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Background: Hyperglycemia is a known risk factor for diabetic retinopathy (DR) but the association between glycemic variability and DR is unclear. We aim to evaluate the glycemic variability in DR through retrospective continuous glucose monitoring (CGM) and assess its effect on the clinical profile of participants with or without DR. Material and Methods: Retrospective observational hospital-based case-control study. We collected anthropometric and clinical data of 74 people with type 2 diabetes from our ophthalmology database whose retrospective CGM data were available. Among them, 37 had DR (cases) and 37 did not have DR (controls). The data were analyzed using SPSS version 27. Results: Duration of diabetes and glycosylated hemoglobin (HbA1c) was significantly higher and the estimated glomerular filtration rate (eGFR) was significantly lower in the cases compared to the controls. CGM markers, like time-above-range, average glucose, glucose management indicator, were higher while time-in-range was lower in the cases compared to the controls (P = ns). Time-below-range targets in people >65 years were met in a lower proportion (p < 0.05) of people in the cases (50%) compared to the controls (92%). Conclusion: Duration of diabetes, low eGFR, and high HbA1c showed significant association with retinopathy in type 2 diabetes. Although markers of glycemic variability did not show a statistically significant difference in cases compared to controls, all indices of glycemic variability were numerically higher in people with DR. Hypoglycemia in elderly participants with DR and its implications on achieving targets requires more research.

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Background: Insulin resistance (IR) is commonly seen in diabetic kidney disease (DKD) and could contribute to the progression of renal disease and cardiovascular risk. In this study, we aim to measure homeostasis model assessment IR (HOMA-IR) in DKD and see the effect of advancing kidney disease on HOMA IR. Material and Methods: We recruited 120 subjects with type 2 diabetes mellitus and divided them into people without kidney disease (controls; n = 20), early DKD (n = 40), and advanced DKD (n = 60). Biochemical tests including fasting plasma glucose and fasting serum C-peptide were done in 120 subjects. IR was calculated by the HOMA model in 109 subjects. Data were presented as median (interquartile range [IQR]). Univariable and multivariable analysis was done. Results: Median of HOMA-IR in the control group was 2.0 (IQR: 1.5–2.8; n = 20), early DKD group was 2.3 (1.8–2.9; n = 37), and advanced DKD group was 3.67 (1.6–3.9; n = 52). P = 0.03 indicated a significant increase in the HOMA IR with advancing kidney disease. Conclusion: In patients with DKD, with advancing kidney disease, there was a significant increase in the HOMA IR, a marker of IR. IR is a modifiable metabolic risk factor, and if it is managed by novel therapeutic ways, it might improve clinical outcomes in DKD.

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Adenosine Mono phosphate -activated protein kinase (AMPK) is a metabolic master switch that senses the cellular AMP levels. However, it is now also regarded as a nutrient-sensing enzyme due to its ability to detect glucose deprivation inside the cell. Under conditions of energy deprivation, AMPK is activated, which in turn switches on all the energy-producing metabolic pathways, while switching off energy-consuming metabolic pathways and cellular processes. There is a growing interest in AMPK due to its role in a wide array of pathological processes including diabetes mellitus. It is the therapeutic target of one of the most commonly prescribed classes of antidiabetic drugs, namely the biguanides such as metformin. The current article presents a review of AMPK structure, triggers, and mechanisms of its activation as well as its role in cell metabolism, mitochondrial homeostasis, autophagy, and cell proliferation. It also briefly addresses the relevance of AMPK to pathogenesis and management of diabetes mellitus.

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Background: Diabetic foot wound is an important health challenge throughout the world. Interleukin 8 (IL8) and macrophage-migration inhibitory factor (MIF) play a significant role in host defense and in wound healing. Immune perturbation and Vitamin D deficiency also contribute to nonhealing of diabetic foot wounds. We aimed to evaluate the serum concentration of IL8 and MIF in diabetic patients with and without foot infection and its association with Vitamin D status. Material and Methods: Serum concentrations of 25 dihydroxyvitamin Vitamin D and cytokines (IL8 and MIF) were measured by radioimmunoassay and enzyme-linked immunosorbent assay, respectively, from 100 subjects with diabetes and foot infection as cases and 73 subjects with diabetes without foot infection as controls. Data were presented as mean (± standard error of mean [SE]) unless otherwise indicated and were analyzed by SPSS 16.0. Results: There was no significant difference in the mean (±SE) of age, duration of diabetes, hemoglobin A1C, and body mass index between the two groups. The mean (±SE) concentration of IL8 was significantly higher and MIF was significantly lower in cases than controls. Vitamin D correlated negatively with IL8 (r = −0.191) and positively (r = 0.1) with MIF. However, only the former correlation was statistically significant (P = 0.01). IL8 was also significantly high in patients with severe Vitamin D deficiency (<10 ng/ml) compared to patients with Vitamin D more than 10 ng/ml. Conclusion: Serum concentration of IL8 is significantly higher in diabetic foot infections compared to controls. Severe Vitamin D deficiency was associated with IL8 concentration in patients with diabetes.

