54 minute read
PD：Poster Presentation-DM (1-30
from 110年會
by Endo 電子書上傳區
PD01 ASSOCIATION OF PREGNANCY OUTCOMES IN WOMEN WITH TYPE 2 DIABETES TREATED WITH METFORMIN VERSUS INSULIN WHEN BECOMING PREGNANT
1,2,3SHU-FU LIN, 3,4,5,6SHANG-HUNG CHANG,
3,7,8CHANG-FU KUO,
5WAN-TING LIN,
8MENG-JIUN CHIOU,
5YU-TUNG HUANG
1Division of Endocrinology and Metabolism, Department of Internal Medicine, New Taipei Municipal TuCheng Hospital, New Taipei City, Taiwan; 2Division of Endocrinology and Metabolism, Department of Internal Medicine, Chang Gung Memorial Hospital, Taoyuan, Taiwan; 3College of Medicine, Chang Gung University, Taoyuan, Taiwan; 4Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital, Taoyuan,Taiwan; 5Center for Big Data Analytics and Statistics, Chang Gung Memorial Hospital, Linkou, No.15, Wunhua 1st Rd., Gueishan Dist, Taoyuan City 333, Taiwan; 6Graduate Institute of Nursing, Chang Gung University of Science and Technology, Taoyuan, Taiwan; 7Division of Rheumatology, Allergy and Immunology, Department of Internal Medicine, Chang Gung Memorial Hospital, Taoyuan, Taiwan; 8Center for Artificial Intelligence in Medicine, Chang Gung Memorial Hospital, Taoyuan, Taiwan.
Background: Metformin use in pregnancy is controversial because metformin crosses the placenta and the safety on the fetus has not been well-established. This retrospective study aimed to compare pregnancy outcomes in women with preexisting type 2 diabetes receiving metformin or standard insulin treatment.
Methods: The cohort of this population-based study includes women of age 20–44 years with preexisting type 2 diabetes and singleton pregnancies in Taiwan between 2003 and 2014. Subjects were classified into three mutually exclusive groups according to glucose-lowering treatments received before and after becoming pregnant: insulin group, switching group (metformin to insulin), and metformin group. A generalized estimating equation model adjusted for patient age, duration of type 2 diabetes, hypertension, hyperlipidemia, retinopathy, and aspirin use was used to estimate the adjusted odds ratio (aOR) and 95% confidence interval (CI) of adverse pregnancy outcomes.
Results: A total of 1166 pregnancies were identified in the insulin group (n = 222), the switching group (n = 318) and the metformin group (n = 626). The insulin group and the switching group had similar pregnancy outcomes for both the mother and fetus, including risk of primary cesarean section, pregnancy-related hypertension, preeclampsia, preterm birth ( 4000 g), large for gestational age, and congenital malformations. The metformin group had a lower risk of primary cesarean section (aOR = 0.57; 95% CI, 0.40–0.82) and congenital malformations (aOR, 0.51; 95% CI; 0.27–0.94) and similar risk for the other outcomes as compared with the insulin group.
Conclusions: Metformin therapy was not associated with increased adverse pregnancy outcomes in women with type 2 diabetes as compared with standard insulin therapy.
PD02 MATERNAL PLASMA LIPIDS DURING PREGNANCY, PLACENTAL GROWTH FACTORS, AND EXCESS FETAL GROWTH: A PROSPECTIVE COHORT STUDY
1KUAN-YU CHEN, 2SHIN-YU LIN,
2CHIEN-NAN LEE, 3HUNG-TSUNG WU,
4,5CHING-HUA KUO, 5HAN-CHUN KUO, 5CHIA-CHI CHUANG,
6CHUN-HENG KUO,
7SZU-CHI CHEN, 8KANG-CHIH FAN, 2MING-WEI LIN, 9CHI-TAI FANG, 10HUNG-YUAN LI
1Department of Internal Medicine, ANSN Clinic, Hsin-Chu, Taiwan; 2Department of Obstetrics and Gynecology, National Taiwan University Hospital, Taipei, Taiwan; 3Graduate Institute of Metabolism and Obesity Sciences, College of Nutrition, Taipei Medical University, Taipei, Taiwan; 4School of Pharmacy, College of Medicine, National Taiwan University, Taipei, Taiwan; 5The Metabolomics Core Laboratory, Centers of Genomic and Precision Medicine, National Taiwan University, Taipei, Taiwan; 6Department of Internal Medicine, Fu Jen Catholic University Hospital, Fu Jen Catholic University; 7Division of Endocrinology and Metabolism, Department of Internal Medicine, Taipei City Hospital, Ren-Ai branch, Taipei, Taiwan; 8Department of Internal Medicine, National Taiwan University Hospital, Hsin-Chu Branch, Taiwan ; 9Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei, Taiwan; 10Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
Background: Intra-uterine environment, not limited to maternal glucose availability, has a great influence on excess fetal growth. Both maternal lipids during pregnancy and placental growth factors contribute significantly. However, how these factors interact to result in increased risk of delivering large-for-gestational-age (LGA) newborns remains unclear. In this study, we investigated the interplay between maternal plasma triglyceride (TG) and free fatty acids (FFAs) during pregnancy, cord blood insulin-like growth factors (IGF), and LGA, and studied the effect of different fatty acids (FAs) on placental IGF-1 secretion.
Methods: This cohort study included pregnant women with singleton and term pregnancy and without diabetes nor hypertensive disorders in pregnancy. Maternal fasting plasma TG and FFAs were measured in the second trimester. Cord blood growth factors including IGF-1, IGF-2, and IGF binding protein-1 and -3 were measured. A human trophoblast cell line, 3A-Sub-E, was used to evaluate the effect of different FAs on placental IGF-1 secretion.
Results: We recruited 598 pregnant women-newborn pairs, including 43 LGA newborns. Maternal plasma TG and cord blood IGF-1 concentrations were higher in the LGA group and were associated with birth weight z-score. Maternal plasma free palmitic acid (PA) and stearic acid (SA), but not oleic acid (OA) nor lenoleic acid (LA), were associated with cord blood IGF-1 concentrations. In 3A-sub-E cells, treatment with PA, SA, and LA, but not OA, induced the expression and secretion of IGF-1.
Conclusions: Certain FAs can induce placental IGF-1 secretion, which is a novel pathophysiology linking maternal plasma lipids and LGA.
PD03 ASSOCIATION STUDY BETWEEN THE STAPHYLOCOCCUS AUREUS STRAINS AND CLINICAL OUTCOMES IN DIABETIC FOOT ULCER
1JUI-HSIANG LI, 2YI-SHENG CHEN,
2YUN-SHIEN LEE, 2{HUI-CHUNG WU
1
Division of Endocrinology and Metabolism, Tao-Yuan General Hospital; 2 Department of Biotechnology, Ming Chuan University
Diabetic foot ulcer (DFU) is one of the most common chronic complications of diabetic patients. Patients often need recurrent hospitalizations or even amputation if the wound heals poorly and continues to deteriorate. Therefore, foot infections in patients with diabetic must be diagnosed and treated appropriately. Studies have pointed out that the microbial flora may affect the healing of diabetic foot ulcers. However, reports of the impact of specific microorganisms on the wound healing of diabetic foot ulcers remains scarce. In addition, the relationship between the microflora of the wound and the occurrence of diabetes complications is still unclear. Many literature points out that Staphylococcus is the most common bacteria observed in DFU. A study “Strain- and SpeciesLevel Variation in the Microbiome of Diabetic Wounds Is Associated with Clinical Outcomes
and Therapeutic Efficacy” (Cell Host Microbe. 2019 8;25[5]:641-655.e5.) revealed the strainlevel variation of Staphylococcus aureus. Using Metagenomic shotgun sequencing to analyze the longitudinal samples of 100 patients, findings suggest that the DFU microbiota may be a marker for clinical outcomes and response to therapeutic interventions. Our study collected samples from 11 patient specimens in Taoyuan Hospital and determined the microflora of the wounds. The result shows that the bacterial test in the hospital laboratory are consistent to the results of the traditional bacterial culture method for detecting Staphylococcus aureus. Importantly, comparing the odds ratio of patients having Staphylococcus aureus and hospitalization for more than one week and patients without Staphylococcus aureus and hospitalization for less than one week, the Odd Ratio is up to 7.5 (p value = 0.20). In addition, by the traditional bacterial culture method, a potential novel species of Streptococcus was identified and the most similar species were Streptococcus mitis NCTC 12261.
PD04 THE EFFECT OF SGLT2 INHIBITOR ON CEREBROVASCULAR EVENTS: A META-ANALYSIS
1WEN-HSUAN TSAI, 1SHIH-MING CHUANG
1 Division of Endocrinology and Metabolism, Department of Internal Medicine, Mackay Memorial Hospital, Taipei, Taiwan (ROC)
Background: Sodium-glucose cotransporter 2 (SGLT2) inhibitors have shown impressive effect in reducing major vascular events in several randomized controlled trials (RCTs). The purpose of this study was to perform a meta-analysis to evaluate the effect of SGLT2 inhibitor on the risk of stroke and its subtypes.
