The incidence of retinopathy in the Glycemia Reduction Approaches in Diabetes: A Comparative Effectiveness study (GRADE).

Based on self-report in the GRADE diabetes study, cumulative incidence of retinopathy was low over 5 years (3.7 %; 184 of 4098 participants) and did not differ among the 4 treatment groups (glargine 4.0 %, glimepiride 3.2 %, liraglutide 3.7 %, sitagliptin 3.8 %). There were no differences in retinopathy with specific therapies in GRADE. Clinicaltrials.gov identifier: NCT01794143.

AN UNEXPECTED COMBINATION OF PROLACTINOMA AND SEPTO-OPTIC DYSPLASIA.

OBJECTIVE: To describe the unusual finding of pituitary adenoma in a patient with septo-optic dysplasia (SOD). METHODS: We describe the clinical presentation, biochemical and radiological evaluation, treatment, and outcomes of a patient with macroprolactinoma and previously undiagnosed SOD. RESULTS: A 41-year-old woman with optic nerve hypoplasia and growth hormone deficiency presented with new-onset galactorrhea, polyuria, and polydipsia. Physical exam was notable for bilateral galactorrhea. Laboratory workup showed a prolactin level of 176 µg/L (reference range is 6 to 20 µg/L), serum cortisol of 7.7 µg/dL (reference range is 5.0 to 20.0 µg/dL), and adrenocorticotropic hormone of 54 pg/mL (reference range is 0 to 46 pg/mL). Thyroid function and pituitary-gonadal axis testing were normal. Low-dose cosyntropin test showed a borderline cortisol response and persistently low adrenal androgens, suggestive of partial secondary adrenal insufficiency. A water deprivation test showed evidence of diabetes insipidus (DI). Magnetic resonance imaging of the sella showed a 1.0 × 1.0 × 1.5-cm mass compatible with pituitary adenoma, absence of septum pellucidum, and atrophy of the optic nerves.The patient was diagnosed with SOD with partial hypopituitarism and a concomitant macroprolactinoma of more recent onset resulting in DI. The patient was treated with cabergoline with good clinical and biochemical response including resolution of DI symptoms. Subsequent magnetic resonance imaging of the sella showed near resolution of the prolactinoma. CONCLUSION: We conclude that a diagnosis of SOD should not exclude the possibility of a pituitary adenoma in the appropriate clinical context, and that the pattern of hormonal deficits in such a combination may be uncharacteristic of the deficits expected with pituitary adenoma alone.

Clopidogrel-Induced Insulin Autoimmune Syndrome: A Newly Recognized Cause of Hypoglycemia in a Patient Without Diabetes.

Insulin autoimmune syndrome (IAS), defined as hyperinsulinemic hypoglycemia with high titers of anti-insulin antibodies, is frequently reported in Japanese patients but rarely observed in whites. We report in this study on a 79-year-old white male without diabetes who developed IAS following exposure to clopidogrel, a drug not previously known to cause hypoglycemia. The patient presented with recurrent symptomatic hypoglycemia. During one episode, serum glucose was 45 mg/dL, whereas insulin and C-peptide levels were 40,000 mIU/mL and 40 ng/mL, respectively. Additional studies revealed no intake of insulin or its secretagogues, whereas anti-insulin antibody titer was high (59.3 nmol/L). Although total insulin levels were consistently high, free insulin concentrations (polyethylene glycol precipitation) were appropriate for ambient glycemia. The patient was found to have HLA-DRB1*0404, a feature often reported in Japanese patients with IAS. Three weeks prior to symptom onset, he was started on clopidogrel, a drug that does not have a sulfhydryl group, but its active metabolite does. Clopidogrel was switched to a nonsulfhydryl antiplatelet agent, and glucocorticoid therapy was initiated. Shortly thereafter, the frequency of hypoglycemic episodes decreased, and glucocorticoids were tapered over the ensuing 3 months. No hypoglycemic episodes were noted during 6 months of observation after discontinuing glucocorticoids, whereas the total insulin and anti-insulin antibody levels normalized. The data indicate that IAS should be considered in the differential diagnosis of hyperinsulinemic hypoglycemia in seemingly well individuals, even when no drugs known to cause IAS were used. Clinical suspicion of IAS can avoid expensive imaging and unnecessary surgery in affected patients.