Ana Margarida Monteiro

Cardiovascular safety of type 2 diabetes medications: Review of existing literature and clinical implications.

Type 2 diabetes mellitus (T2DM), cardiovascular disease (CVD) and the cardiovascular effect of antidiabetic drugs are today critical medical issues, with the prevalence of T2DM in particular showing a steep increase worldwide, mainly due to unhealthy lifestyle habits. T2DM in association with obesity and other cardiovascular risk factors, results in the development of CVD, the leading cause of morbidity and mortality in patients with T2DM. Thus, treatment of T2DM is an individualized and complex challenge in which targeting cardiovascular risk factors is an important component in the decision making. Given the cardiovascular adverse events associated with rosiglitazone, both the Food and Drug Administration and the European Medicines Agency currently require the demonstration of cardiovascular safety of new antidiabetic drugs. Consequently, clinical trials to guarantee their cardiovascular safety are now obligatory. This review aims to summarize the available evidence on the cardiovascular effects and safety of the major drugs used in T2DM treatment and also to provide an overview of upcoming and ongoing clinical trials in this field. Our belief is that this review will be of substantial assistance to all medical doctors who are treating diabetic patients, namely primary care physicians, internal medicine doctors, endocrinologists, diabetologists and less well experienced personnel such as young doctors in training.

Insulinoma: Uma Causa Rara de Hipoglicemia

Insulinoma is the most frequent pancreatic functional neuroendocrine tumour. The clinical presentation is variable and maymimic other diseases. A 61-year-old female patient, with several episodes of behavioural changes in the last 2 years. In one of these episodes, hypoglycemia was noted. The etiological study revealed inappropriately elevated values of insulin and C-peptide, consistent with endogenous hyperinsulinism. In spite of normal abdominal computed tomography, magnetic resonance and somatostatin receptors scintigraphy, the endoscopic ultrasound showed an infracentimetric pancreatic lesion compatible with insulinoma. The patient was submitted to surgical excision of the lesion, and remains asymptomatic and free of disease. We emphasize the unspecific clinical presentation and the small dimension of the lesion, which may lead to a significant time gap between the start of the symptoms and the treatment. Received: 02/06/2017 - Accepted: 27/10/2017

Universal vs. risk-factor-based screening for gestational diabetes—an analysis from a 5-Year Portuguese Cohort

PurposeThe criteria to screen for Gestational Diabetes Mellitus are not internationally consensual. In opposition to the universal screening performed in Portugal, certain countries advocate a risk-factor-based screening. We aim to compare obstetric and neonatal outcomes in pregnant women with and without risk factors treated for Gestational Diabetes Mellitus.MethodsRetrospective and multicentric study of 12,006 pregnant women diagnosed with Gestational Diabetes Mellitus between 2011 and 2015, in Portugal. Gestational Diabetes Mellitus was diagnosed according to the International Association of the Diabetes and Pregnancy Study Groups criteria. Risk factors: body mass index > 30kg/m2, history of Gestational Diabetes Mellitus, history of macrossomic newborn (birth weight > 4000 g) or first-degree relatives with Type 2 Diabetes Mellitus. Exclusion criteria: lack of data concerning risk factors (n = 1563).ResultsAt least one risk factor was found in 68.2% (n = 7123) pregnant women. Pregnant women with risk factors were more frequently medicated with insulin (p < 0.001), caesarean section was more commonly performed (p < 0.001), their newborns were more frequently large-for-gestational-age (p < 0.001) and neonatal morbidity was higher (p = 0.040) in comparison to pregnant women without risk factors. The Diabetes Mellitus reclassification test showed an increased frequency of intermediate hyperglycaemia and Diabetes Mellitus in women with risk factors (p < 0.001).ConclusionAlmost one-third of pregnant women would have remained undiagnosed if risk-based-factor screening were implemented in Portugal. Women without risk factors presented fewer obstetric and neonatal complications. However, more than one third required insulin therapy.

Iatrogenic water intoxication in a female adolescent with hypopituitarism

The authors report a case of a 15-year-old girl with hypopituitarism due to pituitary stalk interruption syndrome diagnosed in the neonatal period. The patient was admitted to the emergency room with impaired consciousness and hypoglycaemia. The day before, she increased her water intake to about 1.5 L to perform a pelvic ultrasound. In the following hours, she developed vomiting and food refusal. Blood analysis revealed hypoglycaemia, hyponatraemia, decreased serum osmolality and normal urinary density. Hyponatraemia and adrenal crisis were managed with a gradual but slow resolution of consciousness and electrolytic balance. This case describes an episode of iatrogenic water intoxication in a patient under desmopressin treatment. Although uncommon, dilutional hyponatraemia is the main complication of desmopressin treatment. We reinforce the importance of patients and caregivers’ long-life education for the potential complications of an increase in fluid intake in patients treated with desmopressin.

Hipertensão de Causa Endócrina: Hiperaldosteronismo Primário por Síndrome de Conn

Primary aldosteronism is one of the most prevalent causes of secondary hypertension. It is characterized by inappropriately high and partially autonomous aldosterone production by the adrenal gland. The diagnosis warrants a high aldosterone/renin ratio and, in some cases, a confirmatory test. The treatment is laparoscopic adrenalectomy or medical therapy with mineralocorticoid receptor antagonists. The authors describe the case of a 55-year-old patient with hypokalemia and hypertension refractory to therapy for 16 years. The investigation was compatible with primary aldosteronism by aldosterone-producing adenoma. The patient underwent right laparoscopic adrenalectomy, with substantial improvement of symptomology. The case report aims to describe an important cause of secondary hypertension that if detected and managed adequately may allow the resolution of hypertension. Received: 10/10/2016 - Accepted: 03/06/2017

Type 2 Diabetes Decompensation as the Clinical Presentation of Thyroid Storm – Cause or Consequence?

Abstract This case study aims to discuss the unusual forms of hyperthyroidism presentation, the nonspecific symptoms and precipitating events. A 70-year-old male was taken to the emergency department for hyperglycaemia, nausea, vomiting and altered mental status with a week of evolution. He had a past medical history of type 2 diabetes, hypertension and dyslipidemia. He had no history of any recent intercurrent illness or infection. At the emergency room, besides hyperglycaemia, ketonemia and slightly elevated C-reactive protein, the basic laboratory panel workup was normal, as was the head computed tomography. He was admitted for metabolic compensation and to study the altered neurological status. During hospitalisation, despite the good glycemic control, he had no improvements in neurological status. At day four of hospitalisation, thyrotoxicosis with thyroid storm criteria was diagnosed. He started on adequate treatment with complete clinical recovery. The associated morbidity and mortality of thyroid storm requires immediate recognition and treatment. Elderly patients are frequently misdiagnosed or diagnosed later due to fewer and less pronounced signs and symptoms.