Methods: All data from prospective randomized placebo-controlled trials up to 27 May 2020 involving SGLT2 inhibitor which reported stroke events as primary endpoints or safety in subjects with type 2 diabetes were meta-analysed
Results: Five eligible randomized placebo-controlled trials (EMPA-REG, CANVAS, DECLARE, CREDENCE and VERTIS CV) involving 46969 participants were included. Pooled analysis of RCTs showed no significant effect of SGLT2 inhibitors on total stroke [risk ration (RR) 0.97; 95% confidence interval (CI) 0.87–1.08, P = 0.614]. The subgroup analysis indicated that the effect of SGLT2 inhibitor had no significant effect against fatal stroke (RR = 0.87, 95% CI 0.61-1.26, P = 0.472), non-fatal stroke (RR = 0.96 95% CI 0.88-1.10, P = 0.750), ischemic stroke (RR = 0.99, 95% CI 0.88-1.12, P = 0.949) or transient ischemic attack (RR: 0.94, 95% CI: 0.80–1.12; P = 0.506). When only hemorrhagic stroke was included, SGLT2 inhibitor was associated with a significant reduction by 50 % compared with placebo (RR = 0.50, 95% CI 0.30–0.83, P = 0.007).
Conclusions: The meta-analysis support SGLT2 inhibitors have neutral effect on risk of stroke and its subtypes, and possible potential protective effects against hemorrhagic stroke despite small number events.
PD05 CONTINUOUS GLUCOSE MONITORING (CGM) AND 5-HOUR ORAL GLUCOSE TOLERANCE TEST IN A RARE CASE WITH INSULINOMA
1CHI-EN YEN, 1SHU-YI WANG,
1SHI-DOU LIN,
1SHANG-REN HSU, 1SHIH-TE TU
1 Division of Endocrinology and Metabolism, Department of Internal Medicine, Changhua Christian Hospital, Taiwan, R.O.C
Insulinoma is a rare pancreatic islet cell tumor that cause high endogenous insulin secretion resulting in episodes of hypoglycemia. We report here the case of an 64-year-old female with a past history of hypertension, hyperlipidemia and diagnosed with diabetesmellitus. She was presented to our clinic, due to frequent hypoglycemic episodes ever with loss of consciousness. Hypoglycemic episodes frequently attack around 10:00 am. These symptoms resolve promptly following glucose administration. Elevated C-peptide level in the presence of hypoglycemia. Abdominal sonography showed cystic lesion 1.4 cm over pancreatic head. Abdominal computed tomography scan revealed a 1.5 cm enhancing nodule in pancreatic neck. Pancreatic insulinoma was highly suspected. Continuous glucose monitoring showed downward glucose excursion after breakfast, with hypoglycemia before lunch. 72 hours fasting test was arranged, but the data is not complete, due to the patient feels hypoglycemia symptoms without hypoglycemia. A 5-hour Oral 75 gm Glucose Tolerance Test (5-hour OGTT) showed hypoglycemia episode noted after glucose intake around 3 ~ 3.5 hours. The patient underwent successful resection of the tumor, and his symptoms showed complete resolution.
PD06 GLP-1 RECEPTOR AGONIST MODULATES BILE ACID METABOLISM TO ATTENUATE HIGH FAT DIET-INDUCED HEPATIC STEATOSIS
1HE-JIUN JIANG,
2TIEN-CHOU SOONG, 1YU-HSI KAO, 1PI-JUNG HSIAO
1Division of Endocrinology and Metabolism, Department of Internal Medicine, E-Da Hospital
2Department of Weight Loss and Health Management Center, E-DA Dachang Hospital
Aim: Glucagon-like peptide 1 receptor analogues (GLP-1 RAs) are currently approved as a class effect to improve hepatic steatosis even absence of GLP-1 receptor on hepatocytes. GLP1RA significantly delays the intestinal motility and transit time, which may affect the enterohepatic circulation of the bile acids homeostasis. Therefore, modification of the enterohepatic circulation and hepatic BA pools was speculated for the hepatoprotective effect of GLP-1RAs.
Materials and Methods: A mice model of high fat diet (HFD) induced hepatic steatosis was designed to test the changes of hepatic histology, lipogenesis (FASN, ACC, SREBP-1) and inflammasome (NLRP3, pNFκB), hepatic bile acids pool and bile acid signaling (FXR, TGR5). The effect to add on Bydureon (extended-released exenatide, 500 g/kg/wk) treatment for 16 weeks was compared with groups of chow diet and HFD. The bile acid analysis was conducted by ultra-highperformance liquid chromatography coupled with triple quadrupole Mass Spectrometer (UPLC/ TQMS).
Results: HFD significantly induced weight gain, hepatic steatosis, insulin resistance, increased lipogenesis and inflammation and altered hepatic BA pool. The total hepatic BA pool was 5438.21 ± 438.75 nM in groups of chow, significantly decreased to 4029.46 ± 198.76 nM by HFD but markedly raised to 6491.47 ± 810.47 nM by add on Bydureon. The hepatic BAs as ligands of the FXR/ TGR5 receptors displayed significant changes by HFD, while both of FXR/TGR5 agonists or FXR antagonists were significantly raised by Bydureon treatment. Hepatic expression of the FXR/TGR5 was downregulated by HFD with relevant to enhanced lipogenesis and inflammasome. But, Bydureon treatment significantly reversed all these changes.
Conclusions: HFD resulted in an altered BA homeostasis. GLP-1RA treatment could modulate
hepatic BA homeostasis and improve hepatic steatosis and inflammation, which may be mediated by the FXR/ TGR5 signaling.
PD07 INFLUENCE OF WEIGHT LOSS ON BLOOD SUGAR CONTROL AND TREATMENT SATISFACTION FROM THE USE OF GLP-1 RA
CHEN-JUNG SHEN, CHIEH-TING YEH
1Division of Endocrinology and Metabolism, Department of Internal Medicine, An Nan Hospital, China Medical University,Tainan, Taiwan, R.O.C.; 2Nursing Department, An Nan Hospital, China Medical University,Tainan, Taiwan, R.O.C.
Background: Less than 35% of diabetic patients reach the standard for HbA1c; most of the cases fail to reach the standard after using a variety of oral drugs. At this time, consider the use of injectable drug treatment, which is one of the effective methods to control blood sugar. However, most patients are reluctant to receive injection therapy because they are worried about side effects and medication inconvenience. Compared with insulin, GLP-1 RA effectively controls blood sugar without causing weight gain, and the risk of hypoglycemia is relatively low. Besides, GLP-1 RA may reduce body weight and motivate the patient to receive medication more aggressively.
Method: Included cases: The following conditions must be met: 1. Type 2 diabetes cases tracked in the outpatient clinic, 2. Have received oral hypoglycemic drugs, but blood sugar control is still reach target, need to receive injection treatment, 3. Have not received insulin treatment, 4. After diabetic education, the patient is willing to receive the treatment of GLP-1 RA injection. In addition to the original diabetes medication, the professional team added GLP-1 RA injection therapy to the admitted patients, plus intervention to improve their lifestyle, and cooperated with health education tools (digital health education manual, blood glucose pull board, diabetes personal dialogue and viewing Picture talk) to improve the compliance of the case, improve the blood sugar control of the case, strengthen weight management, and improve the quality of life It is planned to execute the itinerary from March 1, 2018 to September 30, 2018, a total of seven months. During the acceptance period, each case was fully observed for three months.
Results: A total of 50 people have been included in this project, and the project results are as follows • The average HbA1c of all cases dropped from 8.37% to 6.99%, an improvement of 1.38%. • The average weight of all cases dropped from 82.17 kg to 76.84 kg, and the weight loss ratio: -5.33%. • Changes in fasting blood glucose in the first 2-4 weeks of all cases: 130.68 mg/dL • The average score of patients’ satisfaction with treatment is 26.72 (out of 30)
Conclusion: With the intervention of professional health education, the diabetes team enhances the individual’s understanding of GLP1-RA injection therapy, which can enhance the individual’s compliance with the treatment. With appropriate drug adjustments, the lifestyle improves, which can significantly improve blood sugar control and reduce blood pressure. Blood sugar occurs, reducing weight and improving quality of life.
PD08 PYOGENIC LIVER ABSCESS RISK IN PATIENTS WITH NEWLY DIAGNOSED TYPE 2 DIABETES MELLITUS: A NATIONWIDE, POPULATION-BASED COHORT STUDY IN TAIWAN
1TZU-YUAN WANG, 2HSIN-HUNG CHEN,
1MING-CHIA HSIEH,
1CHING-CHU CHEN,
1CHWEN-TZUEI CHANG, 1RONG-HSING CHEN, 1CHUN-WEI HO, 1WEI-LUM HUANG,
1YI-CHIN HUNG,
1TUEI-YU TSENG,
1JIA-YIN GUO,
1YOU-TING LIN
1Intelligent Diabetes Metabolism and Exercise Center, Department of Internal Medicine, China Medical University Hospital, Taichung,Taiwan, ROC; 2Division of Endocrinology and Metabolism, Department of Internal Medicine, Asia University Hospital, Taichung, Taiwan.ROC.
Background: Pyogenic liver abscess (PLA) is a serious infectious and life-threatening disease with a low but gradually increasing annual incidence rate. To date, no comprehensive epidemiological study exists for PLA risk in patients with newly diagnosed type 2 DM worldwide. The aim of this study is to explore newly diagnosed type 2 DM and PLA risk in Taiwan.
Methods: We extracted a DM and comparison cohorts from the Longitudinal Health Insurance Database and compared PLA risks between them. In the DM cohort, patients newly diagnosed as having type 2 DM (ICD-9-CM 250) from 2000 to 2009 were enrolled. We used date of initial DM diagnosis as the index date. In the comparison, individuals without a history of DM were randomly 1:4 frequency-matched with the DM cohort, the matching was based on the age of cohort entry (per 5 years) and sex. The index date for the comparison cohort was a randomly assigned date, in the same year as that of the index date of their DM cohort patients.
