LAM Extra for General Practicioners

[INSULIN SELF-TITRATION IN TYPE 2 DIABETES MELLITUS: BURDEN OR SOLUTION?]

TAKÁCS Róbert

JUNE 20, 2012

LAM Extra for General Practicioners - 2012;4(03)

[INTRODUCTION - Observational studies have verified that even in routine diabetes care, up to 1.3% reduction in HbA1c can be achieved with the initiation of a long-acting basal insulin analogue. We can get the same results in our patients using an insulin titration algorithm and close diabetological control. CASE REPORT - Metformin therapy of a 68-year old, moderately obese woman with type 2 diabetes was complemented by a long-acting basal insulin analogue (insulin glargine). Before initiation of insulin therapy, the patient received thorough dietetic and diabetic education by a qualified dietician and a diabetes nurse. The starting dose of insulin was 10 U, and then the patient was asked to increase the dose by 2 U every 3rd day depending on the mean of self-monitored fasting plasma glucose values in the previous 2 days. With the aid of a titration algorithm, optimal carbohydrate metabolism has been verified by laboratory parameters assessed 3 months later. CONCLUSION - Insulin self-titration based on appropriate patient education and close professional control makes a relatively simple therapeutic system the optimal decision in terms of a rapid and chronic normalisation of glucose control in a large patient group.]

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LAM Extra for General Practicioners

[BACTERIAL CONTAMINATION AND IRRITABLE BOWEL SYNDROME]

NOVÁK János

[Irritable bowel syndrome (IBS) is one of the most common gastrointestinal condition, which affects 10-15% of adults in developed countries. Recent observations have raised the possibility that disturbances in the gut microbiota and/or the accompanying low-grade inflammatory state might contribute to the etiology and symptomatology of irritable bowel syndrome. Some studies indicate that small intestinal bacterial overgrowth (SIBO), as confirmed by hydrogen breath tests (HBT), is more prevalent in patients with irritable bowel syndrome than in matched controls without IBS. Although the data are conflicting, this observation has led to the hypothesis that bacterial contamination was the primary cause of IBS. As a consequence of this hypothesis, a lot of therapeutic options have found their way into the armamentarium of those who treat patients with IBS. These agents include probiotics, prebiotics, antibiotics and anti-inflammatory agents. This paper describes the various mechanisms by which changes in the gut flora might contribute to IBS and also discusses the efficacy and safety of antibiotic therapies, especially rifaximin, for treating IBS/SIBO symptoms.]

LAM Extra for General Practicioners

[THE DIABETIC FOOT SYNDROME: PATHOMECHANISM, CLINICAL PICTURE, CURRENT TREATMENT AND PREVENTION]

JERMENDY György

[Diabetic foot syndrome is a characteristic late complication of diabetes mellitus. It can develop in patients with type 1 as well as type 2 diabetes mellitus, especially in case of a long duration of diabetes and sustained poor metabolic state. Diabetic neuropathy plays a pivotal role in the pathomechanism, but vascular symptoms might also contribute to the complex clinical picture. For making the diagnosis, evaluation of complaints, performing physical examination and using simple tests for identifying both distal, somatosensory neuropathy and potential angiopathy are of great importance. Therapeutic approaches aim to achieve proper glycaemic control, as well as to ameliorate symptoms of neuropathy, improve peripheral blood supply by medicines, angioplasty or intervention radiological methods, fight against infections and off-load the foot. Surgical intervention might also be necessary, and in severe cases, amputation might be needed. The diabetic foot syndrome increases mortality risk in patients with diabetes. Complaints related to diabetic foot syndrome are often resistant to treatment and tend to recur. Thus, prevention with long-term, good metabolic control and protection of the foot are of particular importance.]

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[INTRODUCTION - Knowing the pharmacokinetic properties of different insulins, useful treatment algorithms can be set up for the majority of our insulin-treated patients. When planning either a human or an analogue basal-bolus regimen, the first task is to determine the daily insulin requirement, followed by determination of the optimal rate of basal and bolus insulins. CASE REPORT - In a 33-year old, moderately obese man with type 1 diabetes who received 180 U daily insulin doses, accumulated hypoglycaemic episodes with neuroglycopenic symptoms occured. After cessation of the original insulin therapy and starting an analogue basal-bolus treatment regimen, both the carbohydrate metabolism and the overall quality of life of the patient have significantly improved. Optimal metabolic control was achieved by a basal insulin ratio above 50%. CONCLUSION - Using elements of the analogue basal-bolus regimen - one of the state-of-the-art forms of insulin treatment - at the appropriate dose and dose ratio, it is possible to comply with the therapeutic requirements of our age. However, if this weapon is used inappropriately, it might actually harm patients.]

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[Titration of insulin glargin in type 2 diabetic patients treated with oral agents and with necessity of basal insulin in everyday medical practice ]

VÁNDORFI Győző, KOVÁCS GÁBOR

[INTRODUCTION - Early insulin treatment is a widely accepted option for combination glucose-lowering therapy, and its most common form is basal insulin supported oral therapy (BOT). Due to its 24-hour action and lack of peaks in plasma insulin concentrations, insulin glargine is an ideal choice for BOT. METHODS - We conducted a prospective, non-interventional study to evaluate the efficiency and safety of dose titration, the period of time necessary to reach the target fasting blood glucose level, and the changes in glargine insulin dose. The study group included patients with type 2 diabetes who had been treated with insulin glargine in BOT regimen for no longer than four weeks. The follow-up period was six months. RESULTS - During the study period, the mean fasting plasma glucose was decreased from 9.8 mmol/L to 6.7 mmol/L, the mean HbA1c level decreased from 8.8% to 7.3%, and the mean postprandial glucose level decreased from 11.5 mmol/L to 8.2 mmol/L. Mild hypoglycaemic episodes occurred in 6.5% of patients in the first 3 months and in 6.9% of patients between months 3 and 6. During the same periods, severe hypoglycaemic episodes occurred in 0.08% and 0.17% of patients, respectively. Both mean body weight and mean BMI decreased during the study period. The average daily dose of glargine continuously increased during the observation period from baseline 10.42 IU to 17.69 IU. DISCUSSION - In the study population, glargine therapy in BOT regimen significantly improved glycaemic control, while a slight but statistically significant reduction was observed in the patients’ body weight. The daily dose of insulin glargine increased during titration, and the therapy proved to be safe.]