Search Results for: "diabetes_articles"

Nearly 15% of U.S. adults have diabetes; type 2 diabetes (T2D) accounts for more than 90% of cases. Approximately one third of all patients with diabetes will develop chronic kidney disease (CKD). All patients with T2D should be screened annually for CKD with both a urine albumin–creatinine ratio and an estimated glomerular filtration rate. Research into strategies to slow the worsening of CKD and reduce renal and cardiovascular morbidity in patients with T2D and CKD has evolved substantially. In 2022, a consensus statement from the American Diabetes Association and the Kidney Disease: Improving Global Outcomes recommended prioritizing the use of sodium–glucose cotransporter-2 inhibitors and metformin and included guidance for add-on therapy with glucagon-like peptide 1 receptors agonists for most patients whose first-line therapy failed. It also recommended nonsteroidal mineralocorticoid receptor antagonists for patients with hypertension that is not adequately controlled with angiotensin-converting enzyme inhibitors or angiotensin-receptor blockers. Here, an endocrinologist and a nephrologist discuss the care of patients with T2D and CKD and how they would apply the consensus statement to the care of an individual patient with T2D who is unaware that he has CKD.

Glucagon-Like Peptide-1 Receptor Agonists and Risk for Suicidal Ideation and Behaviors in U.S. Older Adults With Type 2 Diabetes: A Target Trial Emulation Study: Annals of Internal Medicine: Vol 177, No 8

Background: A major concern has recently emerged about a potential link between glucagon-like peptide-1 receptor agonists (GLP-1 RAs) and increased risk for suicidal ideation and behaviors based on International Classification of Diseases codes. Objective: To investigate the association between GLP-1 RAs, compared with sodium–glucose cotransporter-2 inhibitors (SGLT2is) or dipeptidyl peptidase-4 inhibitors (DPP4is), and risk for suicidal ideation and behaviors in older adults with type 2 diabetes (T2D). Design: Two target trial emulation studies comparing propensity score (PS)–matched cohorts for GLP-1 RAs versus SGLT2is and GLP-1 RAs versus DPP4is. Setting: U.S. national Medicare administrative data from January 2017 to December 2020. Patients: Older adults (≥66 years) with T2D; no record of suicidal ideation or behaviors; and a first prescription for a GLP-1 RA, SGLT2i, or DPP4i. Measurements: The primary end point was a composite of suicidal ideation and behaviors. New GLP-1 RA users were matched 1:1 on PS to new users of an SGLT2i or DPP4i in each pairwise comparison. A Cox proportional hazards regression was used to estimate the hazard ratio (HR) and 95% CIs within matched groups. Results: This study included 21 807 pairs of patients treated with a GLP-1 RA versus an SGLT2i and 21 402 pairs of patients treated with a GLP-1 RA versus a DPP4i. The HR of suicidal ideation and behaviors associated with GLP-1 RAs relative to SGLT2is was 1.07 (95% CI, 0.80 to 1.45; rate difference, 0.16 [CI, −0.53 to 0.86] per 1000 person-years); the HR relative to DPP4is was 0.94 (CI, 0.71 to 1.24; rate difference, −0.18 [CI, −0.92 to 0.57] per 1000 person-years). Limitations: Low event rate; imprecise estimates; unmeasured confounders, such as body mass index; and potential misclassification of outcomes. Conclusion: Among Medicare beneficiaries with T2D, this study found no clear increased risk for suicidal ideation and behaviors with GLP-1 RAs, although estimates were imprecise and a modest adverse risk could not be ruled out. Primary Funding Source: American Foundation for Pharmaceutical Education, Pharmaceutical Research and Manufacturers of America Foundation, National Institute on Aging, and National Institute of Diabetes and Digestive and Kidney Diseases.

