Diabetes mellitus in the young: Gliptins or sulfonylurea after metformin?

INTRODUCTION: Diagnosis and initial management of diabetes mellitus (DM) in the young are clinical dilemma. Gliptins may be a safer and more effective option than sulfonylureas. Few Indian studies have addressed this issue of clinical relevance. AIM: To compare the use of sitagliptin and glimepiride as early add-on drugs along with metformin in young patients with DM to achieve optimum glycemic targets. METHODS: This was a prospective, open-label, cohort study set in a tertiary care hospital in North India. Newly diagnosed patients of DM ≤35 year of age were initially treated to pre-defined glycemic goals (Fasting plasma glucose (FPG) 70-130, post prandial glucose (PPG) < 180 mg/dl) with insulin and metformin 1 g for 8 weeks. Insulin was discontinued and metformin increased to 2 g daily for next 4 weeks. Thereafter, glimepiride 1 mg or sitagliptin 100 mg was randomly added to those who were not maintaining the set glucose targets. Dose of glimepiride was uptitrated every 4 weeks upto a maximum of 4 mg. Three groups (Gp A: Metfromin 2 g/d, Gp B: Metformin 2 g + Glimepiride 1-4 mg/d, and Gp C: Metformin 2 g + sitagliptin 100 mg/d) were followed up over next 24 weeks. They were compared for glycemic control and weight change. Those failing therapy on these drugs (FPG > 180, PPG > 250 mg/dl with/without catabolic symptoms/ketosis) were withdrawn. RESULTS: Sitagliptin with metfromin and metfromin alone group fared better than the glimepiride group for glycemic control, lesser treatment failures, and less weight gain. CONCLUSION: In this limited study, we found that sitagliptin is a safer and more effective option in young, newly diagnosed patients with DM. Findings of this study are relevant for clinical practice in Indian setting.

Correlation between Systemic Lupus Erythematosus Disease Activity Index, C3, C4 and Anti-dsDNA Antibodies.

BACKGROUND: Therapeutic decisions in systemic lupus erythematosus (SLE) are based on the disease activity and nature of organ involvement. There are various clinical and laboratory methods to assess the lupus flares. METHODS: Fifty one SLE patients with active disease (lupus flare) were studied. Systemic lupus erythematosus disease activity index (SLEDAI), C3, C4 and anti-double stranded DNA levels were estimated and repeated monthly till remission. After remission these tests were done three monthly. Values of serological parameters were then correlated with SLEDAI score. RESULT: Thirteen (25.4%) patients had predominantly renal involvement while 38 (74.6%) patients had non-renal affliction. Musculoskeletal and mucocutaneous symptoms were the commonest features of lupus flare (90%). It was observed that 12 out of 13 (92.3%) patients with active renal involvement had low C3 levels and 11 (84.6%) had low C4 levels. The anti-dsDNA levels were elevated in all patients with predominant renal flare. In non-renal flare anti-dsDNA titre was raised only in 35% cases. Low C3 and C4 levels were noticed in 43% and 53% of non-renal flares respectively. Significant positive correlation was noticed between SLEDAI score and anti-dsDNA levels (0.01 level two-tailed prediction) and a significant negative correlation was observed with SLEDAI and C3, C4 levels (0.01 and 0.05 levels, two-tailed prediction) in our patients. On subgroup analysis it was noticed that this correlation is stronger for renal lupus. Negative correlation of SLEDAI and complement levels was not observed in non-renal flares. CONCLUSION: Calculation of SLEDAI is a vital clinical tool for assessment of SLE patients. Serial estimation of anti-dsDNA titre, C3 and C4 levels help us diagnose lupus flare and make appropriate therapeutic decisions in patients with high SLEDAI score.

Prevalence of renal involvement in Indian patients with systemic sclerosis.

