Walid Kaplan

Effects of Mixing Glargine and Short-Acting Insulin Analogs on Glucose Control

Intensive insulin management improves glycemic control and lowers the risks of long-term microvascular complications (1). Several new insulin analogs (2) are in use to improve glycemic control in type 1 diabetes. Glargine in particular is a “basal insulin” (3) and found to be relatively peakless. Glargine is thought to provide glucose profiles similar to insulin pumps (4). Although some clinical studies suggest that glargine lasts 24 h in children with diabetes (5), to date there have been no formal pharmacokinetic and pharmacodynamic data to make that claim in the pediatric population. In fact, clinical observations in pediatric type 1 diabetes suggest that glargine action may be <24 h. This would entail twice-daily glargine dosing and short-acting insulin analogs (SAIs), such as lispro and aspart, given separately three to four times per day, resulting in improved glycemic control but compromising compliance and increasing complexity of management (6). In this study, we tested the hypothesis that mixing glargine with SAIs and dividing the dose of glargine into twice- versus once-daily dosing would not adversely affect glycemic control as assessed by a continuous glucose monitoring system (CGMS). The protocol was approved by the institutional review board of the Baylor College of Medicine, and consent was obtained before each study. Subjects were recruited from Texas Children’s Hospital Diabetes Care Center, Houston, Texas. Subjects had type 1 diabetes for at least 1 year with no other chronic illness and were on …

Short-term effects of recombinant human growth hormone and feeding on gluconeogenesis in humans

After a short-term fast, lactating women have increased rates of glucose production but not gluconeogenesis (GNG) despite relative hypoinsulinemia. We explored the effects of non-insulin-dependent increase in glucose utilization and recombinant human growth hormone (rhGH) on glucose production, glycogenolysis, and GNG in both the fed and overnight-fasted condition. Six controls and 7 lactating women were studied twice, in random order, after 7 days of saline or rhGH. Glucose kinetics and GNG were measured using [U-(13)C]glucose mass isotopomer distribution analysis. The rhGH increased milk production in the lactating women and insulin-like growth factor (IGF) in both groups. Glycogenolysis and GNG were higher in fasting lactating women than controls after either saline or rhGH (P < .05). After rhGH administration, GNG remained higher (P < .02) in the lactating women than controls. Gluconeogenesis was not suppressed in either group during 5 hours of continuous meal ingestion, despite a 5-fold increase in plasma insulin. Lactating women had similar glucose but lower insulin and C-peptide concentrations than controls after both rhGH and saline treatment (P < .01), although rhGH decreased (P < .01) insulin sensitivity in both groups (P < .05). Gluconeogenesis is not affected by short-term increases in insulin and/or rhGH, which suggests a fundamental rethinking of the role of insulin in acutely regulating GNG.

Blood glucose fluctuation during Ramadan fasting in adolescents with type 1 diabetes: findings of continuous glucose monitoring.

Because of the scant data about the effect of fasting on the blood glucose (BG) profile in adolescents with type 1 diabetes (T1D), health care providers have been giving conflicting advice about the feasibility of fasting during the month of Ramadan for this group of patients. This study was done in adolescents with T1D to assess the ability and safety of fasting during Ramadan and to monitor the BG profile with a continuous glucose monitor (CGM). Adolescents with T1D who intended to fast during the month of Ramadan in 2013 were asked to wear a CGM while fasting and to report any episode of severe hypoglycemia or diabetic ketoacidosis or emergency room visit. Pump basal rate was modified according to the eating pattern during Ramadan. The averages of all daily readings were calculated to express the BG values …

Osteopenic effects of MgSO4 in multiple pregnancies.

OBJECTIVE To describe the effects of prolonged maternal treatment with MgSO4 in infants who were products of multiple pregnancies. STUDY DESIGN Case series of infants presenting with osteopenia secondary to MgSO4 administration for preterm labor. RESULTS Ten premature infants with hypermagnesemia (4.5+/-0.2 mg/dl), hypocalcemia (6.0 +/-0.3 mg/dl), and high serum alkaline phosphatase (574+/-96 U/l) underwent imaging studies that showed diffuse osteopenia of the long bones and probable rib fractures. All mothers had isolated premature labor, for which they were given MgSO4; (average dose 3.66+/-0.08 kg/ pregnancy over 10.0+/-0.5 weeks). On follow-up (to 9 months), all infants had complete or near complete resolution of the osteopenia. CONCLUSIONS Premature infants who are exposed to large doses of MgSO4, especially those of multiple pregnancies, have an increased risk of developing hypocalcemia, osteopenia, and fractures. Our findings indicate that these infants should be identified at birth and managed prospectively.