Results: A total of 44728 patients with DM and 178912 patients without DM were enrolled. In DM cohort, 166 patients were diagnosed as having PLA (incidence rate = 5.87 per 10000 personyears) and in comparison cohort, 238 patients were diagnosed as having PLA (incidence rate = 2.06 per 10000 person-years).The DM cohort exhibited higher PLA risk than did the comparison cohort (hazard ratio = 2.83, 95% confidence interval = 2.32-3.46). Furthermore, the adjusted hazard ratio for PLA risk in DM cohort was the highest in those younger, men and patients in the first 2 years after diagnosis of type 2 DM. In the DM cohort, the most common PLA causative agent was Klebsiella pneumoniae. In addition, PLA risk was high in DM patients with gallstone and cholecystitis. Compared with comparison cohort, patients with type 2 DM prescribed acarbose has a lower PLA risk, however glyburide significantly increased PLA risk in DM cohort.
Conclusions: In paitents with newly diagnosed type 2 DM, PLA risk was high and acarbose demonstrated beneficial effect of reducing PLA risk.
PD09 GCK-MODY DIAGNOSED BEFORE 4 YEARS OF AGE: A STUDY ON TWO FAMILIES
1,2,3,4,5YANN-JINN LEE, 1,4,6WEI-HSIN TING,
1,4,6CHI-YU HUANG,
7,8FU-SUNG LO,
9CHAO-HSU LIN,
10YI-LEI WU,
2CHIUNG-LING LIN
1Pediatric Endocrinology, MacKay Children's Hospital; 2Medical Research, MacKay Memorial Hospital Tamsui District; 3Pediatrics, School of Medicine, College of Medicine, Taipei Medical University; 4Medicine, Mackay Medical College; 5Institute of Biomedical Sciences, Mackay Medical College; 6MacKay Junior College of Medicine, Nursing, and Management; 7Pediatrics, Chang Gung Memorial Hospital; 8College of Medicine, Chang Gung University; 9Pediatrics, Mackay Memorial Hospital HsinChu Branch; 10Pediatric Endocrinology and Metabolism, Chuanghua Christian Children's Hospital
Introduction
Maturity onset diabetes of the young (MODY) is caused by single gene mutations, resulting in defects in the development, proliferation/regeneration, and/or function of β cells. Strict criteria for the diagnosis of MODY include diabetes in at least 3 genera¬tions with autosomal dominant transmission and diagnosis before age 25 yr in at least 1 affected subject. We reports 2 children younger than 4 years with hyperglycemia and mutations of the GCK gene, which are transmitted from their parents.
Case reports
Patient 1
1 1/12 year-old boy had fasting hyperglycemia accidentally found. His Glucose was 110 mg/dl and HbA1c 6.2%. His mother also had fasting hyperglycemia and gestational diabetes.
Molecular analysis on the GCK gene was performed by using PCR and sequencing. The variations detected are listed below. The specimen from the client is heterozygous for mutation c.556C>T, p.Arg186Ter which is pathogenic.
The analysis showed that Mother has the variant but her parents did not have. De novo mutations in the GCK gene have been described in literature. Paternity and maternity were confirmed using HLA-B locus genotyping (Table 1, Figure 3).
Table 1. GCK and HLA-B genotypes in patient 1 and his family
Patient ID GCK
allele GCK
other alleleHLA-B
allele HLA-B
other allele 6873 c.556C>T No mutation
6873F No mutation No mutation
6873M c.556C>T No mutation 46:01 81:01/02
6873MF No mutation No mutation 15:01 81:01/02
6873MM No mutation No mutation 38:02 46:01
F, Father; M, Mother; MF, Mother's father; MM, Mother's mother
Figure 1. Mutation c.556C > T, p.Arg186Ter in the GCK gene. The mutation causes a truncated protein of 185 amino acids.
Patient 2
A 3.9-year-old boy was found to have hyperglycemia during a laboratory work-up when he had acute bronchiolitis. His father has diabetes mellitus. A pathogenic variant was detected in GCK (Table 2, Figure 2). He inherited the variant from his father.
Table 2. Patient 2
Patient ID GCK
allele GCK
other allele 7108 c.505A > G No mutation
7108F c.505A > G No mutation
7108M No mutation No mutation
7108S1 No mutation No mutation
F, Father; M, Mother; S1, sister
Figure 2. Mutation c.505A > G, p.Lys169Glu in the GCK gene. The mutation leads to GCKMODY.
Clinical Management
Because GCK-MODY needs no treatment of hypoglycemic agents, healthy daily life is emphasized to avoid obesity and deranged metabolism.
Conclusions
Children with mutations in GCK were instructed to avoid unnecessary treatment with hypoglycemia agents.
PD10 THE EFFECT OF SGLT-2 INHIBITOR ON DIABETIC NEPHROPATHY AND WEIGHT CONTROL
1CHEN-JUNG SHEN, 2CHIEH-TING YEH
1Division of Endocrinology and Metabolism, Department of Internal Medicine, An Nan Hospital, China Medical University,Tainan, Taiwan, R.O.C.; 2Nursing Department, An Nan Hospital, China Medical University,Tainan, Taiwan, R.O.C.; Nursing Department
Background: According to the annual report of kidney disease in Taiwan, there are about 78,000 dialysis patients in Taiwan, among which diabetes patients account for 49.3%. With the increasing prevalence of diabetes, the number of patients with diabetic nephropathy (DKD) has also increased year by year. However, more than 60% of diabetics in Taiwan still fail to meet the standard of glycosylated hemoglobin (HbA1c) (7%), of which 15% of diabetics will develop nephropathy, 39.7% of diabetics have albuminuria, and Taiwan’s acute chronic kidney disease patients More than 40% are caused by diabetes. In addition, 32% of diabetics have cardiovascular disease, and 15% of diabetics have heart failure. There are many treatment options for diabetes, including oral, injection, and lifestyle changes. However, some patients still do not respond well to treatment. SGLT2 inhibitors can improve blood sugar control, as well as kidney protection and weight loss. However, clinical original research data on the effectiveness of indigenous SGLT-2 inhibitors is relatively lacking in Taiwan. This project is expected to evaluate the effectiveness of SGLT-2 inhibitors for blood glucose, renal function, and weight control in patients with diabetes and nephropathy.
Methods:
1. or people with type 2 diabetes who have not been treated with SGLT-2 inhibitors, their eGFR > 45ml/min/1.73m2, and combined with the following two: (1) HbA1c > 7%, (2) UACR > 30mg
/g, give SGLT-2 inhibitor treatment to track the overall HbA1c improvement, weight loss rate, and urine protein (UACR) decline rate of the accepted cases. 2. The acceptance period is 3 months (February 1, 2020 to April 30, 2020), and the observation period is 3 months (May 1, 2020 to July 31, 2020) 3. Exclusion conditions: cases receiving diuretic treatment during the observation period.
Results: A total of 60 people were admitted in this study. After treatment with SGLT2 inhibitors, the overall improvement of the case: the overall average HbA1c decreased from 9.11% to 8.30%, an improvement of 0.805%. The average weight was reduced from 73.82kg to 72.42kg, with an average loss of 1.39kg.
The average UACR decreased from 481.69mg/g to 278.86mg/g, and the average rate of decrease was 19.7%.
Conclusions: SGLT2 inhibitors are a new class of anti-diabetic drugs. This study shows that
SGLT2 inhibitors can significantly improve HbA1c, reduce body weight, and reduce UACR. For patients with diabetes and nephropathy, SGLT-2 inhibitors may be a good choice. However, the overall improvement of diabetes comorbidities may require more clinical treatment data to support it.
PD11 ASSOCIATION OF BODY MASS INDEX WITH ALL-CAUSE MORTALITY IN THE ELDERLY POPULATION OF TAIWAN: A PROSPECTIVE COHORT STUDY
1YU-KAI LIN,
2,3CHUN-CHIEH WANG, 4,5,6YUNG-FENG YEN,
7LI-JUNG CHEN,
8PO-WEN KU, 4CHU-CHIEH CHEN, 7,9,10YUN-JU LAI
1Department of Health and Welfare, College of City Management, University of Taipei, Taiwan; 2Division of Chest Medicine, Department of Internal Medicine, Puli branch of Taichung Veterans General Hospital, Taichung, Taiwan; 3Central Taiwan University of Science and Technology Department of Eldercare, Taichung, Taiwan; 4Department of Health Care Management, National Taipei University of Nursing and Health Sciences, Taipei, Taiwan; 5Section of Infectious Diseases, Taipei City Hospital, Taipei City Government, Taipei, Taiwan; 6Institute of Hospital and Health Care Administration, National Yang-Ming University, Taipei, Taiwan; 7Department of Exercise Health Science, National Taiwan University of Sport, Taichung, Taiwan; 8Graduate Institute of Sports and Health, National Changhua University of Education, Changhua, Taiwan; 9School of Medicine, National Yang-Ming University, Taipei, Taiwan; 10Division of Endocrinology and Metabolism, Department of Internal Medicine, Puli Branch of Taichung Veterans General Hospital, Nantou, Taiwan
Background: The nutritional status of the elderly is different from that of young people. Body composition changes as people age, for example, fat mass increases, muscle mass decreases, and body fat distribution is changed. We aimed to investigate the association of body mass index (BMI) with cause-specific mortality in elderly population.
Methods: The data of annual health examination for the older citizens (≥ 65 years old) from 2006 to 2011 in Taipei City Hospital were used. Information on baseline demographics, lifestyle behaviors, medical and drug usage were collected by a self-administered questionnaire. Cause-specific mortality was ascertained from the National Registration of Death. Individuals were followed-up until death or December 31, 2012, whichever was earlier. Univariable and multivariable Cox proportional hazard analyses were applied to investigate the association between BMI and all-cause mortality.