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Background: In India, glimepiride has become a promising option for add-on therapy with metformin in patients with type-2 diabetes mellitus (T2DM) owing to its efficacy, safety, and cost-effectiveness. This study aimed to analyze the clinical utility of multiple strengths of glimepiride and metformin fixed-dose combination (FDC) in obese/overweight patients with T2DM. Methods: This case-based questionnaire survey was conducted between June 2020 and June 2021 and included health-care professionals across India to assess the usage pattern of glimepiride and metformin FDC. Results: Overall, data from 1345 patients taking multiple strengths of glimepiride and metformin FDC were analyzed, of which 64.7% were men. A total of 57.6% of patients were overweight, 29.4% were obese Class I, 9.6% were obese Class II, and 3.4% belonged to obese Class III. Sedentary lifestyle (60.3%), smoking (36.7%), and emotional stress (33.3%) were the most common risk factors. Among the available strengths, glimepiride 2 mg and metformin 500/850/1000 mg FDC was most widely used in 50.5% and 47.4% of patients from overweight and obese groups, respectively. A total of 90.3% and 89.1% of patients, respectively, from the overweight and obese groups did not observe weight gain. The majority of the patients from overweight and obese groups observed blood pressure within optimum levels (68.5% and 71.4%, respectively). The mean glycated hemoglobin, fasting plasma glucose, and postprandial plasma glucose levels were significantly reduced with posttreatment of glimepiride and metformin FDC with a mean change of 1.4%, 44.3 mg/dL, and 73.5 mg/dL, respectively (P < 0.01). The physician global evaluation of efficacy (90.3%) and tolerability (91.1%) showed the majority of the patients on a good to excellent scale. Conclusion: The real-world evidence in the Indian clinical setting indicates that the glimepiride and metformin FDC was found to be effective in achieving glycemic control and it is observed to be safer in terms of weight gain and hypoglycemia.

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The prevalence of gestational diabetes mellitus (GDM) has been increasing globally and in India too, because of urbanization and the increasing occurrence of obesity. The management of GDM poses a clinical challenge, and this article focuses on its diagnosis and treatment. In India, screening of all pregnant women is recommended at the first antenatal visit and then repeat screening at 24–28 weeks of gestation if the initial screen is normal. Early intervention with counseling, glucose monitoring, diet, and exercise to achieve good glucose control could reduce both the maternal and fetal complications associated with hyperglycemia in pregnancy. The majority of cases of GDM may be managed by lifestyle modifications alone. Metformin may be prescribed as an alternative to insulin as per certain guidelines, though insulin remains the cornerstone of pharmacotherapy. Long-acting insulin detemir and short-acting insulin analogs such as insulin lispro or aspart are safe in pregnancy and help with control of blood glucose. Good glycemic control, achieved by lifestyle measures, monitoring, and medications when needed, may help achieve the goal of a successful pregnancy outcome.

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Diabetes is considered as a risk factor for the severity of coronavirus disease 2019 (COVID-19). The mortality rate of COVID-19 was found to be high among patients with diabetes. The exact molecular mechanism involved in diabetes-associated COVID-19 severity is not established. In this review, we discuss the exacerbated formation of advanced glycation end products (AGEs), AGE-receptor for AGE (RAGE) signaling induced spike in inflammatory cytokines, and the role of metformin, an antidiabetic drug with glycation inhibition property. The commonality between these two diseases is exacerbated immune response. AGEs interact with RAGE, leading to oxidative stress, activation of the pro-inflammatory pathway, and production of inflammatory cytokines, which may aberrantly activate the immune response. Based on these pieces of evidence, we propose a role for glycation in the pathogenesis of COVID-19 severity.