Newer Pharmacologic Treatments in Adults With Type 2 Diabetes: A Clinical Guideline From the American College of Physicians

Description: The American College of Physicians (ACP) developed this clinical guideline to update recommendations on newer pharmacologic treatments of type 2 diabetes. This clinical guideline is based on the best available evidence for effectiveness, comparative benefits and harms, consideration of patients’ values and preferences, and costs. Methods: This clinical guideline is based on a systematic review of the effectiveness and harms of newer pharmacologic treatments of type 2 diabetes, including glucagon-like peptide-1 (GLP-1) agonists, a GLP-1 agonist and glucose-dependent insulinotropic polypeptide agonist, sodium–glucose cotransporter-2 (SGLT-2) inhibitors, dipeptidyl peptidase-4 (DPP-4) inhibitors, and long-acting insulins, used either as monotherapy or in combination with other medications. The Clinical Guidelines Committee prioritized the following outcomes, which were evaluated using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach: all-cause mortality, major adverse cardiovascular events, myocardial infarction, stroke, hospitalization for congestive heart failure, progression of chronic kidney disease, serious adverse events, and severe hypoglycemia. Weight loss, as measured by percentage of participants who achieved at least 10% total body weight loss, was a prioritized outcome, but data were insufficient for network meta-analysis and were not rated with GRADE. Audience and Patient Population: The audience for this clinical guideline is physicians and other clinicians. The population is nonpregnant adults with type 2 diabetes. Recommendation 1: ACP recommends adding a sodium–glucose cotransporter-2 (SGLT-2) inhibitor or glucagon-like peptide-1 (GLP-1) agonist to metformin and lifestyle modifications in adults with type 2 diabetes and inadequate glycemic control (strong recommendation; high-certainty evidence). • Use an SGLT-2 inhibitor to reduce the risk for all-cause mortality, major adverse cardiovascular events, progression of chronic kidney disease, and hospitalization due to congestive heart failure. • Use a GLP-1 agonist to reduce the risk for all-cause mortality, major adverse cardiovascular events, and stroke. Recommendation 2: ACP recommends against adding a dipeptidyl peptidase-4 (DPP-4) inhibitor to metformin and lifestyle modifications in adults with type 2 diabetes and inadequate glycemic control to reduce morbidity and all-cause mortality (strong recommendation; high-certainty evidence).

Association of Semaglutide With Tobacco Use Disorder in Patients With Type 2 Diabetes: Target Trial Emulation Using Real-World Data: Annals of Internal Medicine: Vol 177, No 8

Background: Reports of reduced desire to smoke in patients treated with semaglutide, a glucagon-like peptide receptor agonist (GLP-1RA) medication for type 2 diabetes mellitus (T2DM) and obesity, have raised interest about its potential benefit for tobacco use disorders (TUDs). Objective: To examine the association of semaglutide with TUD-related health care measures in patients with comorbid T2DM and TUD. Design: Emulation target trial based on a nationwide population-based database of patient electronic health records. Setting: United States, 1 December 2017 to 31 March 2023. Participants: Seven target trials were emulated among eligible patients with comorbid T2DM and TUD by comparing the new use of semaglutide versus 7 other antidiabetes medications (insulins, metformin, dipeptidyl-peptidase-4 inhibitors, sodium-glucose cotransporter-2 inhibitors, sulfonylureas, thiazolidinediones, and other GLP-1RAs). Measurements: The TUD-related health care measures (medical encounter for diagnosis of TUD, smoking cessation medication prescriptions, and smoking cessation counseling) that occurred within a 12-month follow-up were examined using Cox proportional hazards and Kaplan–Meier survival analyses. Results: The study compared 222 942 new users of antidiabetes medications including 5967 of semaglutide. Semaglutide was associated with a significantly lower risk for medical encounters for TUD diagnosis compared with other antidiabetes medications, and was strongest compared with insulins (hazard ratio [HR], 0.68 [95% CI, 0.63 to 0.74]) and weakest but statistically significant compared with other GLP-1RAs (HR, 0.88 [CI, 0.81 to 0.96]). Semaglutide was associated with reduced smoking cessation medication prescriptions and counseling. Similar findings were observed in patients with and without a diagnosis of obesity. For most of the group comparisons, the differences occurred within 30 days of prescription initiation. Limitation: Documentation bias, residual confounding, missing data on current smoking behavior, body mass index, and medication adherence. Conclusion: Semaglutide was associated with lower risks for TUD-related health care measures in patients with comorbid T2DM and TUD compared with other antidiabetes medications including other GLP-1Ras, primarily within 30 days of prescription. These findings suggest the need for clinical trials to evaluate semaglutide’s potential for TUD treatment. Primary Funding Source: National Institutes of Health.

