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DICHIARAZIONE CONFLITTO D’INTERESSE DOCENTI
In ottemperanza alla normativa ECM ed al principio trasparenza delle fonti di finanziamento e dei rapporti con soggetti portatori di interessi commerciali in campo sanitario, il docente deve “rilasciare al provider o all’organizzatore la dichiarazione di conflitto d’interessi (ultimi 2 anni rapporti diretti con aziende) e che successivamente debba informare l’aula all’atto della sua presentazione o comunque prima della lezione/relazione dichiarandolo ai discenti”.
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Endocrinologia, Diabetologia e Metabolismo
Glucocorticoid-induced hyperglycemia Antonio PEREZ Journal of Diabetes 6 (2014) 9–20
Steroid-induced diabetes
C L E V E L A N D C L I N I C J O U R N A L O F M E D I C I N E V O L U M E 7 8 • N U M B E R 1 1, 2 0 1 1, 749
…. …a physiologic dose per day will be defined as up to: hydrocortisone 30 mg ≈ prednisone or prenisolone 7.5 mg ≈ dexamethasone 1.125 mg.
However, there is not much information on interconversion for the local preparations
(intra-articular, epidural, inhaled, topical).
Risk of Diabetes Associated With Prescribed Glucocorticoids in a Large Population. M C. GULLIFORD
DIABETES CARE, VOLUME 29, NUMBER 12, DECEMBER 2006
orally administered glucocorticoids may be associated with up to 2% of incident cases of diabetes in a primary care population
REVIEW ARTICLE Glucocorticoid-induced hyperglycemia Antonio PEREZ, Journal of Diabetes 6 (2014) 9–20
-The prevalence up to 40% of patients with neuropathy (shamoon 1980) -in patients with respiratory diseases 14.7% (kim 2011) -greater in rheumatoid arthritis (panthkalam 2004)
The incidence of hyperglycemia (blood glucose >200 mg/dL) in hospitalized patients without a known history of diabetes and treated with corticosteroids is > 50% (donihi 06).
Examples of incidence of steroid-induced diabetes following solid organ transplantation
Hwang and Weiss
Diabetes Metab Res Rev. 2014
-In transplant patients, given the concomitant use of other immunosuppressive drugs, 2% and 53% (bonato 2008) -in cases of functioning pancreas transplant after 39 months follow-up, 19% (dean 2008).
The prevalence of abnormal glucose metabolism in patients with an organ transplant with glucocorticoid therapy has been reported to be 17% to 32% (bonato 2008)
12% in anziano (blackburn 2002)
Glucocorticoid-induced hyperglycemia A PEREZ, Journal of Diabetes 6 (2014) 9–20
…….predictors include the -dose and duration of steroid treatment (gurwitz 94) -age (hjelmesaeth 1997, uzu 07) -weight (uzu 2007) -previous glucose intolerance (davidson 2003) -reduced sensitivity to insulin or impaired insulin secretion stimulated by glucose (larsson 1999) -a family history of diabetes (depezynski 2000) or race (frazier 2010) -in transplant patients Type A30, B27, and Bw42 leukocyte antigens, and receiving a kidney transplant from a deceased donor (vesco 96) not seem to be a predictor -gender (binnert 2004) a protective factor. -the early withdrawal of corticosteroids (walczak 2005)
Risk increased with increasing average daily steroid dose, in hydrocortisone-equivalent milligrams; the odds ratio was 1.77 for 1 to 39 mg/d, 3.02 for 40 to 79 mg/d, 5.82 for 80 to 119 mg/d, and 10.34 for 120 mg/d or more.
VIII. Cura del diabete in contesti specifici A. Cura del diabete in ospedale B. Altri tipi di diabete a. Diabete indotto da glicocorticoidi b. Diabete associato a malattia pancreatica c. Diabete associato a HIV/AIDS C. Cura del diabete a scuola e nell’assistenza diurna D. Cura del diabete nei campi educativi per persone con diabete E. Cura del diabete negli istituti di correzione F. Diabete e cure palliative
B. ALTRI TIPI DI DIABETE Nell’ambito degli altri tipi di diabete meritano una trattazione specifica per la loro frequenza:
Il diabete indotto da glicocorticoidi, il diabete associato a malattie del pancreas esocrino e il diabete indotto da farmaci antiretrovirali in soggetti HIV positivi
a. DIABETE INDOTTO DA GLICOCORTICOIDI RACCOMANDAZIONI La diagnosi di diabete mellito indotto da steroidi sulla base della presenza di due valori a digiuno uguali o superiori a 126 mg comporta la mancata identificazione di una elevata percentuale di soggetti affetti. (Livello della prova VI, Forza della raccomandazione D) La diagnosi di diabete mellito indotto da steroidi dovrebbe essere effettuata clinicamente sulla base della glicemia 2 ore dopo il pranzo. (Livello della prova VI, Forza della raccomandazione A) I soggetti diabetici, sottoposti a trattamento con steroidi, dovrebbero essere educati alla rilevazione della glicemia capillare soprattutto dopo pranzo e prima di cena. (Livello della prova III, Forza della raccomandazione A) La terapia insulinica rappresenta l’opzione terapeutica più sicura ed efficace nei pazienti con iperglicemia associata a terapia steroidea. (Livello della prova VI, Forza della raccomandazione A) I farmaci agenti sull’asse incretinico, per il loro meccanismo d’azione e il loro profilo di sicurezza, potrebbero rappresentare un’opzione terapeutica efficace nei pazienti con iperglicemia associata a terapia steroidea. (Livello della prova V, Forza della raccomandazione B) COMMENTO L’iperglicemia indotta da glucocorticoidi è comune in soggetti diabetici e non diabetici.