Results: Among 81,221 older people included in the analysis, 42,602 (52.45%) were men. The mean age was 73.85 ± 6.32 years. Among the 81,221 participants, 3,398 (4.18%) were underweight, 36,476 (44.91%) were normal weight, 25,708 (31.65%) were overweight, and 15,639 (19.25%) were obese. Those in the BMI category 27 ≤ BMI < 28 kg/m2 had the lowest all-cause mortality risk. The BMI of lowest cause-specific mortality was between 27 kg/m2 and 28 kg/m2 in infection mortality, between 28 kg/m2 and 29 kg/m2 in circulation mortality, between 29 kg/m2 and 30 kg/m2 in respiratory mortality, between 31 kg/m2 and 32 kg/m2 in cancer mortality.
Conclusions: The current study found J-shaped relation between BMI and cause-specific mortality in elderly population of Taiwan.
PD12 A SIMPLE TREATMENT FOR AN EFFECTIVE OUTCOME: USE OF IGLARLIXI TOGETHER WITH REAL-TIME CONTINUOUS GLUCOSE MONITORING TO ACHIEVE BLOOD GLUCOSE STABILITY IN NEWLY DIAGNOSED TYPE 2 DM
1CHUN-HSING LIN, 1CHENG-PIN CHENG ,
1YA-CHUN LI,
1MAN-NI LU,
1TING-YU CHEN,
1,2,3CHUN-JUI HUANG
1 Division of Endocrinology and Metabolism, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; 2 Faculty of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan; 3 Institute of Public Health, School of Medicine, National Yang-Ming University, Taipei, Taiwan
Background: iGlarLixi, a fixed-ratio combination of insulin glargine 100 U/mL (iGlar -100) and the GLP-1 RA lixisenatide, is robustly used to improve glycemic control of patients with T2DM. Its effectiveness has been demonstrated in a wide variety of clinical settings, including patients inadequately controlled with basal insulin or oral anti-diabetic agents. However, there is less experience in using iGlarLixi in people newly diagnosed with T2DM and concomitantly applying realtime continuous glucose monitoring (RT-CGM).
Methods: Three patients with newly diagnosed type 2 DM and HbA1c >9.0% were selected in Taipei Veterans General Hospital to initially receive insulin glargine 300 U/mL combined with oral agents and further shifted to iGlarLixi to simplify regimen and reduce glucose fluctuation. During titration phase I, insulin glargine 300 U/mL was initiated along with metformin and mitiglinide. The insulin dosage was titrated to reach a fasting blood glucose (FBG) of 150 mg/dl and RT-CGM was introduced for the following 7 days. In titration phase II, insulin was substituted with iGlarLixi and the dosage was titrated to reach FBG around 130 mg/dl. RT-CGM was applied for another 7 days thereafter. To prevent hypoglycemia in phase II, mitiglinide was either discontinued or the dosage was reduced. In both phases, patients maintained a detailed dietary record and shared the information with diabetes educator through Health2Sync.
Results: The first case was a 32 year-old male who experienced very high post-prandial blood glucose around 250-350 mg/dl in phase I. After introducing iGlarLixi, the percentage of time in range (TIR, 70-180 mg/dl) improved from 22% to 89% without any blood glucose level exceeding 250 mg/ dl. The second and third case were 60 year-old female and 55 year-old male whose TIR did not differ significantly between the two phases (case 2: 80% v.s. 78%, case 3: 97% v.s. 98%). However, the 2% of blood glucose above 250 mg/dl disappeared in case 2 and hypoglycemia improved in case 3 under the use of iGlarLixi along with dietary modifications. The overall reduction of HbA1c in three months were 2.0%, 6.1%, and 4.6% respectively (HbA1c: 9.2% to 7.2%, 13.3% to 7.2%, and 12.5% to 7.9%). Patient’s response to direct glucose readings were rapid and the dietary adjustments were rewarding.
Conclusions: The use of iGlarLixi in patients with newly diagnosed T2DM not only simplified treatment regimen but also improved glucose stability. Both iGlarLixi and RT-CGM were able to enhance patients’ compliance and treatment outcome.
PD13 THE EFFECTIVENESS OF PAY-FOR-PERFORMANCE PROGRAM ON DIABETES CARE FOR OUTPATIENTS IN A PSYCHIATRIC REGIONAL HOSPITAL IN MIDDLE TAIWAN.
1,2CHIN-CHOU YANG, 2SHIAO-CHI WU, 2MING-CHEN GUO,
2WEI-CHENG TSAI
1Department of Psychiatry, Division of General Medicine, TsaoTun Psychiatric Center, Ministry of Health and Welfare, Taiwan; 2Institute of Health and Welfare Policy, National Yang-Ming University
Background: Diabetes is a common health issue in the world. The prevalence of diabetes in patients with mental illnesses, such as schizophrenia, bipolar disorder, and anxiety disorder, are higher than general population(Grigolon et al., 2019; Mamakou et al., 2018), including Taiwan (Chien et al., 2010; Chien et al., 2009). The coincidence of mental disorders and diabetes mellitus has adverse effects on diabetes control (Abrahamian et al., 2019).
Good diabetes control has already been proved efficacious to prevent many acute and chronic diabetic complications (Turner, 1998). Pay-for-performance(P4P) program of diabetes care (or Diabetes Shared Care Program), which was initiated in 2001 by the Ministry of Health and Welfare in Taiwan, helps patients with diabetes to achieve better glycemic control (Wang et al., 2014). This care model has demonstrated successful outcomes in the P4P participants with type 2 diabetes (Hao et al., 2011). However, there were no endocrinologist hired by any psychiatric hospital in Taiwan before 2019, and P4P program of diabetes has never been adopted in these psychiatric hospitals.
Nearly everyone in Taiwan is covered with National Health Insurance, including those with mental disability. Up to 2017, according to the National Statistic Report of Ministry of Health and Welfare in Taiwan, there were about 1,167,000 people certified mental disability. Some of them were living in community. However, for some patients who have severe mental illness, they may reside in chronic wards of psychiatric hospitals for a long period of time. Psychiatric hospitals also have outpatient departments providing services for patients with mental illness. Beside treatment for mental illness, patients may also receive treatment for diabetes from psychiatrist in the same time.
In 2019, P4P program of diabetes care was implemented in a regional psychiatric hospital in middle Taiwan, which was also the only psychiatric hospital hired a full-time endocrinologist in Taiwan. This regional psychiatric hospital had about total 1,200 hospital beds, including emergency department, intensive care unit, 6 acute and 16 chronic wards, and 4 nursing homes. The objective of this study is to examine the effectiveness of P4P program of diabetes for outpatients, assess the quality of care and outcome of psychiatric patients with diabetes, and share the feasibility and experiences of building a diabetes care system in a regional psychiatric hospital in middle Taiwan.
Methods: Our study utilized a retrospective cohort design to examine the effect of P4P program of diabetes care for psychiatric patients with diabetes. The intervention took place in the outpatient
department of a regional psychiatric hospital in middle Taiwan. The program was applied since Jan 2019. The staff members of P4P program worked as a coordinated multidisciplinary team, which consisted of a full-time endocrinologist, diabetes nurses, and dieticians. According to the rules of P4P program, the care team was required to provide regular evaluations for the enrolled patients, including biochemical tests, educational programs, and management plans. Because all hospitals participating the P4P program were required to submit data to receive P4P follow-up payments, our database is undoubtedly reliable.
The study selection process is illustrated in Figure 1. In the 1st quarter of 2019, there were total 129 psychiatric patients with diabetes participated in P4P program of diabetes care. According to the rule of P4P program, HbA1c should be tested every 3 months. Individualized health education was also provided every 3 months. Those who loss follow-up for more than twice during 2019 were excluded from our study. We collected HbA1c data of the 4th quarter in 2018 as baseline, while P4P program was not applied yet. HbA1c data of every quarter in 2019 was collected as dependent variable. The basic characteristics of our patient, including sex, age, body mass index (BMI), and comorbidities (hypertension and hyperlipidemia) were recorded as covariance. Generalized estimating equations (GEE) with SPSS 26 was used for statistical analysis. The study was approved by the institutional review board of Tsaotun psychiatric center for medical ethics.
Results: There were total 129 patients enrolled in our study. 53.5% of them was male, and 46.5% was female. The mean HbA1c level of female patients were significantly higher than HbA1c level of male patients. The prevalence of hypertension and hyperlipidemia was slightly higher (without significance) among male patients. The results of statistical analysis were demonstrated in Table-2. The HbA1c level increased slightly in the first quarter (p>0.05), and then decreased gradually since the second quarter. The HbA1c level got significant improvement in the third quarter (P<0.05), and the effectiveness of P4P persisted to the fourth quarter. The mean HbA1c level of male patients seems got more improvement than female patients after P4P intervention. Patients with hyperlipidemia also got more improvement than those without hyperlipidemia.
Conclusions: The implementation of P4P program of diabetes care is a novel way to deliver diabetes care services for patients with mental illness, and it should be actively promoted.
PD14 CEMIP-HBC DNA VACCINE INHIBITS KIDNEY FIBROSIS IN HIGH FAT DIET MICE THROUGH INTERFERING WNT/Β-CATENIN SIGNALING
1PI-CHEN LIN, 2YI-CHEUNG WONG,
1KUN-DER LIN,
2GUAN-MING KE,
2,3CHAO-HUNG CHEN
1 Division of Endocrinology and Metabolism, Kaohsiung Medical University Hospital, Kaohsiung Medical University; 23 Graduate Institute of Animal Vaccine Technology, College of Veterinary Medicine, National Pingtung University of Science and Technology; 3 General Research Service Center, National Pingtung University of Science and Technology
Background: Obesity is a common risk for cardiovascular diseases and type 2 diabetes, which both result in developing chronic kidney disease (CKD). berration of wnt/β-catenin signaling is associated with obesity, dyslipidemia, diabetes and nephropathy.The hyaluronan-binding protein (CEMIP) is identified to mediate hyaluronan degradation and participate in migration and tumorigenesis. In addtion, CEMIP involves fibrosis, proliferation and migration of atherosclerosis. This study intended to design CEMIP-HBc (human hepatitis virus B core portein) DNA vaccines for nephropathy in obesity, through diminishing Wnt1/β-catenin pathway.