Comparison of continuous glucose monitoring in adolescents with type 1 diabetes: Ramadan versus non-Ramadan

AIM To assess the impact of fasting on interstitial glucose (IG) in adolescents with type 1 DM (T1DM) by using continuous glucose monitoring (CGM). METHOD A minimum of 2.5 days CGM was done on adolescents with T1DM during fasting in Ramadan and in the month before or after Ramadan to compare the differences in mean IG, and in the durations of hypoglycemia (<70 mg/dL), hyperglycemia (200-299 mg/dL), and severe hyperglycemia (≥300 mg/dL). RESULTS Fourteen adolescents were studied, age 15 ± 4 years, duration of diabetes 6 ± 4 years, and HbA1C 8.6 ± 1.1% (70.3 mmol/mol). There was no difference in the mean IG (190 ± 39 and 180 ± 37, p= 0.4), or in the durations of hypoglycemia (5.14 ± 5% and 7.03 ± 4.9%, p=0.3), hyperglycemia (25.35 ± 11.3% and 24.24 ± 10.1% (P=0.7)), and severe hyperglycemia (13.21 ± 13.4% and 10.96 ± 10.6%, P=0.6), between Ramadan and, non-Ramadan, respectively. CONCLUSION Adolescents with T1DM have the same wide fluctuation in IG during fasting in Ramadan as they do outside Ramadan. Insulin regimen adjustment should be targeting both extremes of glucose abnormality.

Prevalence of autoantibodies in type 1 diabetes patients and its association with the clinical presentation – UAE Eastern Region experience

Abstract Background: Positive autoantibodies and its association with the clinical course of type 1 diabetes mellitus (T1DM) have been reported worldwide, however, no such data have been reported in United Arab Emirates population. Objectives: To study the prevalence of positive autoantibodies in T1DM pediatric patients and its association with the clinical presentation. Methods: Descriptive retrospective chart review of all new cases of pediatric T1DM at Tawam Hospital. Electronic patient records accessed to obtain data. Results: 61 patients were identified. 88%±8.1 had at least 1 positive antibody and 82% of all patients were positive for anti-glutamic acid decarboxylase (GAD). While comparing the group of any positive antibody (n=54) with the group of all negative antibodies (n=7), a significant difference was found in the mean HbA1C (p=0.02) and nationality (p=0.03). Conclusion: The vast majority of our T1DM pediatric patients are autoantibody positive, and anti-GAD antibodies were the most commonly detected antibodies.

Rate, Timing, and Severity of hypoglycemia in adolescents with Type 1 diabetes during ramadan fasting: A study with freestyle libre flash glucose monitoring system

Objectives: The objective of this study is to assess the frequency, timing, and severity of hypoglycemia in adolescents with type 1 diabetes mellitus (T1DM) during fasting the month of Ramadan. Patients and Methods: Twenty-five adolescents with T1DM who fasted Ramadan were monitored using the FreeStyle Libre® flash glucose monitoring (FGM) system. Percentage and total duration of hypoglycemia were extracted from the FGM downloads, and the differences were compared between different times of the day and night according to the eating pattern in Ramadan. Results: Mean age was 16 ± 3 years and mean glycated hemoglobin was 8.6 ± 1.2%, mean glucose level was 200 ± 84 mg/dl (11.1 ± 4.7 mmol/L), and the overall time spent in hypoglycemia was 5.7% ±3.0%. The average daily time spent in hypoglycemia was 1.39 h per patient. The incidence of hypoglycemia was 0% from 19:00 to 23:00 pm and 69% from 11:00 to 19:00. Analysis of hypoglycemia revealed that 65% were between 61 and 70 mg/dl and 8% lower than 50 mg/dl. Conclusions: Hypoglycemia is typically encountered during the hours preceding Iftar time indicating an over-effect of basal insulin. Basal insulin reduction is necessary to minimize the risk of hypoglycemia

Effect of Growth Hormone on Final Height in Children with Idiopathic Short Stature: A UAE, Eastern Region Experience

Objectives The use of growth hormone (GH) in idiopathic short stature (ISS) has been a subject of debate for the past two decades. We sought to assess the effect of GH on final height (FH) in patients with ISS in our region, which has a high consanguinity rate, and compare it to the effect observed in GH deficient (GHD) patients. Methods We conducted a retrospective chart review from 1 January 2005 to 31 December 2013 for patients with ISS or GHD from the local United Arab Emirates population who received GH treatment and were followed-up regularly in our clinic. The change in height Z-score at 12 months and FH were assessed within each group and between the two groups. Results Twenty-one patients with ISS and 29 patients with GHD were studied. There was a significant change in height Z-score at 12 months and FH in both groups (p < 0.001). The improvement in the ISS group was comparable to the response seen in GHD patients at 12 months (0.5±0.3 standard deviation score (SDS), and 0.5±0.4 SDS, respectively; p = 0.540). The effect on FH was better in ISS group than the GHD group of all etiologies (1.3±0.6 SDS vs. 0.9±0.7 SDS, respectively; p = 0.050), there was no difference between the ISS and the subgroup of idiopathic GHD (1.3±0.5 SDS and 1.2±0.8 SDS, respectively). Conclusions In our local population, GH has a positive effect on the short-term growth and FH of children with ISS to the same extent that has been observed in children with idiopathic GH deficiency.

Hyperglycaemic hyperosmolar syndrome in a 5-year-old girl with newly diagnosed type 2 diabetes mellitus

Diabetes & Metabolism - In Press.Proof corrected by the author Available online since samedi 9 decembre 2017