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Background: There is an increasing need to revise diabetes management. Two-thirds of patients with diabetes do not have their blood sugar under control. There has been increasing evidence suggesting the positive impact of diet and lifestyle on blood sugar control. This study aims to demonstrate the adoption of the Glucose Level-Assisted Monitoring Diet (GLAM diet) validated by the aid of ambulatory glucose profiling and examine the impact of the GLAM diet on blood glucose concentration, lipid profile, and glucose variability. Methods: In this open-label, interventional pilot study, we enrolled 50 diabetes patients with or without hypertension to receive a GLAM diet, in addition to counseling. The primary outcome was the control and remission of diabetes. The secondary outcome was a composite of optimal maintenance of glucose concentration, optimal lipid profile, glucose variability evaluation, reduced insulin supplementation, diabetes-related complications following the GLAM diet, lifestyle modification, and overall quality of life through indicators such as sleep, stress, and nutrition. Results: GLAM diet significantly reduced Fasting Blood Sugar (FBS) (202 ± 65.47 mg/dL vs. 160.2 ± 37.75 mg/dL, P < 0.001), postprandial blood sugar (PPBS) (246.1 ± 74.74 mg/dL vs. 196.5 ± 45.48 mg/dL, P < 0.001), laboratory glycated-hemoglobin (9.2 ± 1.74% vs. 8.1 ± 1.5%, P < 0.001), and average glucose (182.4 ± 47.54 mg/dL vs. 152.2 ± 39.32 mg/dL, P < 0.001). The glucose remained within target increasing frequently after the diet was implemented (49.7 ± 27.11% vs. 65.6 ± 20.01%, P < 0.001) and although fell just short of statistical significance, there was a percentage decrease in glucose level above target (46.6 ± 29.17% vs. 27.6 ± 22.71%, P = 0.109) observed in the study group. Patients also experienced significantly reduced body weight, body mass index, waist circumference, hip circumference, body fat percentage, and Mean amplitude of glycemic excursions (MAGE), Continuous overall net glycemic action (CONGA), and standard deviation values in comparison to baseline. Conclusion: Patients initiated onto the GLAM diet had better glycemic control, lipid profile, and glucose variability along with enhanced sleep, reduced stress, and improved nutrition understanding in study participants. In conclusion, the GLAM diet apart from reducing glycemic burden also helped to improve the overall quality of life.

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Background: The renin–angiotensin–aldosterone system (RAAS) is important in regulating blood pressure and electrolyte balance. The main effector hormone of the RAAS is angiotensin II, which is generated from angiotensin I in the circulation and in the tissues, mostly as a result of the action of angiotensin-converting enzyme (ACE). The ACE gene has received substantial attention in recent years as a candidate gene for a variety of diseases. Objective: This study was conducted to determine the association of insertion/deletion (I/D) polymorphism of ACE gene in type 2 diabetes mellitus (T2DM), hypertension (HT), and chronic kidney disease (CKD) subjects among South Indian regional population. Methods: A total of 105 subjects participated in this study including 30 T2DM (Group 1), 30 HT (Group 2), 35 CKD (Group 3) patients and 10 controls (Group 4). Blood samples were collected and biochemical investigations were done. Polymerase chain reaction amplification was performed to genotype the DNA. The distribution and allelic frequency of I/D (rs1799752) polymorphism at the 287-base pair Alu repeat sequence in the intron 16 of ACE gene were analyzed using specific primers. Results: The ACE genotypes were distributed as II, 17%; DD, 47%; and ID, 37% in the T2DM group; II, 10%; DD, 50%; and ID, 40% in the HT group; II, 17%; DD, 54%; and ID, 29% in the CKD group; and II, 50%; DD, 20%, and ID, 30% in the control group. The frequency of DD genotype was significantly higher in HT (P = 0.05) and CKD patients (P = 0.05) compared to controls. In codominant model analysis, DD genotype versus II genotype was associated with increased risk of T2DM (odds ratio [OR] = 4.37; 95% confidence interval [CI] = 1.31–14.504), HT (OR = 9.0; 95% CI = 2.23–36.17), and/or CKD (OR = 5.73; 95% CI = 1.906–17.282), respectively. The D allele was more frequent in T2DM (65%), HT (70%), and CKD patients (69%) compared to controls (35%) (P = 0.018, P = 0.005, and P = 0.006, respectively). The D allele was associated with increased risk of T2DM (OR = 3.44; 95% CI = 1.19–9.96), HT (OR = 4.33; 95% CI = 1.48–12.65), and CKD (OR = 4.05; 95% CI = 1.42–11.55). Conclusion: The DD genotype and the D allele of the ACE I/D gene polymorphism can be a risk factor for T2DM, HT, and CKD in South Indian regional population. This result suggests that T2DM and HT patients should be offered analysis to identify defects in ACE I/D polymorphism, which might help to determine the course of CKD disease and aid to choose appropriate antihypertensive therapy with ACE inhibitor/angiotensin receptor blockers.