Methods: In an 8-week experiment, plasmid-encoding CEMIP and HBc was vaccinated high fat diet(HFD) mice in the first 4 weeks, and then vaccination was stopped for at least 4 weeks.At the end point, mice were sacrificed for analysis of the CEMIP/Wnt1/β-catenin pathway and fibrogenesis in kidneys.
Results: Anti-CEMIP antibody was successfully produced in the CEMIP-HBc vaccinated group, while Wnt1/β-catenin signaling and fibrosis was consistently lower in this group.
Conclusions: This study revealed that application of CEMIP-HBc DNA vaccine efficiently repressed expressions of Wnt1/β-catenin/ECM pathway in kidney tissue of HFD mice.Based on these outcomes, CEMIP/ Wnt1/β-catenin pathway is considered as novel therapeutic target of nephropathy.
PD15 THE EFFECTS OF DIPEPTIDYL PEPTIDASE 4 INHIBITORS ON RENAL OUTCOMES IN PATIENTS WITH TYPE 2 DIABETES MELLITUS
1WAN-CHIA HSU, 1JUNG-FU CHEN,
2CHUN-SHENG LIN, 1CHIH-MIN CHANG
1Department of Endocrinology and Metabolism, Kaohsiung Chang Gung Memorial Hospital, Taiwan, R.O.C.;
2Kaohsiung Chang Gung Memorial Hospital, Taiwan, R.O.C.
Background: Many prior clinical trials confirmed glucagon-like peptide 1 receptor agonists (GLP-1 RAs) have benefits on renal outcomes in patients with type 2 diabetes mellitus (DM). This study evaluated whether dipeptidyl-peptidase 4 (DPP-4) inhibitors, an anti-hyperglycemic drug to increase GLP-1 serum concentration, also have benefits on renal function as GLP-1 RAs.
Methods: We conducted this retrospective cohort study by using the Chang Gung Research Database, which is an electronic medical record derived from Chang Gung Memorial Hospital.
In this retrospective cohort study, patients aged ≥ 18 years diagnosed with type 2 DM treated with anti-hyperglycemic agents between January 1, 2008 and December 31, 2011 were enrolled.
We compared the time to first occurrence of eGFR decline of ≥ 30% from baseline between patients treated with DPP-4 inhibitors and with other anti-hyperglycemic drugs except for DPP-4 inhibitors for 5 years. Subgroups stratified by baseline chronic kidney disease (CKD) stage and other risks factors for eGFR decline were also analyzed.
Results: A total of 12073 eligible patients, 7525 in DPP-4 inhibitors users group and 4548 in non-DPP-4 inhibitors group, were identified. 1101 DPP-4 inhibitors users and matched non-DPP-4 inhibitors users were finally analyzed after propensity score matching with 1:1 ratio. The incidence of eGFR decline of ≥ 30% from baseline was 10.08% in DPP-4 inhibitors group comparing with 16.17% in non-DPP-4 inhibitors group with significant difference (p < 0.001).
The mean time to event is significant longer in patients using DPP-4 inhibitors (2.84 ± 1.60 years vs. 1.96 ± 1.30 years, p < 0.001). The cumulative incidence of eGFR decline ≥ 30% is lower in DPP4 inhibitors users (log-rank test, p = 0.001), and regardless of baseline CKD stage, DPP-4 inhibitors users have lower incidence rate of eGFR decline ≥ 30%. Patients who are younger than 65 years old (HR 0.36, 95% CI: 0.25 - 0.53, p for interaction < 0.001), with better baseline eGFR (p for interaction = 0.001), without preexisting hyperlipidemia (HR 0.31, 95% CI: 0.22 - 0.45, p for interaction < 0.001), and without prior statin use (HR 0.29, 95%CI: 0.21 - 0.41, p for interaction = 0.028) have more reduced risks of declined renal function.
Conclusions: There are significant lower risks in patients with normal or mildly impaired baseline renal function, having risks reduction of 69% for eGFR ≥ 90 mL/min/1.73m2 and 59% for ≥ 60 to < 90 mL/min/1.73m2, respectively.
In conclusion, our study demonstrated that adult patients diagnosed of type 2 diabetes receiving
DPP-4 inhibitors with or without other anti-hyperglycemia agents have lower risks of eGFR decline, comparing to patients under other types of anti-hyperglycemia agents except for DPP-4 inhibitors.
PD16 OXIDATIVE LDL ACTIVATES INTERACTION OF SARS-COV2 SPIKE PROTEIN AND TMPRSS4 RESULTED IN LIVER INJURY
1PI-CHEN LIN,
2YI-CHEUNG WONG,
2CUI-YAN WANG, 1KUN-DER LIN,
2GAUN-MING KE, 2,3CHAO-HUNG CHEN
1 Division of Endocrinology and Metabolism, Kaohsiung Medical University Hospital, Kaohsiung Medical University; 2,3Graduate Institute of Animal Vaccine Technology, College of Veterinary Medicine, National Pingtung University of Science and Technology; 3 General Research Service Center, National Pingtung University of Science and Technology
Background: In 2019, SARS-CoV-2 first spread and caused severe pneumonia and high fatality rate.In particular, clinical studies have found that a considerable proportion of SARS-CoV-2 infected persons have severe acute respiratory diseases with liver damages. However, SARS-CoV-2 receptors, ACE2 in the liver were significantly lower than that in the lungs or gastrointestinal tract. Transmembrane Protease, Serine 4, TMPRSS4 has been considered as SARS-CoV-2 co-receptors for infecting human cells. Clinical studies have also found that a high proportion of COVID-19 patients with dyslipidemia or metabolic syndrome will develop severe illnesses such as liver failure. Therefore, investigating the capable mechanism of high negative charge LDL in assisting the SARS-CoV-2 virus to infect the liver has considerable research value in the therapy on COVID-19 combined with acute liver damages.
Methods: This study is based on SARS-CoV-2 epidemic prevention work and laboratory safety considerations, and uses pseudovirus which carries SARS-CoV-2 spike protein (S-protein) to simulate SARS-CoV-2 infection in oxLDL-cultured control siRNA or TMPRSS4 siRNA-transfected human
hepatic cells . Furthermore, SARS-CoV-2 pseudovirus was injected to chow or high fat diet (HFD) mice. At end of experiments, livers and cultured hepatic cells were harvested for analysis.
Results: Under SARS-CoV-2 pseudovirus infection, hepatic TMPRSS4 highly expressed in HFD mice compared with chow mice. Proximal ligation assay shows high expression of S-proteinTMPRSS4 complexes in HFD mice. Immnuoprecipitation showed S-protein significantly expressed on serum LDL of HFD mice. TUNEL assay demonstrated more increase of apoptotic cells on liver of HFD than chow mice with SARS-CoV-2 pseudovirus infection. In vitro, oxLDL-cultured hepatic cells significantly presented S-protein-TMPRSS4 complexes and apoptosis compared with normal LDLcultured hepatic cells. However, these oxLDL effects were repressed by TMPRSS4 siRNA.
Conclusions: This first study first elucidated that possibility of dyslipidemia or metabolic syndrome contributes COVID-19 combined with acute liver injury is through high negative charge LDL participating interaction of SARS-CoV-2 S-protein and TMPRSS4.
PD17 CIRCULATING LEVELS OF SOLUBLE TUMOR NECROSIS FACTOR RECEPTOR 2 ARE ASSOCIATED WITH PROGRESSIVE DIABETIC KIDNEY DISEASE IN PATIENTS WITH TYPE 2 DIABETES MELLITUS
1,2LIANG-YU LIN, 1,2TSUNG-HUI WU, 3LI-HSIN CHANG, 1,2CHII-MIN HWU,
1,2HARN-SHEN CHEN
1Division of Endocrinology and Metabolism, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; 2Faculty of Medicine, National Yang-Ming University, Taipei, Taiwan; 3Division of Endocrinology and Metabolism, Department of Medicine, Yeezen General Hospital, Taoyuan, Taiwan
Background: Chronic low-grade inflammation is considered one of the major mechanisms for the progression of diabetic kidney disease. We investigated the prognostic value of circulating soluble tumor necrosis factor receptor 2 (sTNFR2) for early nephropathy in patients with type 2 diabetes.
Materials and methods: A total of 346 patients with type 2 diabetes and an estimated glomerular filtration rate (eGFR) ≥30 mL/min/1.73m2 were followed up for a median of 4 years. Renal outcomes were defined as a composite of either or both a >30% decline in the eGFR and/or albuminuria stage progression determined with consecutive tests.
Results: Sixty-nine patients developed renal composite events. Serum concentrations of sTNFR2 were strongly associated with the risk of renal function decline and progressive changes in albuminuria. Through a receiver operating characteristic curve analysis, a serum sTNFR2 level of 1.608 ng/mL was adopted as the discriminator value for predicting renal outcomes (area under the curve 0.61, 95% confidence interval 0.54-0.68, p = 0.005), yielding a sensitivity of 73.9% and a specificity of 48.7%. The association of sTNFR2 levels ≥1.608 ng/mL to renal outcomes was significant after adjusting for relevant variables (hazard ratio 1.95, 95% confidence interval 1.01-3.74, p = 0.046) and remained consistent across subgroups stratified by age, sex, systolic blood pressure, eGFR, albuminuria, and the use of renin-angiotensin system blockers.
