Portuguese-Brazilian evidence-based guideline on the management of hyperglycemia in type 2 diabetes mellitus.

BACKGROUND: In current management of type 2 diabetes (T2DM), cardiovascular and renal prevention have become important targets to be achieved. In this context, a joint panel of four endocrinology societies from Brazil and Portugal was established to develop an evidence-based guideline for treatment of hyperglycemia in T2DM. METHODS: MEDLINE (via PubMed) was searched for randomized clinical trials, meta-analyses, and observational studies related to diabetes treatment. When there was insufficient high-quality evidence, expert opinion was sought. Updated positions on treatment of T2DM patients with heart failure (HF), atherosclerotic CV disease (ASCVD), chronic kidney disease (CKD), and patients with no vascular complications were developed. The degree of recommendation and the level of evidence were determined using predefined criteria. RESULTS AND CONCLUSIONS: In non-pregnant adults, the recommended HbA1c target is below 7%. Higher levels are recommended in frail older adults and patients at higher risk of hypoglycemia. Lifestyle modification is recommended at all phases of treatment. Metformin is the first choice when HbA1c is 6.5-7.5%. When HbA1c is 7.5-9.0%, dual therapy with metformin plus an SGLT2i and/or GLP-1RA (first-line antidiabetic agents, AD1) is recommended due to cardiovascular and renal benefits. If an AD1 is unaffordable, other antidiabetic drugs (AD) may be used. Triple or quadruple therapy should be considered when HbA1c remains above target. In patients with clinical or subclinical atherosclerosis, the combination of one AD1 plus metformin is the recommended first-line therapy to reduce cardiovascular events and improve blood glucose control. In stable heart failure with low ejection fraction (< 40%) and glomerular filtration rate (eGFR) > 30 mL/min/1.73 m2, metformin plus an SGLT-2i is recommended to reduce cardiovascular mortality and heart failure hospitalizations and improve blood glucose control. In patients with diabetes-associated chronic kidney disease (CKD) (eGFR 30-60 mL/min/1.73 m2 or eGFR 30-90 mL/min/1.73 m2 with albuminuria > 30 mg/g), the combination of metformin and an SGLT2i is recommended to attenuate loss of renal function, reduce albuminuria and improve blood glucose control. In patients with severe renal failure, insulin-based therapy is recommended to improve blood glucose control. Alternatively, GLP-1RA, DPP4i, gliclazide MR and pioglitazone may be considered to reduce albuminuria. In conclusion, the current evidence supports individualizing anti-hyperglycemic treatment for T2DM.

Hyperglycemia effect on coronary disease in patients with metabolic syndrome evaluated by intracoronary ultrasonography.

INTRODUCTION: Metabolic syndrome (MS) is characterized by dyslipidemia, central obesity, hypertension and hyperglycemia. However, type 2 diabetes mellitus (T2DM) may or may not be present in metabolic syndrome. MS and T2DM are considered important cardiovascular risk factors, but the role of hyperglycemia in coronary disease is still contested in the literature. Therefore, we decided to evaluate the effect of hyperglycemia on the severity of coronary disease in MS patients, with or without T2DM, submitted to coronary angiography (CA) and intravascular ultrasonography (IVUS). MATERIALS AND METHODS: This is a cross sectional, observational study with 100 MS patients (50% with T2DM), 60% male. All of the patients had been referred for CA procedures. The obstruction was considered severe when stenosis was greater than 70% and moderate if it was between 50-69%. Patients detected with a moderate obstruction by CA were indicated to IVUS. A minimal luminal area of less than 4mm2 detected by IVUS was also considered severe. IDF criteria were used to define Metabolic Syndrome and T2DM diagnosis was defined according to the American Diabetes Association criteria. Student's t-test and Pearson Chi-square were used for statistical analysis, considering p < 0.05 statistically significant. RESULTS AND DISCUSSION: The majority of T2DM patients presented severe arterial lesions (74% vs 22%, p<0.001). Using CA procedure, 12% of T2DM had moderate obstructions, compared to 38% of the non-diabetic group (p< 0.05). 8% of patients with moderate lesions by CA were diagnosed with a luminal area less than 4mm2 using IVUS. This luminal area was significantly smaller in the T2DM group than in the control group (3.8mm2 ± 2.42. vs 4.6mm2 ± 2.58, p = 0.03). CONCLUSION: Patients with MS and T2DM submitted to angiography and IVUS, had more severe coronary lesions compared to MS patients without diabetes. This finding suggests that beyond insulin resistance that is present in MS, hyperglycemia may also play a role in the development of atherosclerotic disease. IVUS was useful for diagnosing 8% of severe cases initially considered to be moderate obstructions when using just CA in this scenario.