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Displaying 11 - 20 of 138 in Annals of Internal Medicine: Clinical Cases

Severe Presentation of Acute Eosinophilic Pneumonia Possibly Secondary to Recent E-Cigarette Use | Annals of Internal Medicine: Clinical Cases

A 52-year-old man with type 2 diabetes mellitus presented with fever and hypoxemic respiratory failure requiring intubation. He had no history of pulmonary disease but recently started smoking nicotine-containing electronic cigarettes (e-cigarettes) after 10 years of tobacco abstinence. He had diffuse bilateral ground-glass opacities on chest imaging, 11% peripheral eosinophilia (absolute eosinophil count 1300/µL), and 50% eosinophilia in the bronchoalveolar lavage fluid without evidence of bacterial, viral, fungal, or parasitic infection. Hypoxia and pulmonary infiltrates rapidly resolved after initiation of high-dose corticosteroids after bronchoscopy. A diagnosis of acute eosinophilic pneumonia was made, possibly secondary to recent e-cigarette use.

Sarcoidosis in Disguise: A Malignancy Mimic | Annals of Internal Medicine: Clinical Cases

Sarcoidosis is a granulomatous disorder with a heterogeneous presentation that can mimic other disease processes or appear nonspecific. Although pulmonary manifestations are most common, sarcoidosis can impact many different organ systems, causing a wide range of symptoms. This report details a case of a patient with sarcoidosis who presented with hypercalcemia, cutaneous manifestations, and lymphadenopathy in the context of plasma cell dyscrasia work-up. Initial suspicion was greatest for malignancy, but further work-up revealed a final diagnosis of sarcoidosis. Overall, this case underscores the importance of tissue biopsy to establish a definitive diagnosis and the risk for anchoring bias in the work-up of hypercalcemia.

Generalized Weakness Due to Hypocalcemia and Hypophosphatemia From Potent Acid Suppression | Annals of Internal Medicine: Clinical Cases

Potent gastric acid suppression can disrupt mineral homeostasis. An older woman receiving alfacalcidol developed weakness accompanied by profound hypophosphatemia with hypocalcemia and secondary hyperparathyroidism after initiation of the potassium-competitive acid blocker vonoprazan. Laboratory findings showed an elevated intact parathyroid hormone level and renal phosphate wasting, whereas her serum magnesium level was 2.7 mg/dL (reference range, 1.7–2.6 mg/dL) and her intact fibroblast growth factor 23 was 41.7 pg/mL (reference range, 19.9–52.9 pg/mL). The patient's weakness and calcium–phosphate abnormalities resolved with mineral repletion and switching from vonoprazan to a proton-pump inhibitor. This case highlights that strong acid suppression may precipitate significant calcium–phosphate derangements despite active vitamin D therapy. Early evaluation of mineral metabolism and reassessment of acid-suppressive therapy are especially important in patients with unexplained weakness.

Opioid-Induced Adrenal Insufficiency With Concurrent Opioid-Induced Esophageal Dysfunction Presenting With Achalasia-Like Features | Annals of Internal Medicine: Clinical Cases

Long-term opioid therapy has been increasingly recognized to cause multisystem complications beyond dependence and respiratory depression. Among these, opioid-induced adrenal insufficiency and opioid-induced esophageal dysfunction remain underdiagnosed and poorly understood in routine clinical practice. We report the case of a 64-year-old woman with chronic high-dose methadone use who developed secondary adrenal insufficiency with refractory hypotension and subsequently manifested with progressive esophageal dysfunction with imaging findings suggestive of achalasia. This case highlights the need for increased clinical suspicion of endocrine and gastrointestinal complications in patients undergoing prolonged opioid therapy.

Silencing Exploding Head Syndrome: Resolution With CPAP Therapy | Annals of Internal Medicine: Clinical Cases

A 77-year-old man with severe obstructive sleep apnea (OSA) developed classic exploding head syndrome (EHS), with sudden nocturnal “explosions” at sleep onset. He initially used a mandibular advancement device, which only partially controlled respiratory events. After starting continuous positive airway pressure with excellent adherence and with a residual Apnea-Hypopnea Index score below 5 events per hour, EHS episodes decreased from frequent, debilitating events to about once monthly, alongside improved sleep continuity and daytime alertness. This case suggests that OSA may be a modifiable contributor to EHS and supports routine evaluation for sleep-disordered breathing in patients with this underrecognized parasomnia.