Conclusions: Higher circulating levels of sTNFR2 are independently associated with an eGFR decline and progressive albuminuria in patients with type 2 diabetes.
PD18 NON-ISLET CELL TUMOR HYPOGLYCEMIA SECONDARY TO A GIANT BREAST TUMOR: A CASE REPORT AND REVIEW OF LITERATURE
1YU-LIN YANG, 1CHUN-TA HUANG, 2CHI-YUAN TZEN, 1CHUN-CHUAN LEE
1Division of Endocrinology and Metabolism, Department of Internal Medicine, MacKay Memorial Hospital, Taipei 10449, Taiwan, R.O.C.; 2Department of Pathology, MacKay Memorial Hospital, Taiwan, R.O.C.
Case presentation: A 41-year-old non-diabetic woman was brought to emergency department for unconsciousness before dinner. Severe hypoglycemia (serum glucose 21 mg/dL) was documented and her symptoms had full recovery with no neurologic deficit after the correction of hypoglycemia. Lab results and brain image were unremarkable but physical exam revealed a huge right breast tumor, which she ignored intentionally for years. Refractory hypoglycemia (35 mg/dL) occurred during hospitalization despite continuous hypertonic glucose infusion. Diagnostic studies including 72-hour prolonged fasting tests were performed. Low serum C-peptide and insulin level were detected during hypoglycemia with serum glucose increased by more than 25 mg/dL after glucagon injection. Insulin antibody was negative and we carefully excluded adrenal insufficiency and hypopituitarism. The above findings are suggestive of non-islet cell tumor hypoglycemia (NICTH). Her hypoglycemia improved after steroid use and she was free of hypoglycemia after complete resection of the right breast tumor. Final pathology of right breast tumor was compatible with a phyllodes tumor.
Conclusion: Although NICTH due to IGF-2 overproduction is a rare phenomenon, mainly observed in case of mesenchymatous tumor, it should be considered in presence of severe hypoglycemia with plump mass and without hyperinsulinism.
PD19 WAIST CIRCUMFERENCE IS A DETERMINANT FOR MUSCLE QUALITY IN PATIENTS WITH TYPE 2 DIABETES MELLITUS
1YI-LUN CHIANG, 2TING-CHUNG CHEN, 3HSUAN WU, 4TING-GRU LIN,
2JING-YA PENG, 3SHIOW-CHWEN TSAI, 2CHIAO-NAN CHEN, 5CHII-MIN HWU
1Division of Endocrinology, Department of Internal Medicine, Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan; 2Departent of Physical Therapy and Assistive Technology, National Yang-Ming University, Taipei, Taiwan; 3Institute of Sports science, University of Taipei, Taipei, Taiwan; 4Departent of Nursing, National Taipei university of Nursing and Health Science, Taipei, Taiwan; 5Section of Endocrinology and Metabolism, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
Background: Muscle damage has recently been recognized as a complication of type 2 diabetes mellitus (T2DM), and impaired muscle function adversely affects physical activities, quality of life and mortality. Waist circumference (WC) is related with visceral fat and insulin resistance. The present study aimed to evaluate the relationship of muscle quality and WC in patients withT2DM.
Methods: We recruited 145 patients with T2DM aged ≥ 50 years. Subjects divided into three groups based on WC. Total muscle mass, grip strength, knee extension strength and ankle dorsiflexion and plantarflexion strength were assessed.
Results: 145 subjects were subdivided into three groups according to the tertiles of WC. These subjects with a wider WC tended to be more obese, had more muscle mass, higher level of fasting plasma glucose and little muscle quality.
Muscle quality of bilateral arms was correlated with age, gender, WC and estimated Glomerular filtration rate (eGFR). Muscle quality of lower limbs was correlated with age, WC and eGFR. After multivariant analyses, WC was the only factor which still showed significant to muscle quality of four limbs.
Conclusions: Independent from muscle mass, WC is a good determinant for muscle quality in T2DM subjects.
PD20 SARC-CALF AND OTHER RISK FACTORS IN PREDICTION OF SARCOPENIA IN ELDERLY WITH TYPE 2 DIABETES
1BO-CHUN CHEN, 1HUI-I YU, 1TSAI-SUNG TAI, 1FANG-PING KUNG, 2SHU-FEN SHEN
1Division of Endocrinology and Metabolism, Department of Internal Medicine, Ditmanson Medical Foundation Chia-yi Christian Hospital; 2Diabetic Center
Background: Diabetes patients have higher prevalence of sarcopenia. Sarcopenia is often associated with frailty and had poor prognosis. Recently SARC-F questionnaire is recommended as a tool for screening sarcopenia. However, it has low sensitivity. Though adding calf circumference measurement can increase sensitivity, we want to know combine with SARC-F and calf size, if adding clinical risk factors will increase prediction of sarcopenia in type 2 diabetes.
Methods: We enrolled 166 type 2 DM patients from 201912 to 202003, who were older than 50 years of age, and received diabetes education at least twice in our META OPD. We excluded patients with previous stroke history, carpal tunnel syndrome, severe hip or knee osteoarthritis, dysarthria, dysphagia, use of a walker, physical disability that affects hand grip or walking. SARC-F questionnaire was asked and calf circumference was measured by DM educator. Appendicular skeletal muscle mass was measured by bioelectrical impedance analysis (BIA) and handgrip strength was evaluated. Definition of sarcopenia was diagnosed if appendicular muscle mass/height 2 < 7kg/m2 in men and < 5.4 kg/m2 in women. Hand grip strength < 26kg in men and < 18kg in women. Patients’ working status, health behaviors, body composition, and serum biomarkers were collected for analysis.
Results: There were 56 patients have sarcopenia according to muscle mass and muscle strength measurement. 35 (62.5%) patients were female. Sarcopenia patients were older (mean age 68 y/o vs 64 y/o). They have significantly lower BMI and blood pressure, waist circumference, triglyceride, liver enzyme (ALT) but higher HDL-C. There were no differences in diet pattern and health behavior or working condition. For prediction of sarcopenia, we found in receiver operating characteristics (ROC) analysis, SARC-CalF alone showed AUC is 0.76, p< 0.005, sensitivity 0.436, specificity 0.86. If we added gender, age, A1C, HDL-C, TG, GPT, exercise, BMI can increase AUC value to 0.825, sensitivity is 0.655 and specificity is 0.86. The sensitivity is still not good. Further risk factors or biomarkers survey might be needed.
Conclusions: In elderly type 2 diabetic patients, adding clinical risk factors such as age, BMI, exercise behaviors, glycemic control, lipid profile, liver profile with SARC-CalF might increase sensitivity in prediction of sarcopenia. Further validation is still needed.
PD21 EUGLYCEMIC KETOACIDOSIS IN PATIENT TREATED WITH SGLT-2 INHIBITOR
1CHE-YU LIU, 1HUI-I YU, 1RU-LAI HUANG
1Division of Endocrinology and Metabolism, Department of Internal Medicine, Ditmanson Medical Foundation Chia-yi Christian Hospital
Euglycemic diabetic ketoacidosis was ever reported in diabetic patient who treated with SGLT-2 inhibitor. It may occur in several conditions such as patient took SGLT-2 inhibitor without adequate hydration, reduced or discontinued insulin therapy, underwent prolonged fasting or ate low carbohydrate diet. These conditions were often accompanied with metabolic acidosis.
We presented this patient who developed euglycemic ketoacidosis after the tooth extraction surgery. The patient was a 33-year-old man and was admitted for face cellulitis. He took SGLT2 inhibitor for diabetic treatment before. The glycemic control was not well and the recent HbA1c revealed 10.1%.
This time, he suffered from focal infection over face after tooth extraction surgery recently. After the surgery, the amount of oral intake reduced, however, he took SGLT-2 inhibitor as usual. During the hospital course, he still had poor oral intake. Initially, we discontinued the medicine (SGLT-2 inhibitor), but found severe metabolic acidosis 2 days after admission (pH 7.069, HCO3 4.1 mmol/L) with euglycemic status (196 mg/dl) and increased serum ketone. We gave intravenous fluid hydration, insulin therapy, started enteral feeding and the ketoacidosis improved gradually.
Our report demonstrates a rare but important side effect of SGLT-2 inhibitor (the euglycemic diabetic ketoacidosis). Hold SGLT-2 inhibitor temporarily is important to reduce euglycemic ketoacidosis risk, especially before surgery or during acute illness.
PD22 HYPERLIPIDEMIA ASSOCIATED WITH LORLATINIB, IMPROVED AFTER ALIROCUMAB USED: A CASE REPORT
1FANG-YU CHEN, 1TSUNG-HUI WU, 1HUI-LING LIN,
1,2TANG-YI LIAO, 1,3CHII-MIN
HWU
1 Division of Endocrinology and Metabolism, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; 2 Division of Endocrinology and Metabolism, Department of Internal Medicine, Dalin Tzu Chi Hospital, Chiayi, Taiwan; 3 Faculty of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan.
Background: Lorlatinib is a highly potent, brain-penetrant, third generation ALK/ROS1 tyrosine kinase inhibitor (TKI) and has potency against most known resistance mutations developed during treatment with crizotinib and second-generation ALK TKIs. Hyperlipidemia was the most common adverse event reported with Lorlatinib and most patients need at least one lipid-lowering agent within three weeks of the first Lorlatinib dose. Usually, treatment with statins was first considered at the first sign of elevated cholesterol and/or triglyceride levels.