BACKGROUND: Renal involvement in systemic sclerosis (SSc) either in the form of scleroderma renal crisis (SRC) or nonrenal crisis abnormalities has been reported to be in the range of 60-80%. Renal involvement is thought to be rare in Indian patients with SSc. However, there is paucity of data. AIMS: To study the frequency and pattern of renal involvement in Indian patients with SSc. SETTINGS AND DESIGN: A single center prospective, cross sectional study. MATERIALS AND METHODS: We prospectively evaluated the patients with SSc attending the Rheumatology Clinic. All patients were evaluated for renal involvement. All patients underwent measurement of blood pressure, urine examination, glomerular filtration rate (GFR) estimation using Cockcroft-Gault formula and kidney biopsy when indicated. STATISTICAL ANALYSIS: Statistical analysis was performed using SAS 8.0 statistical package. RESULTS: Eighty-seven patients were included in the study from July 2001 to December 2004. Mean age of patients was 36.88 +/- 12.51 years. About 30% of patients had diffuse cutaneous SSc. None of these patients had SRC either at enrollment in the study or during follow-up. Eleven (12.6%) patients had hypertension. Six (6.9%) patients had abnormal urinary findings in the form of either active urinary sediment or significant proteinuria. Only one patient had azotemia (plasma creatinine > 1.8 mg/dl). Calculated GFR CONCLUSION: SRC is very rare in Indian patients with SSc. However, non-renal crisis abnormalities appear to be as common in Indian patients as compared to the western literature.

Renal thrombotic microangiopathy and cerebral venous thrombosis in a young man.

We report a patient of primary catastrophic antiphospholipid syndrome who presented with rapidly progressive renal failure and seizures. He was detected to have thrombotic microangiopathy on kidney biopsy and deep cerebral venous thrombosis. The patient was successfully managed with anticoagulants, steroids, plasmapheresis and cyclophosphamide.

Fibrous dysplasia localized to spine: a diagnostic dilemma.

Fibrous dysplasia of the spine is uncommon, especially in monostotic form. Isolated vertebral involvement in polyostotic form is very rare. We report a case of polyostotic fibrous dysplasia with lesions localized to dorso-lumbar spine in a 45-year-old rheumatoid arthritis patient. No associated appendicular lesions, cutaneous manifestations or endocrinopathies were seen. The extreme rarity of this type of lesion can pose a diagnostic dilemma, and biopsy is required for diagnosis. The association with rheumatoid arthritis in our case seems to be a chance occurrence.

Sjogren's syndrome presenting with interstitial lung disease.

We report a patient of primary Sjogren's syndrome presenting with interstitial lung disease. The clinical picture was dominated by respiratory symptoms leading to a delay in diagnosis.

Emergencies in rheumatology.

Rheumatological conditions can sometimes present as emergencies. These can occur due to the disease process or may be iatrogenic. Some of the important articular emergencies are septic arthritis, acute polyarthritis and atlanto-axial dislocation. Classical polyarteritis nodosa may present with massive gastro-intestinal bleeding, intestinal perforation or acute pancreatitis. Adult respiratory distress syndrome, bilateral pneumonitis and diffuse alveolar haemorrhage due to systemic lupus erythematosus or systemic necrotising vasculitis and ventilatory failure due to polymyositis are some of the respiratory emergencies. Scleroderma is well known to cause renal crisis which can be fatal if not diagnosed and managed promptly. Microscopic polyangiitis and Wegener's granulomatosis may cause rapidly progressive renal failure. Cerebrovascular accident, cortical vein thrombosis, seizures and acute psychosis are important neurological complications of rheumatic disease. Cardiac emergencies include tamponade, acute myocarditis and acute myocardial infarction. Vision can be threatened in Behcet's disease, temporal arteritis and seronegative spondylarthritis. Catastrophic antiphospholipid syndrome is a devastating emergency. The management of above emergencies includes critical care, immunosuppression when indicated and withdrawal of the offending drug. Anticoagulants have to be used in the management of antiphospholipid syndrome. A good understanding of these conditions is of paramount importance for proper management.