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Painful diabetic peripheral neuropathy (PDPN) is a commonly encountered problem by a physician and poses a major treatment challenge. Although poor glycemic control is considered to be a main cause for the development of peripheral neuropathy, the overall etiopathogenesis remains unclear and needs further research. There are various tools to assess the status of nerves, but PDPN being a subjective factor is often measured in terms of pain scores or pain scale looking at the intensity and the phenotype of pain. PDPN affects the individual's quality of life and daily living and often disturbs the sleep and mental health. The management of PDPN includes achieving good glycemic control, following foot care practices, including the use of appropriate footwear and treatment for pain relief. The treatment of choice varies from topical application to the pain relieving patches and use of drugs such as anticonvulsants, antidepressants, and opioids which have shown some beneficial effect. Interventional and regional anesthesia have also been tried for the treatment of PDPN. Surgical decompression has shown a favorable effect on pain relief. There are unmet needs in the therapeutic management of PDPN, as available drugs give acceptable pain relief in very few patients, and fear of side effects may limit full-dose treatment. Till date, no medicine is available to reverse neuropathy.

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Obesity is a chronic metabolic disease affecting individuals all over the world and is known to be a main risk factor for type 2 diabetes (T2D). In countries like India, T2D occurs with a lower degree of obesity as compared to T2D in western countries. It is important to tackle obesity in T2D because studies have shown that modest weight loss leads to improvements in glycemic levels, thereby reducing the risk of diabetes-related complications and comorbidities. Obesity complicates the management of diabetes, particularly the goal of achieving tight glycemic control as it is associated with insulin resistance. In this article, we are going to discuss choice of therapies in the management of T2D in obese individuals. In patients with T2D and obesity treatment approach should be individualized and it includes intensive lifestyle intervention, pharmacologic therapy, and/or metabolic surgery. Additional attention should be given to concomitant therapies for other comorbidities which may further lead to weight gain. Considering the strong link between obesity and T2D, the first choice of therapy after lifestyle modification should be glucose-lowering agents, which promote weight reduction or are at least weight neutral. Metformin, alpha-glucosidase inhibitor, sodium-glucose co-transporter 2 (SGLT-2) inhibitor, glucagon-like peptide–1 receptor agonist (GLP-1 RA), and amylin mimetic promote weight loss along with additional cardiovascular benefits of GLP-1 RA, SGLT-2 inhibitor, and improved renal outcomes with SGLT-2 inhibitor. Weight neutral therapies include dipeptidyl peptidase-4 inhibitors and fixed ratio insulin/GLP-1 RA combination therapies (insulin degludec/liraglutide, insulin glargine and lixisenatide) can also be considered as they help to limit weight gain. Therapies such as thiazolidinedione, insulin secretagogue (sulfonylurea and meglitinide), and insulin are less suitable for individuals with obesity and T2D as they are associated with weight gain.

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Iatrogenic hypoglycemia is the most feared and common complication of insulin therapy. Hypoglycemia can have serious consequences and can be potentially life-threatening. In addition to the neurological manifestations of severe hypoglycemia, hypoglycemia may be associated with cognitive dysfunction, cardiovascular events, arrhythmias, and increased mortality. Recurrent episodes of hypoglycemia may lead to hypoglycemia unawareness, which increases the risk of severe hypoglycemia. Therefore, prevention of hypoglycemia remains a priority in persons with diabetes on insulin therapy. The “THINK” strategy provides a comprehensive approach for diabetes care providers to minimize the risk of hypoglycemia related to insulin therapy by mitigating factors that increase the risk. This requires setting reasonable glycemic Targets keeping in mind a person's risk of hypoglycemia; choosing the right Tools such as insulin formulation and regimen with lower risk and adequate glucose monitoring; judicious Titration of insulin doses; use of modern Technology such as continuous glucose monitoring, continuous subcutaneous insulin infusion, and sensor augmented pumps in patients at high risk; maintaining Harmony between insulin dose, diet, physical activity, and changes in lifestyle; Individualization of diabetes therapy; ensuring there are No errors in insulin administration; and empowering patients with Knowledge about hypoglycemia. The THINK strategy offers a handy tool for tailoring insulin therapy to minimize hypoglycemia risk.