Methods: We report a case of successfully improved lipid profile under Alirocumab treatment in a lung cancer patient with Lorlatinib related hyperlipidemia. .
Results: This 58- year-old male patient with lung adenocarcinoma of left upper lobe, stage IV, was receiving TKI treatment due to tumor tissue pathology yield anaplastic lymphoma kinase (ALK) mutation positive. Hyperlipidemia developed soon after Lorlatinib taken and a statin was given as treatment. However, the treatment showed ineffective and Ezetimibe was added with laboratory data revealed partial improvement. Acute onset right sided weakness with slurred speech for hours developed during lung cancer related admission 16 months after starting Lorlatinib treatment. Brain MRI showed small early subacute infarct in left corona radiata. Due to hyperlipidemia complicated by subacute ischemic stroke despite Rosuvastatin and Ezetimibe used, we applied Alirocumab for reducing the risk of recurrent atherosclerotic cardiovascular disease event. After agreed by National Health Insurance Committee, Alirocumab 75mg was given every two weeks while Rosuvastatin and Ezetimibe kept given. Lipid profiles showed dramatic improvement after we added Alirocumab in antihyperlipidemic treatment.
Conclusions: Proprotein convertase subtilisin/kexin type 9 inhibitors may be effective in secondary prevention of atherosclerotic cardiovascular disease in hyperlipidemia patients receiving Lorlatinib treatment if statins and ezetimibe is ineffective.
PD23 DIABETES SECONDARY TO ACROMEGALY, AND ACROMEGALY SECONDARY TO DIABETES: BIDIRECTIONAL ANALYSES USING A NATIONAL COHORT
1YUAN-HORNG YAN, 2I-JU TSAI, 1SHIH-TING TSENG
1Division of Endocrinology and Metabolism, Department of Internal Medicine, 2Department of Medical Research, Kuang Tien General Hospital, Taichung, Taiwan, R.O.C.; 2Department of Medical Research, Kuang Tien General Hospital, Taichung, Taiwan, R.O.C.
Background: Diabetes mellitus (DM) is a known complication of acromegaly. However, diagnosis of acromegaly in patients with coexisting DM is difficult. The objective of this study is to evaluate the associations between DM and acromegaly using bidirectional analyses in a national cohort.
Methods: This is a retrospective cohort study using Taiwan's National Health Insurance Research Database. We conducted bidirectional analyses in this study. Analysis 1 consisted of 181,573 patients with newly diagnosed DM in 2005-2017 and 181,573 randomly selected normal controls frequencymatched by index year, age and sex. Analysis 2 compared 280 patients with newly diagnosed acromegaly in 2005-2017 and 1,120 randomly selected normal controls frequency-matched by index year, age and sex. At the end of 2017, analysis 1 measured the risk of developing acromegaly and analysis 2 measured the risk of developing DM.
Results: In analysis 1, patients with coexisting DM had significantly higher risk of acromegaly compared with normal controls, with an adjusted HR of 4.09 (95% CI = 2.27-7.37). The risk of acromegaly in coexisting DM patients regardless of age or sex stratification was higher than in the normal controls. In analysis 2, patients with acromegaly had significantly higher risk of developing DM within 1-year follow-up (adjusted HR = 2.47 with 95% CI = 1.17-5.20).
Conclusions: Acromegaly was significantly associated with DM bidirectionally.
PD24 RETROPERITONEAL SOLITARY FIBROUS TUMOR PRESENTED WITH HYPOGLYCEMIA: A CASE REPORT
1YI-CHING TSAI, 1CHING-CHUNG CHANG, 1CHING-CHU CHEN,
1CHWEN-TZUEI CHANG, 1MING-JIA XIE, 1RONG-HSHING CHEN, 1TZU-YUAN WANG,
1JUN-WEI HE, 1WEI-LUN HUANG
1Division of Endocrinology and Metabolism, Intelligent Diabetes Metabolism and Exercise Center, Department of Medicine, China Medical University Hospital, Taichung, Taiwan
Background: Non-diabetic hypoglycemia is a rare condition. It may result from drugs, critical illness, hormone deficiency, non-islet cell tumors, endogenous hyperinsulinemia or exogenous hyperinsulinemia. Among non-islet cell tumors induced hypoglycemia, mesenchymal tumors and hepatocellular origin tumors are most commonly described. Here, we present a case of retroperitoneal fibrous tumor presented with hypoglycemia.
Case report: A 51 year-old woman without significant medical history presented to Emergency Department due to traffic accident resulting from conscious loss. Hypoglycemia (plasma glucose 30mg/dl) with c-peptide 0.104 ng/ml (reference range: 0.9-7.1 ng/ml) was detected. The patient also mentioned a palpable abdominal mass for 4 months. Abdominal CT scan showed a 10cm x 8cm welldefined enhancing mass over left proximal ureter with left hydronephrosis. Laboratory data showed insulin level 0.07mU/L (reference range: 1.9-23 IU/mL), insulin-like growth factor-1 15.3ng/mL (reference range: 55-248 ng/mL), normal reference range of HbA1c, cortisol, ACTH, aldosterone, renin, β-HCG and tumor markers including SCC, CA-199, CA125. Urine cytology showed negative for high grade urothelial carcinoma. She received left retroperitoneal tumor excision and left nephrectomy. Pathology disclosed a retroperitoneal fibrous tumor involving left renal vein. After then, hypoglycemia resolved, and insulin and c-peptide levels returned to normal range.
Discussion: olitary fibrous tumor associated with non-islet cell tumor hypoglycemia is called Doege–Potter syndrome which was first described in 1930. It is a rare mesenchymal tumor. It may present with slowly growing mass or paraneoplastic syndrome. Most solitary fibrous tumors (up to 80%) are benign but some have aggressive behaviors. The solitary fibrous tumor may overproduce big IGF2, an unprocessed high-molecular-weight that has insulin-like activity. As a result, It increases glucose utilization and induces hypoglycemia. Surgical resection of tumor is the first priority of management.
Conclusion: Non-diabetic hypoglycemia may be a paraneoplastic syndrome related with nonislet cell tumor.
PD25 SGLT-2 INHIBITOR TREATMENT FOR ALPELISIB (PI3K INHIBITOR) INDUCED SEVERE HPERGLYCEMIA
1,3TANG-YI LIAO, 1HARN-SHEN CHEN, 2CHUN-YU LIU,
1FANG-YU CHEN,
1HUI-LING LIN, 1TSUNG-HUI WU
1Division of Endocrinology and Metabolism, Department of Medicine Taipei Veterans General Hospital, Taipei, Taiwan; 2Division of Oncology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; 3Division of Endocrinology and Metabolism, Department of Internal Medicine, Dalin Tzu Chi Hospital, Chiayi, Taiwan
This 80-year-old woman with medical history of hypertension, and invasive ductal carcinoma of right breast with lymph node metastasis(pT2N1Mx). In 2009, she received modified radical mastectomy and chemotherapy with FEC(5-FU+epirubicin+cyclophosphamide). During 2010~2015, she received chemotherapy of Taxotere and hormone therapy. In 2018, invasive ductal carcinoma of left breast(triple negative breast cancer) was diagnosd, and she received wide excision and sentinel lymph node biopsy. After the surgery, she received oral navelbine, aromasin (aromatase inhibitor), and afinitor (mTOR inhibitor) treatment. However, progressive disease was noted (CEA and CA-153 continued elevating, and new chest lesions at CT finding). On 2020/07, gene survey revealed PIK3CA mutation (E545K), then she started to received the compassionate treatment of alpelisib 300mg QD (PI3K inhibitor).
Few days after alpelisib treatment, obviously elevated glycemic condition was noted(selfmonitoring of blood glucose more than 500 mg/dL). Then the patient was admitted for blood glucose control. During the hospitalization, oral antidiabetic drugs were administered as metformin and acarbose. Multiple dose insulin injection with insulin aspart and insulin glargine was also applied. The insulin dosage was up-titrated to 2 units/kg/day one week after admission; however, hyperglycemia was still noted (blood glucose more than 350 mg/dL). Due to the obvious adverse effect, Alpelisib was held for four days, and then hyperglycemia resolved gradually and insulin dosage was tapered to 0.3 units/kg/day. After the glycemic condition became relatively stable, alpelisib was resumed with lower dosage (200mg QD). In the following days, hyperglycemia attacked again, and insulin dosage was up-titrated to 1.6 units/kg/days. Due to difficulty control of glycemia by insulin, SGLT-2 inhibitor (empagliflozin 25mg QD) was added. Then hyperglycemia improved dramatically and insulin dosage was tapered rapidly.
PD26 THE BENEFICIAL EFFECTS OF VITAMIN E SUPPLEMENT ON METABOLIC SYNDROME COMPONENTS IN HEALTHY POPULATION
Background: Vitamin E, well known as an antioxidant agent, is proved to reduce inflammation and oxidative damage. Some clinical investigations indicated vitamin E deficiency is associated with increased risk of cardiovascular events. We explored the change of metabolic syndrome components in subjects with or without vitamin E supplement for two years.
Methods: Subjects receiving routine annual health examinations were divided to with or without vitamin E supplement according to questionnaire. Demographic data, anthropometry and metabolic syndrome components were collected respectively with interval of two years. Finally, the variations of metabolic syndrome components in two years were analyzed in age- and sex-match individuals between two groups.
