Actualización en el uso de insulinas para el médico de familia / Update on the use of insulins for the primary care physician

El tratamiento con insulina en personas con diabetes mellitus tipo 2 (DM2) continúa siendo fundamental y su consumo ha aumentado en los últimos años. A pesar de ello, el grado de control para esta patología continúa siendo muy deficiente. El inicio del tratamiento con insulina se realiza con cifras muy por encima de las recomendaciones de las Guías de Práctica Clínica (GPC) y los pacientes están sometidos a cifras de glucemia muy elevadas durante largos periodos de tiempo. En este artículo se revisa el papel de la insulina siguiendo las diferentes GPC, los criterios para el inicio y la intensificación con dicha terapia, los diferentes tipos de insulina comercializados en nuestro país, la insulinización en situaciones especiales (tratamiento con corticoides, en el anciano frágil, personas en situación de cuidados paliativos, enfermedad renal crónica y personas que cumplen el Ramadán) y finalmente se aborda el problema de la inercia terapéutica en la insulinización (AU)

Insulin treatment in type 2 diabetes mellitus patients is still essential and its usage has increased during recent years. Despite this, the level of control continues to be very poor. Insulin treatment is initiated with control levels above the recommendations set by the Clinical Practice Guidelines (CPG) and patients are exposed to very high blood glucose levels during long periods of time. This paper reviews the role of insulin in the different CPG, the criteria for therapy initiation and intensification, the beginning of the intensification and the different types of insulin which are commercialized in our country. Moreover, we discuss insulinization in special situations such as corticosteroid treatment, fragile elderly patients, palliative care situations, chronic kidney disease or during Ramadan. Finally, the problem of therapeutic inertia in insulinization is also addressed (AU)

Impacto de la inercia terapéutica y del grado de adherencia al tratamiento en los objetivos de control en personas con diabetes / The impact of therapeutic inertia and the degree of the medication adherence on the control goals for patients with diabetes

Objetivo: El objetivo de este estudio fue analizar el impacto de la baja adherencia terapéutica (AT) y la inercia terapéutica de los profesionales (IT) sobre el mal control glucémico y de los factores de riesgo cardiovasculares en personas con DM2. Material y métodos: Estudio transversal realizado en atención primaria. Se incluyeron 320 personas con DM2. Se valoró si cumplían los objetivos de control (HbA1c≤7%, PA≤130/80mmHg, LDL≤100mg/dl). Se consideró falta de AT la retirada de farmacia <80% de las recetas prescritas e IT la no modificación del tratamiento en personas mal controladas. Resultados: Presentaron buen control de HbA1c, PA y cLDL el 62,5, el 40,9 y el 35,9%, respectivamente. Las personas mal controladas presentaron cifras de AT menores y la IT no se relacionó con la AT. En sujetos mal controlados para HbA1c, presentaban IT el 25,8%, el 24,8% mala AT y el 11,9% estaban afectados por ambos comportamientos. Para cLDL, el 3,6% presentaban mala AT, el 70,4% IT y el 16,0% mala AT e IT (p<0,001). Respecto a la PA, el 3,5% tenían mala AT, el 54,6% IT y el 21,5% presentaban mala AT e IT (p<0,01). Conclusiones: La falta de AT y la IT han estado implicadas en un porcentaje elevado de personas con DM2 mal controladas. La IT ha resultado de gran relevancia en el presente estudio

Objective: The purpose of this study was to analyse both the impact of low therapeutic adherence (TA) and therapeutic inertia (TI) on poor blood glucose control and on risk factors for heart disease in patients with DM2. Material and methods: A cross-sectional study was conducted in a Primary Halth Care centre. A total of 320 patients with DM2 were included and an assessment was made of control goals (HbA1c≤7%, blood pressure ≤130/80mmHg, and LDL-cholesterol≤100mg/dl). A pharmacy retrieval <80% was considered as a lack of TA and the non-modification of treatment in badly controlled patient as TI. Results: The percentage of patients with good control of HbA1c, blood pressure and LDL-cholesterol was 62.5%, 40.9%, and 35.9%, respectively. Lower figures of TA were present in poorly controlled patients, and TI was not found to be related to TA. In the patients with poor HbA1c control, 25.8% had TI, 24.8% poor TA, and 11.9% had both of them. As regards LDL-cholesterol, 3.6% presented poor TA, 70.4% showed TI, and 16% with poor TA and TI (P<.001). As for blood pressure, 3.5% of patients had poor TA, 54.6% had TI, and 21.5% of them had poor TA as well as TI (P<.01). Conclusions: Lack of therapeutic adherence and therapeutic inertia were found in a high percentage of poorly-controlled DM2 patients with bad control. Therapeutic inertia was found to be of great relevance in this study

[The impact of therapeutic inertia and the degree of the medication adherence on the control goals for patients with diabetes]. / Impacto de la inercia terapéutica y del grado de adherencia al tratamiento en los objetivos de control en personas con diabetes.