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Infectious diseases are more common and severe in diabetes. Diabetes predisposes to various infections through alterations in innate and acquired immune defences. Outcomes of infection are worse in people with uncontrolled glycemia, including an increased mortality. The infections can affect all organs and all systems. In patients with diabetes, the infections can be broadly classified into two categories. Infections that are common in the general population have more severe clinical presentation and worse outcomes among patients with diabetes. The second group is of infections that are peculiar to patients with diabetes, being virtually rare in the normal population, such as foot infections, malignant external otitis, rhinocerebral mucormycosis, emphysematous pyelonephritis and gangrenous cholecystitis, etc. Epidemiological data on the true incidence of atypical and rare infections are scarce. This review will highlight the prevalence, consequences, severity, and pattern of infections in the population with diabetes in India. This review of epidemiological prevalence may guide the clinicians for early suspicion, identification of infectious disease, and right selection of the antimicrobial agents which may lead to a better outcome.

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The chronic low-grade inflammation in obesity and multiple pleiotropic effects of adipokines on the immune system has been implicated in the pathogenesis of various rheumatic autoimmune and inflammatory conditions. Obesity is a low-grade systemic inflammatory condition with elevated levels of inflammatory markers such as leptin, C-reactive protein, tumor necrosis factor-α, and interleukin-6. Dysregulation of the cytokines and adipokines is a feature of metabolic syndrome, suggesting a complex relationship between autoimmunity, obesity, and atherosclerosis. We discuss the effects of obesity and its association with newly diagnosed immune-mediated disorders such as Sjogren's syndrome, systemic lupus erythematosus, rheumatoid arthritis, and antiphospholipid antibody syndrome in a case series of eight patients.

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Background: An early initiation of statins in the diabetes population helps in prevention of atherosclerotic cardiovascular disease (ASCVD). However, there is a paucity of data on its use in young Indian patients with diabetes. This survey report aimed to provide opinion-based recommendations for pragmatic usage of statin in diabetes population of India. Material and Methods: Discussion and virtual survey (a questionnaire of 18 questions) was conducted at 16 round table meetings (RTMs) which included participation of health-care practitioners (HCPs) from India. On the basis of their opinions and discussion, general recommendations about early usage of statins in diabetes for prevention of ASCVD were derived. Results: Out of 261 HCPs participated, 56.1% recommended initiating statins in patients aged 41–50 years irrespective of their total/low-density lipoprotein cholesterol (LDL-C) levels. Among people with diabetes aged between 20 and 39 years, 38.9% of HCPs considered LDL-C >100 mg/dL and 77% of HCPs considered history of ASCVD as a risk factor for early statin initiation. Overall, 98.9% of HCPs agreed that early initiation of statin in people with diabetes and ASCVD risk factors will help reduce ASCVD. The majority of HCPs recommended initiating moderate-intensity (51.2%) and low-intensity (43.8%) statins and assess every 3 months for tolerance and compliance in people with diabetes (aged 20–39 years) and additional ASCVD risk factors. The use of rosuvastatin (78.5% of HCPs) was preferred for early initiation in people with diabetes. Majority of HCPs agreed (57.3%) or strongly agreed (36.2%) that rosuvastatin has more clinical utility compared to other statins due to better LDL-C-lowering effect and other pleiotropic effects. Physician's inertia limits the effective use of statins among young adults with diabetes (55.8%), and 65.8% of HCPs recommended screening of people with diabetes for additional ASCVD risk factors. Conclusion: The participating HCPs opined that early initiation of statin therapy in people with diabetes and ASCVD risk factors will help reduce ASCVD. Rosuvastatin is mostly recommended for early initiation of statin therapy among the diabetes population for prevention of ASCVD. There is a necessity of using a proactive approach to screen for additional ASCVD risk factors in young individuals with diabetes and further increase the awareness about benefits of initiating statin therapy from an early stage.

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There are more than 1 million people living with type 1 diabetes worldwide. People with classical type 1 diabetes are often, though not always young and require insulin therapy life long without which they are at risk of ketoacidosis. The proper and early diagnosis of type 1 diabetes is critical because of therapeutic implications and the prevention of diabetes-related complications. As the incidence of type 1 diabetes is increasing in India, and given unique socioeconomic challenges in the diagnosis and management of type 1 diabetes in India, it is important to approach the diagnosis from an Indian perspective. In this article, we discuss the practical aspect of clinical presentation and diagnosis of type 1 diabetes.