Beyond the Dermatome: Varicella-Zoster Virus Hits the Brain and Heart | Annals of Internal Medicine: Clinical Cases

Varicella-zoster virus (VZV), best known for its cutaneous manifestations, can also cause severe neurologic and cardiac complications. We report a 63-year-old man with VZV meningoencephalitis confirmed by cerebrospinal fluid (CSF) polymerase chain reaction who subsequently developed suspected myocarditis—an uncommon extradermatomal manifestation described primarily in case reports. Cardiac magnetic resonance imaging demonstrated diffuse T1/T2 abnormalities and late gadolinium enhancement consistent with suspected viral myocarditis. The patient improved with intravenous acyclovir and guideline-directed medical therapy. This case underscores the urge to consider VZV in atypical encephalitis and recognizes the possibility of concurrent myocardial involvement even in an apparently immunocompetent adult.

Infratentorial-Predominant Posterior Reversible Encephalopathy Syndrome With Respiratory Arrest After Triple Vaccination | Annals of Internal Medicine: Clinical Cases

Infratentorial-predominant posterior reversible encephalopathy syndrome (IPPRES) is a rare variant mimicking posterior circulation stroke. We report the case of a 57-year-old woman without chronic hypertension who developed thunderclap headache, visual disturbance, and respiratory arrest within 2 hours of COVID-19, influenza, and pneumococcal vaccination—to our knowledge, the most rapid vaccine-associated PRES reported. Initial computed tomography images suggested cerebellar infarction; magnetic resonance imaging confirmed bilateral vasogenic edema involving the cerebellum and brainstem. After exclusion of alternative causes, vaccine-associated immune activation may have lowered the hypertensive threshold for PRES. The case illustrates IPPRES as a stroke mimic and brainstem PRES as a cause of respiratory failure.

Multisystem Neuroimmune, Autonomic, Thromboembolic, and Vestibular Dysfunction Following mRNA COVID-19 Vaccination: A Case Report | Annals of Internal Medicine: Clinical Cases

Multisystem neurologic, autonomic, immune, and vestibular complications following mRNA COVID-19 vaccination remain rare. We report a previously healthy woman who developed profound dysautonomia, constant neuropathic pain, persistent postural-perceptual dizziness, mast cell activation–like symptoms, acquired thrombophilia requiring anticoagulation, migraines, and new-onset generalized seizures shortly after vaccination. Symptoms persisted despite extensive evaluation and treatment. Although causality cannot be established from a single case, the temporal association, extensive diagnostic evaluation, and biological plausibility warrant clinical awareness and further study.

Heavy Chain Deposition Disease Presenting as Rapidly Progressive Nephrotic/Nephritic Syndrome | Annals of Internal Medicine: Clinical Cases

Nephrotic–nephritic syndrome represents a severe process requiring prompt recognition and targeted therapy. We report a case of heavy-chain deposition disease (HCDD) presenting as rapidly progressive nephrotic–nephritic syndrome. The patient presented with severe proteinuria, progressive renal dysfunction, and hypocomplementemia. He underwent urgent kidney biopsy. Light microscopy revealed membranoproliferative glomerulonephritis, immunofluorescence revealed IgG1 and complement deposits with absent light chains, and electron microscopy revealed electron-dense deposits. Treatment with cyclophosphamide–bortezomib–dexamethasone, followed by autologous stem cell transplantation, resulted in sustained renal recovery. This case underscores the importance of considering HCDD in patients with unexplained nephrotic–nephritic overlap, hypocomplementemia, and monoclonal gammopathy of renal significance.

Racemose Neurocysticercosis Presenting as Subarachnoid Hemorrhage Mimic | Annals of Internal Medicine: Clinical Cases

Neurocysticercosis (NCC) remains the most common parasitic infection of the central nervous system worldwide and is a leading cause of acquired epilepsy in endemic regions. The racemose variant, characterized by cyst proliferation in subarachnoid spaces without identifiable scolices, poses unique diagnostic challenges due to its atypical imaging findings and clinical presentations. We present a case of racemose NCC in a 30-year-old Guatemalan immigrant whose initial magnetic resonance imaging findings mimicked subarachnoid hemorrhage, leading to tertiary transfer for aneurysmal work-up. This case illustrates critical learning points regarding the recognition of NCC variants, appropriate diagnostic work-up, and the importance of epidemiologic risk stratification in patients with meningeal symptoms.

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