Results: There were 699 healthy subjects enrolled this study. Subjects with vitamin E supplement had lower waist circumference (WC), fasting plasma glucose (FPG), systolic blood pressure (SBP), uric acid (UA) and higher high density lipoprotein cholesterol (HDL-C). After sex- and age- match, subjects with vitamin E supplement had lower WC, body mass index (BMI), body fat (BF), FPG, triglyceride (TG), UA, and higher HDL-C. Two years later, half of heath subjects continued supplement of vitamin E. However, metabolic syndrome components between continuing and noncontinuing group showed no significant difference.
Conclusions: Subjects with vitamin E supplement had less risk of obesity, hyperglycemia, and dyslipidemia. However, the beneficial effects of vitamin E supplement showed no significant difference after discontinue vitamin E.
Background: Several studies showed propolis has beneficial effects on anti-inflammation and anti-oxidative damage. Propolis is a widespread health food applied on anti-aged and promoting immunity. We explored the effects of white blood cell count and metabolic syndrome components in subjects with or without supplement of propolis.
Methods: Subjects receiving routine annual health examinations were divided to with or without propolis supplement according to questionnaire. Demographic data, anthropometry and metabolic syndrome components were collected. Finally, the metabolic syndrome components and white blood cell count were analyzed in age- and sex-match individuals.
Results: There were 134 healthy subjects enrolled this study after sex- and age-match pair. Subjects with propolis supplement had lower waist circumference, fasting plasma glucose, systolic blood pressure, diastolic blood pressure and higher high density lipoprotein cholesterol. However, white blood cell count between subjects with and without propolis supplement showed no significant difference.
Conclusions: Subjects with propolis supplement had lower waist circumference, blood pressure and fasting glucose, and higher high density lipoprotein cholesterol. However, white blood cell count showed no significant difference between subjects with and without propolis supplement.
PD28 A SHORT SLEEP DURATION IS ASSOCIATED WITH INCREASED RISK OF PRE-DIABETES: A COMMUNITY-BASED COHORT STUDY IN TAIWAN
1I-RUEI YU, 2SHIH-TE TU, 2SHU-YI WANG, 3MAO-SHIN LIN, 3SHYANG-RONG SHIH,
4CYUE-HUEI HUA, 4YENH-CHEN HSEIN, 3HUNG-YUAN LI
1Department of Family Medicine, Changhua Christian Hospital, Changhua, Taiwan.; 2 Division of Endocrinology and Metabolism Changhua Christian Hospital, Changhua, Taiwan.; 3 Division of Endocrinology and Metabolism, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan.; 4 Division of Clinical Pathology National Taiwan University Hospital, Yun-Lin Branch, Yun-Lin, Taiwan.
Background: Sleep duration is reported to be associated with increased risk of pre-diabetes and diabetes in the literature. However, the relationship remains unexplored in Taiwan. In this study, we investigated the relationship between sleep duration, pre-diabetes, and diabetes in Taiwan.
Methods: In this community-based study, 2084 subjects were enrolled in 2006-2019. Prediabetes and diabetes were diagnosed by the results of oral glucose tolerance tests and hemoglobin A1c, or if anti-diabetic agents were used. Sleep duration was acquired by a questionnaire.
Results: Subjects slept < 6 hours had a higher risk of pre-diabetes (odds ratio (OR) 2.03, p < 0.001) and diabetes (OR 1.64, p = 0.04), compared with subjects who slept 6-7.5 hours. However, the OR of diabetes became insignificant after adjusted for age (OR 0.80, p = 0.416), although the OR of pre-diabetes remained significantly elevated (OR 1.49, p = 0.024). The results were similar after further adjustment for age, body mass index, plasma high-density lipoprotein cholesterol, plasma triglyceride, gender, and homeostasis model assessment 2 insulin resistance index (OR for pre-diabetes in subjects slept < 6 hours 1.52, p = 0.021, compared with subjects who slept 6-7.5 hours). There was no significant difference in the risk of pre-diabetes and diabetes in subjects who slept ≥ 7.5 hours, compared with subjects who slept 6-7.5 hours.
Conclusion: Subjects who slept < 6 hours had an increased risk of pre-diabetes, compared with subjects who slept 6-7.5 hours.
PD29 EMPAGLIFLOZIN AND LIRAGLUTIDE DIFFERENTIALLY MODULATE CARDIAC METABOLISM IN DIABETIC CARDIOMYOPATHY
1NGUYEN NGOC TRANG, 2,3CHENG-CHIH CHUNG, 4,5TING-WEI LEE,
2,6WAN-LI CHENG, 2,6YU-HSUN KAO, 4,5,7TING-I LEE, 2YI-JEN CHEN
1International Ph.D. Program in Medicine, College of Medicine, Taipei Medical University; 2Cardiovascular Research Center, Wan Fang Hospital, Taipei Medical University; 3Division of Cardiology, Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University; 4Division of Endocrinology and Metabolism, Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University; 5Division of Endocrinology and Metabolism, Department of Internal Medicine, Wan Fang Hospital, Taipei Medical University; 6Graduate Institute of Clinical Medicine, College of Medicine, Taipei Medical University; 7Department of General Medicine, School of Medicine, College of Medicine, Taipei Medical University.
Background: Glucagon-like peptide 1 receptor agonists (GLP-1RAs) and sodium-glucose cotransporter-2 inhibitors (SGLT2is) are antihyperglycemic agents with cardioprotective properties against diabetic cardiomyopathy (DCM). However, the distinctive mechanisms underlying GLP-1RAs and SGLT2is in DCM are not fully elucidated. The purpose of this study was to investigate the impacts of GLP1RAs and or SGLT2is on myocardial energy metabolism, cardiac function, and apoptosis signaling in DCM.
Materials and Methods: Biochemistry and echocardiograms were studied before and after treatment with empagliflozin (10 mg/kg/day, oral gavage), and/or liraglutide (200 μg/kg every 12 h, subcutaneously) for 4 weeks in male Wistar rats with streptozotocin (65 mg/kg intraperitoneally)induced diabetes. Cardiac fibrosis, apoptosis, and protein expressions of metabolic and inflammatory signaling molecules were evaluated by histopathology and Western blotting in ventricular cardiomyocytes of different groups.
Results: Empagliflozin and liraglutide normalized myocardial dysfunction in diabetic rats. Upregulation of phosphorylated-acetyl-CoA-carboxylase, carnitine palmitoyl transferase 1β, cluster of differentiation 36, and peroxisome proliferator-activated receptor gamma coactivator, and downregulation of phosphorylated adenosine monophosphate-activated protein kinase α2, glucose transporter 4, phosphorylated protein kinase B, and phosphoinositide 3-kinase protein levels in diabetic cardiomyocytes were restored by treatment with empagliflozin or liraglutide. Nucleotide-binding oligomerization domain, leucine-rich repeat and pyrin domain-containing 3, interleukin-1β, tumor necrosis factor-α, and cleaved caspase-1 were significantly downregulated in empagliflozin-treated and liraglutide-treated diabetic rats. Both empagliflozin-treated and liraglutide-treated diabetic rats exhibited attenuated myocardial fibrosis and apoptosis.
Conclusion: Empagliflozin modulated fatty acid and glucose metabolism, while liraglutide regulated inflammation and apoptosis in DCM. The better effects of combined treatment with GLP1RAs and SGLT2 is may lead to a potential strategy targeting DCM.
PD30 A CASE REPORT OF 31-YEAR-OLD WOMAN, PRESENTING AS NEWLY DIAGNOSED TYPE 2 DIABETES MELLITUS COMBINED WITH MYELITIS
1YU YI LIN, 2YU-HUA LAI, 3KAI-CHEN WANG
1Division of general medicine, Department of Internal Medicine, Cheng Hsin Hospital, Taiwan, R.O.C 2,3Division of neurology, Department of Internal Medicine, Cheng Hsin Hospital, Taiwan, R.O.C
Introduction: Diabetes neuropathy is the most prevalent complications of diabetes, initial presenting as limbs numbness. However other neuropathy or myelopathy may be accompanied in diabetic patient. Case Report:We present a case of 31-year-old Taiwanese single woman visited to endocrine outpatient clinic for progressive severe bilateral legs numbness with weakness, unsteady gait, recurrent falling down episodes for 2 months and apparent body weight loss of 4 kg (80 to 76 kg) within one month. Initial work up showed newly diagnosed type 2 diabetes mellitus with poor glycemic control (HbA1c 13.6%, fasting c-peptide 2.74 ng/mL, no ketoacidosis ). She was admitted for intensive insulin therapy. After admission, her limbs numbness and weakness got worse rapidly and which was not compatible with usual diabetic neuropathy. Neurologist was consulted and neurological examination revealed sensory impairment below the umbilical region with left upgoing planter reflex and lower legs muscle power of 3-4 over both sides. Myelopathy was highly suspected. NCV and EMG limbs revealed normal result. Spine MRI disclosed long spinal cord lesions. T3-6 myelopathy with paraparesis and hypoesthesia was impressed . Autoimmune studies including ANA, ds-DNA, STS, SSA/SSB and CPK, myoglobin, folic acid, vitamin B12 level were within normal limit. AntiAQP4 Ab was also negative. After exclusion of possible infection and tumor by lumbar puncture, high dose steriod pulse therapy was administered urgently under the diagnosis of myelitis. Rehabilitation was arranged together. Steriod dose were tapered when her weakness got improved. During the follow up, another attack of myelitis recurred and also responding to steroid pulse therapy as well. Recurrent myelitis with long term immunosuppressant and low dose steroid were needed under intensive blood glucose control. Due to person reason, she was transferred to southern Taiwan hospital for further rehabilitation program. Conclusion: Clinicians caring for patients with diabetes should be keep in mind possibility of myelopathy in addition to diabetic neuropathy. Proper neurological examination and clinical awareness is very important to avoid delayed diagnosis and management.