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Background: Management of glucose levels in patients with diabetes mellitus and end-stage renal disease (ESRD) is challenging. There are various factors contributing to glycemic variability (GV), including altered metabolism of glucose and insulin in the ESRD stage. Continuous glucose monitoring (CGM) system measures glucose levels continuously and helps to study the glucose profile of patients undergoing hemodialysis (HD). This pilot study aimed to analyze the ambulatory glucose profile (AGP) of type 2 diabetes patients with ESRD undergoing HD and study the GV when patients were on HD (referred to as ON days) versus when patients were not on HD (referred as OFF days). Materials and Methods: We enrolled 10 patients with type 2 diabetes mellitus and ESRD undergoing maintenance HD in the study. Data regarding patient characteristics, including age, gender, duration of diabetes mellitus, HbA1c, and serum fructosamine, were collected. The AGP data obtained by the CGM sensor on the HD ON days was compared to AGP data on HD OFF days. Results: There was a significant linear correlation of CGM-derived average blood glucose with HbA1c value; however, the association was not significant with fructosamine level. The CGM-derived average glucose level was significantly lower during HD ON days compared to HD OFF days, difference being 29.9 mg/dl (−33.7, −26.0; P < 0.001), whereas GV was significantly higher during HD OFF days compared to ON days. Conclusion: The variation in the glucose levels was higher during the HD OFF days compared to HD ON days. Future AGP studies recruiting more number of patients on HD will help better understand the clinical impact of glucose profile and GV in ESRD patients.

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Background: There is a lack of consensus regarding efficacy and cardiovascular (CV) safety of testosterone-replacement therapy (TRT) in men with late-onset hypogonadism (LOH) secondary to obesity ±type 2 diabetes mellitus (T2DM). This is because of limited number of prospective randomized clinical trials (RCTs) in this cohort. Methods: A comprehensive retrospective review of medical literature was carried out using Preferred Reporting Items for Systematic Reviews and Meta-Analyses framework to assess the CV outcomes and safety of TRT in men with LOH. The review included scientific publications from January 2000 to July 2021, which included men with obesity ± T2DM. Results: Out of the 723 publications, which were identified on preliminary screening, 154 conformed to broad inclusion criteria for this systematic review of literature. Out of these 154 publications, 34 studies with a total number of 4,365,684 patients were finally included for this systematic review (9 randomized controlled trials, 6 meta-analyses and 19 observational studies). Studies investigating whether TRT offers protection against CV disease (CVD) and stroke generally concluded that the use of Testosterone (T) in middle-aged to elderly men has no detrimental impact on their CV risk. Older men with T2DM, obesity and metabolic syndrome are likely to benefit from TRT, as several studies point to an improvement in insulin sensitivity, markers of inflammation, time to Angina, CV risk, CV mortality, and even all-cause mortality. Conclusions: This retrospective systematic review of the literature, suggests modest efficacy of TRT in reducing major adverse cardiovascular events (MACEs) and all-cause mortality in men with LOH secondary to obesity and/or T2DM. TRT was associated with an increased risk of overall CVDs and MACE only when T preparations were given at supratherapeutic dosage or when TRT was offered to frail men. The findings of the current review could not confirm TRT as a cause of adverse CV events.

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Up to 40% of patients undergoing elective surgeries have underlying diabetes mellitus (DM), and therefore an elevated risk of perioperative adverse cardiovascular outcomes. Preoperative cardiovascular risk assessment and therapeutic optimization are warranted in all patients with DM. This is an updated review on preoperative evaluation of cardiac risk in patients with DM undergoing surgery and strategies to minimize the risk. This article summarizes the current evidence and recommendations for cardiac evaluation in DM before noncardiac surgery. Preoperative risk estimation includes risk stratification of the proposed surgery and estimating the risk in the patient using available risk calculators such as the Revised Cardiac Risk Index and assessment of the functional status of the patient in terms of metabolic equivalents of tasks. Preoperative cardiac investigations such as electrocardiogram, echocardiography, stress testing, or cardiac biomarkers should be done in high-risk surgeries, and in certain subsets of patients undergoing low- or intermediate-risk surgeries. Additional testing and preoperative optimization are warranted in patients with heart failure and reduced or preserved ejection fraction, those with cardiac autonomic neuropathy, hypertension with or without end-organ damage, and patients undergoing transplant surgery, all of which are discussed in the current review.

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