relapsed, which required repeated plasmaphereses with temporarily remarkable effect. Mixed and transient results were seen with rituximab, mycophenolic acid and bortezomib but glycemic control has remained suboptimal. Lack of compliance and recurrent infections may have contributed to this.

Atypical diabetes: a diagnostic challenge.

In medical school, we learned how to classify diabetes according to different clinical characteristics. However, at the dawn of the precision medicine era, it is clear that today's clinical reality does not always align well with textbook teachings. The terms juvenile versus elderly-onset diabetes, as well as insulin-dependent versus non-insulin-dependent diabetes, have become obsolete. Contrary to what is often taught severe ketoacidosis may occur in type 2 diabetes. Patients may also suffer from two or more forms of diabetes simultaneously or consecutively. Five authentic cases of diabetes with uncommon characteristics that pose diagnostic challenges are presented here.

Type B insulin resistance syndrome in a patient with type 1 diabetes.

SUMMARY: Type B insulin resistance syndrome (TBIRS) is a very rare autoimmune disorder with polyclonal autoantibodies against the insulin receptor, resulting in severe and refractory hyperglycemia. Described here is a patient who within a few months after the onset of autoimmune type 1 diabetes increased her insulin requirements more than 20-fold; despite this she had considerable difficulty maintaining a plasma glucose value of <40-60 mmol/L (720-1100 mg/dL). On suspicion of TBIRS, the patient was started on tapering dose of glucocorticoids to overcome the autoimmune insulin receptor blockade, resulting in an immediate and pronounced effect. Within days, insulin requirements decreased by 80-90% and plasma glucose stabilized around 7-8 mmol/L (126-144 mg/dL). The presence of antibodies to the insulin receptor was detected by immunoprecipitation and binding assays. After a 4-month remission on low maintenance dose prednisolone, the patient relapsed, which required repeated plasmaphereses and immune column treatments with temporarily remarkable effect. Mixed and transient results were seen with rituximab, mycophenolic acid and bortezomib, but the glycemic status remained suboptimal. Lack of compliance and recurrent infections may have contributed to this. LEARNING POINTS: Type B insulin resistance syndrome (TBIRS) is a very rare autoimmune disorder with acquired polyclonal autoantibodies against the insulin receptor, resulting in severe and refractory hyperglycemia. We describe here a young patient in whom, a few months after the onset of a regular autoimmune diabetes, insulin requirements in a short time increased more than 20-fold, but despite this, the plasma glucose level could be kept at <40-60 mmol/L only with considerable difficulty. Did this patient have TBIRS? On suspicion of TBIRS, the patient was started on tapering glucocorticoids to overcome the autoimmune insulin receptor blockade, resulting in an immediate and pronounced effect; within days insulin requirements decreased by 80-90% and plasma glucose stabilized around 7-8 mmol/L. The presence of antibodies to the insulin receptor was detected by immunoprecipitation and binding assays. After a 4-month remission on low maintenance dose prednisolone, the patient relapsed, which required repeated plasmaphereses with temporarily remarkable effect. TBIRS should be considered in diabetic patients whose glycemia and/or insulin requirements are inexplicably and dramatically increased.

[Double diabetes - a metabolic challenge]. / Dubbel diabetes ­ metabol utmaning.

In Northern Europe, we are used to classifying diabetes as either type 1 or type 2 (with some exceptions). These exceptions include secondary diabetes (e.g. gestational diabetes, after pancreatectomy, steroid therapy, etc.) and monogenic diabetes. However, the fact that one can actually suffer from (at least) two different types of diabetes, simultaneously or consecutively, is rarely discussed. This article describes a case of monogenic diabetes with autoantibodies against the ß-cell antigen GAD-65. The existence, and implications, of other constellations of ¼double diabetes« are discussed.

Ketosis-Prone Type 2 Diabetes: A Case Series.

Ketosis-prone type 2 diabetes ("Flatbush diabetes") carries features of both classical type 1 and type 2 diabetes and is highly prevalent in African populations. The disease, which is highly ketosis-prone, but neither chronically insulinopenic nor autoimmune, is discussed regarding pathogenesis, diagnosis and treatment from a patient case perspective.

[Hemichorea/hemiballism a rare complication of hyperglycemia]. / Hemikorea/hemiballism ­ ovanlig komplikation till hyperglykemi - Ofrivilliga rörelser hos patient med nydebuterad diabetes.

We present a case of hemichorea/hemiballism, a rare complication of hyperglycemia. Diagnosis is made clinically by signs of unilateral involuntary movements of the extremities combined with typical neuroradiological findings in the basal ganglia. Guidelines for treatment of the condition are lacking but in many cases correction for hyperglycemia is sufficient for full symptom relief. In other cases, symptomatic treatment with haloperidol and tetrabenazine can be used.

[A survey of various adjuvant treatments used against type 1 diabetes, focusing on SGLT2 inhibitors]. / Adjuvant behandling vid diabetes typ 1 ­ en översikt - Nyligen godkändes dapagliflozin som första adjuvanta läkemedel till insulin hos vissa vuxna med typ 1-diabetes.

Insulin and its analogues have so far and for almost 100 years been the only officially approved treatment for type 1 diabetes in Europe. However, in clinical practice, various drugs against type 2 diabetes have sometimes been used off label as adjuvants to insulin for type 1 diabetes. Recently, the EMA approved the SGLT2 inhibitor dapagliflozin as an adjuvant treatment for type 1 diabetes in adults. This article is a survey of various adjuvant treatments used against type 1 diabetes, focusing on SGLT2 inhibitors and their pros and cons.

[Possible to prevent prediabetes from progressing to manifest type 2 diabetes]. / Prediabetes ­ mål för intervention.

Different prediabetic states precede overt type 2 diabetes. Prediabetes also carries an increased cardiovascular risk per seand may be divided into fasting hyperglycemia, impaired glucose tolerance and intermediate hyperglycemia. Mixed forms of these are very common. Prediabetes develops insidiously for many years and usually produces no symptoms until very late. It is possible to prevent prediabetes from progressing to manifest type 2 diabetes and it can also be made to revert to normoglycemia. The importance of lifestyle interventions, pharmacological treatment, surgical treatment and community efforts is discussed.

[Life-threatening ketoacidosis in patients with type 2 diabetes on LCHF diet]. / LCHF-kost gav svår keto­acidos hos patienter med typ 2-diabetes - Intensivvård krävdes för att häva livshotande tillstånd.

Patients with type 2 diabetes may develop severe ketoacidosis. A low carb high fat (LCHF) diet is oftentimes used by these patients for weight loss purposes but is also ketogenic. Antidiabetic SGLT2 inhibitors may increase glucagon secretion and may predispose to ketoacidosis, which is normoglycemic and thus makes it more difficult to suspect. We present two cases of severe ketoacidosis in type 2 diabetes patients on LCHF diet, one of which was also on SGLT2 inhibitor therapy.