[The metabolic impact of fiber in gestational diabetes]. / Impact métabolique des fibres en cas de diabète gestationnel.

An adequate fiber intake is recommended for pregnant women, with or without gestational diabetes, similarly to the general population. Due to the lack of precise data on the composition of fiber in foods, dietary advices are not specific. Their objective is to increase the overall fiber consumption, ideally up to a daily consumption of 28g. Fiber intake has diverse effects and it is predominantly the intake of the viscous soluble fibers that improves the glycemic profile. In the case of gestational diabetes, supplementation with fiber products can be of interest in addition to the dietary recommendations to improve the postprandial glycemic profiles. More precise information on the impact of foods according to their fiber composition is needed to optimize the dietary advice.

Une consommation suffisante de fibres fait partie des recommandations pour les femmes enceintes, avec ou sans diabète gestationnel, tout comme pour la population générale. Par manque de données précises sur la composition des fibres des aliments, les conseils alimentaires se trouvent être peu spécifiques, avec pour objectif d'augmenter la consommation de manière générale à 28 g par jour. Les fibres ont des effets divers, et ce sont surtout les fibres solubles visqueuses qui améliorent le profil glycémique. En cas de diabète gestationnel, une supplémentation est intéressante pour limiter les élévations glycémiques, en plus des conseils pour majorer les fibres de manière générale dans l'alimentation. Plus de détails sur l'impact des aliments en fonction de leur composition en fibres sont nécessaires pour optimiser les conseils alimentaires.

[Rapid and ultrarapid insulins: when and how?] / Insulines rapides et ultrarapides : quelles indications et utilités ?

Treatment combining long-acting and short-acting insulins is essential for people with type 1 diabetes, but may become also compulsory in other forms of diabetes in case of insulinopenia. The purpose of short-acting insulins is to mimic physiological insulin secretion in response to carbohydrate intake at meals. There is a delay between the injection and its action, sometimes limiting their use and effectiveness. Ultra-rapid insulins have been developed to more closely approximate the expected insulin response to a meal, through faster absorption. They do not improve diabetes control but allow more flexibility with mealtime injections. These new analogues are also an attractive alternative for use in insulin pumps.

Un traitement combinant insulines lente et rapide est essentiel pour les personnes avec un diabète de type 1, mais peut le devenir dans d'autres formes de diabète en cas d'insulinopénie. Le but des insulines rapides est de mimer la sécrétion physiologique d'insuline en réponse à la prise de glucides aux repas. Il y a un délai entre l'injection et son action, limitant parfois leur usage et leur efficacité. Des insulines ultrarapides ont été développées pour se rapprocher davantage de la réponse insulinique attendue à un repas, grâce à une absorption plus rapide. Elles n'améliorent pas le contrôle du diabète mais permettent plus de flexibilité avec les injections aux repas. Ces nouveaux analogues sont également une alternative intéressante pour une utilisation dans les pompes à insuline.

Exposure to alirocumab during the first trimester of pregnancy: A case report.

BACKGROUND: Familial hypercholesterolemia can be efficiently treated with combined lipid-lowering drugs. Lipid-lowering drugs are usually withdrawn for pregnancy and breastfeeding, ideally preconception, followed by lipid apheresis, however, careful plans can be precipitated due to unexpected pregnancy. CASE: A 28-year old woman with familial hypercholesterolemia due to heterozygous LDLR mutations had an LDL-cholesterol level at 14.6 mmol/L and Lp(a) at 1150 mg/L. She required a three-vessel coronary artery bypass graft, drug-eluting stents, rosuvastatin, ezetimibe, and alirocumab at maximal dosage. Contraception was advised during the following 12 months, with a planned drug withdrawal to bridge with lipid apheresis, such as the direct adsorption of lipoproteins (DALI). However, an unplanned pregnancy required an abrupt stop of all oral medications at six gestational weeks, except for aspirin. Lipid apheresis controlled LDL-cholesterol in the range of 4.9-7.9 mmol/L (before DALI session) to 1.2-3.2 mmol/L (after DALI session). Later, the regular pregnancy ultrasounds highlighted an isolated agenesis of the corpus callosum later confirmed by magnetic resonance imaging. CONCLUSIONS: A causal link between the early pregnancy exposure to PCSK9 inhibitors (or statins and ezetimibe taken concomitantly) and the observed complete agenesis of the corpus callosum seems unlikely in this case. Guidelines do not specifically recommend preconception measures to lower fetal and/or maternal risks of patients with severe FH considering pregnancy. We argue that lipid apheresis and other measures should be discussed with women with FH and maternity project on an individual basis, until pharmacoepidemiology studies assessing the safety of PCSK9 inhibitors in pregnancy are available.

[Basal insulin therapy in patients with type 2 diabetes]. / Insulinothérapie basale chez les patients diabétiques de type 2.

Insulin therapy, often initiated after hygiene and dietary measures and non-insulin antidiabetics, is part of the treatment of patients with type 2 diabetes. Fear of injections or hypoglycemia often delays its implementation. However, its introduction is recommended in cases of poorly balanced diabetes despite a well-controlled therapeutic escalation but also in cases of acute imbalance. Introduction of insulin therapy requires patient education and close monitoring by the healthcare team. Type of insulin and its titration reduce the incidence of hypoglycemia in patients at risk. The determination of the fasting glycemic target - relative to HbA1c - for the titration of insulin is important to define for an optimal benefit (prevention of secondary complications)/risk (hypoglycemia, weight gain) balance.