Implantação de sistema de suporte a decisão clínica e análise de dados em pacientes com hipoglicemia / Clinical decision-support system implementation and data analysis in patients with hypoglycemia / Implantación del sistema de apoyo a la toma de decisiones y análisis de los datos en pacientes con hipoglucemia

Foi desenvolvido no Hospital Sírio Libanês um sistema de apoio à decisão de condutas nas linguagens de programação JAVA e Delphi. Foi implantado no sistema um protocolo para tratamento de hipoglicemia que após o diagnóstico através da glicemia capilar e inserção do dado no sistema, inicia-se um processo que finaliza em uma conduta. O objetivo deste estudo foi descrever o processo de implantação deste sistema, além de analisar os dados demográficos das hipoglicemias. É um estudo observacional, transversal, retrospectivo. Os dados foram coletados de 01/2014 a 12/2015.635 episódios de hipoglicemia foram avaliados. 87,1% das 635 hipoglicemias foram leves (50 a 60mg/dL). A unidade de internação oncológica mostrou a menor prevalência de hipoglicemias (17,8%), enquanto internações prolongadas entre16 e 30 dias mostraram maior prevalência (21,6%). As hipoglicemias também foram mais comuns em homens acima de45 anos e em mulheres entre 15 e 44 anos.

A decision support system was developed at Sírio Libanês Hospital using the programming languages JAVA and Delphi. A hypoglycemic protocol was inserted in the system to test the support to clinical decision. After a hypoglycemia diagnosis using the capillary glucose test, the data was inserted in the system and a process was generated with some steps that finished with an intervention procedure. The objective of this study was to describe the system implementationprocess and to analyze demographic characteristics of hypoglycemic episodes. This is an observational,cross-sectional, retrospective study. The data was from January 2014 to December 2015. 635 hypoglycemic episodeswere included in this analysis. 87.1% hypoglycemic episodes were mild. Oncology unit was the one with lower prevalence(17.8%), while a longer stay at the hospital (16 to 30 days) had a high prevalence (21.6%). Hypoglicemic episodes were more common in men over 45 years old and among women between 15 and 44 years old.

Influência da composição da dieta na gordura intramiocelular, função endotelial e resistência à insulina, em mulheres jovens com sobrepeso metabolicamente saudáveis / High fat and high cab diet effects on intramyocellular lipids, endothelial function and insulin resistance in young metabolic healthy overweight women

Dietas ricas em gordura ou carboidrato têm sido difundidas e consumidas nas últimas décadas, entretanto pouco é conhecido sobre as consequências metabólicas destas em longo prazo. Neste estudo, foram analisados a quantidade de gordura intramiocelular (IMCL), a função endotelial, além da lipemia, glicemia, insulinemia e resistência à insulina após semanas de dieta rica em gordura ou carboidrato, perdendo ou mantendo peso. De 43 mulheres triadas com sobrepeso (25< BMI <29.9 Kg/m2), 22 foram randomizadas para duas diferentes sequências de dietas. O IMCL foi medido através de espectroscopia por ressonância magnética 1H e a função endotelial pela pletismografia. Após 4 semanas de dieta rica em carboidrato, mantendo peso, foi observado aumento no IMCL do músculo tibial anterior (2.06 ± 1.27 vs. 3.52 ± 1.92, p=0.04) e na insulinemia em jejum (11.55 ± 4.43 vs. 14.03 ± 5.23, p=0.04), enquanto a dieta rica em gordura, no mesmo período, ocasionou aumento no HDL-C (37.06 ± 8.42 vs. 42.5 ± 9.32, p=0.003) e redução nos níveis de triglicerídeos em jejum (102,83 ± 34,10 vs. 75,83 ± 20,91, p=0,02). A função endotelial, colesterol total, LDL-C e resistência à insulina não mudaram durante esta fase. A perda de peso (média de 5%, por 8 semanas), não promoveu modificações nos parâmetros metabólicos vistos com a dieta de manutenção de peso. A partir destes resultados, concluiu-se que a ingestão de dieta rica em carboidrato, por 4 semanas de manutenção de peso, aumenta a insulinemia em jejum e o IMCL do músculo tibial anterior, enquanto a dieta rica em gordura pelo mesmo período aumenta o HDL-C e reduz triglicerídeos em mulheres saudáveis com sobrepeso.

High fat or high carbohydrate (cab) diet have been widely difunded and consumed during last decades; however it is not clear their metabolic effects in long term. In the present study we analyzed intramyocellular lipids (IMCL), endothelial function, plasma lipids, glucose, insulin and insulin resistance after high fat or high cab diet during weeks, maintaining or losing weight. 43 overweight women (25< BMI <29.9 Kg/m2) were screened, 22 of them were randomized to two different diet sequence. IMCL was measured by using 1H magnetic resonance spectroscopy and endothelial function by using plethysmography method. Tibialis anterior IMCL (2.06 ± 1.27 vs. 3.52 ± 1.92, p=0.04) and fasting insulinemia increased (11.55 ± 4.43 vs. 14.03 ± 5.23, p=0.04) after four weeks of high cab diet after maintenance phase, while fasting HDL-C increased (37.06 ± 8.42 vs. 42.5 ± 9.32, p=0.003) and triglycerides levels decreased (102.83 ± 34.10 vs. 75.83 ± 20.91, p=0.02) after maintenance phase of high fat diet. Endothelial function, total cholesterol, LDL-C and insulin resistance did not alter during maintenance phase. A weight loss of 5%, after eight weeks, did not promote changes in the metabolic parameters, as seen during maintenance phase. Based on these results, it was concluded that high cab diet, four weeks with no weight change, increases tibialis anterior IMCL and fasting insulinemia, while high fat diet during same period increases HDL-C and decreases triglycerides in a healthy overweight women population.