OBJECTIVE: The purpose of this study was to analyse both the impact of low therapeutic adherence (TA) and therapeutic inertia (TI) on poor blood glucose control and on risk factors for heart disease in patients with DM2. MATERIAL AND METHODS: A cross-sectional study was conducted in a Primary Halth Care centre. A total of 320 patients with DM2 were included and an assessment was made of control goals (HbA1c≤7%, blood pressure ≤130/80mmHg, and LDL-cholesterol≤100mg/dl). A pharmacy retrieval <80% was considered as a lack of TA and the non-modification of treatment in badly controlled patient as TI. RESULTS: The percentage of patients with good control of HbA1c, blood pressure and LDL-cholesterol was 62.5%, 40.9%, and 35.9%, respectively. Lower figures of TA were present in poorly controlled patients, and TI was not found to be related to TA. In the patients with poor HbA1c control, 25.8% had TI, 24.8% poor TA, and 11.9% had both of them. As regards LDL-cholesterol, 3.6% presented poor TA, 70.4% showed TI, and 16% with poor TA and TI (P<.001). As for blood pressure, 3.5% of patients had poor TA, 54.6% had TI, and 21.5% of them had poor TA as well as TI (P<.01). CONCLUSIONS: Lack of therapeutic adherence and therapeutic inertia were found in a high percentage of poorly-controlled DM2 patients with bad control. Therapeutic inertia was found to be of great relevance in this study.

Determinaciones analíticas en el paciente diabético / Laboratory tests and the diabetic patient

En el paciente diabético se han de realizar analíticas para conocer su control metabólico, así como los factores de riesgo cardiovascular. En este artículo se analizan las determinaciones analíticas recomendadas y la frecuencia de su realización. La hemoglobina glucosilada es el parámetro que valora el control metabólico; hemos revisado el consenso para la armonización de los resultados y la reciente aceptación de esta determinación para el diagnóstico de diabetes tipo 2. Para el estudio de la dislipemia diabética hemos explicado todos los parámetros que son útiles, aunque el colesterol LDL es el aceptado para el diagnóstico y seguimiento. Para la valoración de la nefropatía diabética se utiliza la excreción urinaria de albúmina y la creatinina sérica para estimar el filtrado glomerular. Debido a que la disfunción tiroidea es común en los pacientes diabéticos, también se recomienda la determinación de TSH (AU)

Laboratory tests must be performed on diabetic patients in order to monitor metabolic control and their cardiovascular risk factors. In this paper, we review the recommended analytical determinations and the frequency of performing them. Glycosylated haemoglobin is the parameter used for assessing metabolic control. We have reviewed the Consensus for result harmonisation and the recent acceptance of this determination for the diagnosis of type 2 diabetes. We have explained all useful parameters for the study of diabetic dyslipidaemia, although LDL cholesterol is the accepted parameter for diagnosis and follow-up. Albumin excretion in urine is used in order to assess diabetic nephropathy and serum creatinine is used in order to assess glomerular filtration. As thyroid dysfunction is common in diabetic patients, TSH determination is recommended (AU)

Hepatocarcinoma en un paciente de 23 años de origen subsahariano portador del virus de la hepatitis B / No disponible

El hepatocarcinoma (HCC) es la tercera causa de muertepor cáncer en el mundo, siendo los factores etiológicos másfrecuentes el virus de la hepatitis B (VHB) y el virus de lahepatitis C (VHC). Presentamos el caso de un varón de 23años natural de Ghana, infectado por el VHB, que consultópor ictericia conjuntival y ascitis. Fue diagnosticado deHCC, siendo candidato para el tratamiento paliativo, y cuyasupervivencia fue inferior al mes desde el momento deldiagnóstico. En la actualidad, en los países desarrolladoslos casos de HCC atribuibles a VHB son escasos, debido ala implantación de programas de vacunación y al tratamientode los portadores del VHB. Dado el número importanteen nuestras consultas de inmigrantes originarios de paísescon alta prevalencia de infección por el VHB, deberíamoshacer una búsqueda activa de los pacientes portadores,para valorar si son candidatos para realizar un tratamientoantivírico (AU)

Hepatocellular carcinoma (HCC) is the third cause ofdeath by cancer in the world. The hepatitis B (HBV) andhepatitis C (HCV) viruses are the most frequent etiologicalfactors. We present the case of a 23-year-old male patientfrom Ghana, infected by HBV, who consulted for conjunctivaljaundice and ascites. He was diagnosed with HCC andthus he became a candidate for palliative treatment. His survivalwas less than one month after diagnosis. Nowadays indeveloped countries, the cases of HCC caused by HBV arescarce, due to implementation of vaccination programs andto treatment of HBV carriers. Given the important number ofpatients who immigrate from countries with a high prevalenceof HBV infection receiving medical care in our HealthSystem, we should carry on active search for HBV carriers inorder to assess whether they are candidates for antiviral treatment (AU)