L'insulinothérapie, souvent mise en place après les mesures hygiéno-diététiques et les antidiabétiques non insuliniques, fait partie du traitement des patients diabétiques de type 2. La peur des injections ou des hypoglycémies retarde souvent sa mise en place. Cependant, son introduction est recommandée en cas de diabète mal équilibré malgré une escalade thérapeutique bien conduite mais aussi en cas de déséquilibre aigu. L'insulinothérapie implique un enseignement au patient et un suivi rapproché par l'équipe soignante. Le type d'insuline et sa titration progressive permettent de réduire l'incidence des hypoglycémies chez les patients à risque. La détermination de la cible glycémique pour la titration de l'insuline est importante à définir pour une balance bénéfice (prévention des complications secondaires)/risque (hypoglycémie, prise pondérale) optimale.

Blood Pressure and Renal Responses to Orthostatic Stress Before and After Radiofrequency Renal Denervation in Patients with Resistant Hypertension.

BACKGROUND/AIMS: In patients with resistant hypertension, renal denervation (RDN) studies have mainly focused their outcomes on blood pressure (BP). The aim of this study was to evaluate the long-term effect of RDN on neurohormonal profiles, renal hemodynamics and sodium excretion in a resting state and during stress induced by lower body negative pressure (LBNP). MATERIALS AND METHODS: This was a single center prospective observational study. Norepinephrine, plasma renin activity (PRA), glomerular filtration rate (GFR), renal plasma flow (RPF) and sodium excretion were measured in unstimulated conditions (rest) and after one hour of LBNP at three different time points: before (M0), one (M1) and twelve months (M12) after RDN. RESULTS: Thirteen patients with resistant hypertension were included. In the resting state, no differences were observed in norepinephrine, PRA, sodium excretion and mean BP levels after RDN. GFR (78 ± 32 ml/min at M0 vs 66 ± 26 ml/min at M12 (p = 0.012) and filtration fraction (22.6 ±5.4% at M0 vs 15.1 ±5.3% at M12 (p = 0.002)) both decreased after RDN. During LBNP, the magnitude of the mean BP increase was reduced from +6.8 ± 6.6 mm Hg at M0 to +2.3 ± 1.3 mm Hg at M12 (p = 0.005). The LBNP-induced increase in norepinephrine and decrease in GFR and sodium excretion observed before RDN were blunted after the procedure. CONCLUSION: A decrease in GFR and filtration fraction was observed one year after RDN. In addition, our results suggest that RDN blunts not only the norepinephrine but also the mean BP, the GFR and the sodium excretion responses to an orthostatic stress one year after the intervention. REGISTRY NUMBER: NCT01734096.

[Hypertension and medication compliance: a challenge every day]. / Hypertension et adhérence thérapeutique: un challenge de tous les jours.

Hypertension is a cardiovascular risk factor frequently encountered in everyday practice. A drug therapy is often necessary to normalize blood pressure. However, despite adequate intensive drug treatment, adequate blood pressure target are not reached. Lack of adherence to treatment is often the cause. This article reviews various techniques for assessing patients' adherence and offers several ways to improve it.

L'hypertension artérielle est un facteur de risque cardiovasculaire fréquemment rencontré dans la pratique quotidienne. Une prise en charge médicamenteuse est très souvent nécessaire afin de normaliser la pression artérielle. Il arrive cependant que le traitement médicamenteux intensif ne permette pas d'atteindre les cibles tensionnelles. Un manque d'adhérence au traitement en est fréquemment la cause. Cet article passe en revue diverses techniques pour évaluer l'adhérence des patients et propose plusieurs moyens afin de l'améliorer.

State-of-the-art treatment of hypertension: established and new drugs.

The treatment of essential hypertension is based essentially on the prescription of four major classes of antihypertensive drugs, i.e. blockers of the renin--angiotensin system, calcium channel blockers, diuretics and beta-blockers. In recent years, very few new drug therapies of hypertension have become available. Therefore, it is crucial for physicians to optimize their antihypertensive therapies with the drugs available on the market. In each of the classes of antihypertensive drugs, questions have recently been raised: are angiotensin-converting enzyme (ACE) inhibitors superior to angiotensin II receptor blockers (ARB)? Is it possible to reduce the incidence of peripheral oedema with calcium antagonists? Is hydrochlorothiazide really the good diuretic to use in combination therapies? The purpose of this review is to discuss these various questions in the light of the most recent clinical studies and meta-analyses. These latter suggest that ACE inhibitors and ARB are equivalent except for a better tolerability profile of ARB. Third generation calcium channel blockers enable to reduce the incidence of peripheral oedema and chlorthalidone is certainly more effective than hydrochlorothiazide in preventing cardiovascular events in hypertension. At last, studies suggest that drug adherence and long-term persistence under therapy is one of the major issues in the actual management of essential hypertension.