DM
The majority of inpatients receiving glucocorticoid therapy at a dose equivalent of at least 40 mg/d for more than 2 days
developed hyperglycemia. No glucose monitoring was performed in 24% of patients receiving
high-dose glucocorticoid therapy
Amy Calabrese Donihi
T. Uzu Nephron Clin Pract 2007;105:c54–c57
Steroid DM in Renal Diseases
24-hour urinary glucose analyses and postprandial plasma glucose
are useful for detecting glucocorticoid-induced DM.
STEROID-INDUCED DIABETES IN PATIENTS WITH NEUROLOGIC DISEASES Iwamoto et al PHARMACOTHERAPY Volume 24, Number 4, 2004
To detect SDM and begin therapy for it in the early stages, the monitoring of plasma glucose concentrations 2 hours after lunch
is recommended in all patients receiving high doses of steroids.
Daily profiles of plasma glucose concentrations in the SDM and non-SDM groups
Daily profiles of plasma glucose concentrations in SDM on the day of administration or not of oral prednisolone who received drug every other day.
Conclusions: Prednisolone predominantly causes hyperglycemia in the afternoon and evening. Treatment of prednisolone-induced hyperglycemia should be targeted at this time period.
Clin
End
ocrin
ol (O
xf).
2012
Aug
ust ;
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2): 2
24–2
32
Steroid-induced diabetes C L E V E L A N D C L I N I C J O U R N A L O F M E D I C I N E V O L U M E 7 8 • N U M B E R 1 1, 2 0 1 1, 749
5.4 Glucocorticoid-induced diabetes 5.4.1 We recommend that bedside POC testing be initiated for patients with or without a history of diabetes receiving glucocorticoid therapy. (1QQQE) 5.4.2 We suggest that POC testing can be discontinued in nondiabetic patients if all BG results are below 7.8 mmol/liter (140 mg/dl) without insulin therapy for a period of at least 24–48 h. (2QEEE) 5.4.3 We recommend that insulin therapy be initiated for patients with persistent hyperglycemia while receiving glucocorticoid therapy. (1QQEE) 5.4.4 We suggest CII as an alternative to sc insulin therapy for patients with severe and persistent elevations in BG despite use of scheduled basal bolus sc insulin. (2QEEE)
C l i n i c a l P r a c t i c e G u i d e l i n e J Clin Endocrinol Metab 97: 16–38, 2012 Management of Hyperglycemia in Hospitalized Patients in Non-Critical Care Setting: An Endocrine Society Clinical Practice Guideline
Optimised glucocorticoid therapy: the sharpening of an old spear Buttgereit, Frank;Gerd-Rüdiger Burmester;Lipworth, Brian J The Lancet; Feb 26-Mar 4, 2005; 365, 9461
Systemic Glucocorticoid Therapy: a Review of its Metabolica nd Cardiovascular Adverse Events Laurence Fardet •Drugs (2014) 74:1731–1745
These results suggest that (a) administration of an antiinflammatory dose of prednisone for 7 d induces insulin resistance in man; (b) this is more dependent on depressed peripheral glucose utilization than on increased endogenous production; (c) total insulin binding on isolated adipocytes is not significantly affected; (d) insulin resistance is primarily the outcome of postreceptor defect (impaired glucose transport). G. PAGANO et al J Clin Inv 1983
J. L. Hwang 2014
Effets sur le métabolisme hépatique du glucose - activation du glycogène synthétase, qui entraîne une augmentation de la synthèse du glycogène ..augmentation de la disponibilité de précurseurs de la néoglucogenèse comme les acides aminés ou le glycérol ; -stimulation de la sécrétion de glucagon et surtout stimulation de la transcription d’enzymes clés de la néoglucogenèse -à forte dose de GCS d’une inhibition de l’action hépatique de l’insuline
Effets sur le muscle - l’utilisation périphérique du glucose est plus faible - une diminution du transport du glucose par une translocation inverse des transporteurs de glucose, de la membrane plasmatique vers un compartiment Intracytosolique - au niveau du muscle myocardique, la DXM serait capable d’induire, chez le rat, une insulinorésistance, une réduction de l’oxydation du glucose et un stockage de celui-ci sous forme de glycogène
Presse Med. 2012; 41: 393–399
Actions sur les cellules bêta de Langerhans - effet délétère direct des GCS sur la capacité insulino-sécrétoire de la cellule β - moduler le développement du pancréas et sa différenciation endocrine - augmentent la sécrétion de glucagon
Systemic Glucocorticoid Therapy: a Review of its Metabolic and Cardiovascular Adverse Events Laurence Fardet •Drugs (2014) 74:1731–1745
Systemic Glucocorticoid Therapy: a Review of its Metabolic and Cardiovascular Adverse Events Laurence Fardet •Drugs (2014) 74:1731–1745
Systemic Glucocorticoid Therapy: a Review of its Metabolic and Cardiovascular Adverse Events LFardet •Drugs (2014) 74:1731–1745
B. ALTRI TIPI DI DIABETE Nell’ambito degli altri tipi di diabete meritano una trattazione specifica per la loro frequenza:
Il diabete indotto da glicocorticoidi, il diabete associato a malattie del pancreas esocrino e il diabete indotto da farmaci antiretrovirali in soggetti HIV positivi
a. DIABETE INDOTTO DA GLICOCORTICOIDI RACCOMANDAZIONI La diagnosi di diabete mellito indotto da steroidi sulla base della presenza di due valori a digiuno uguali o superiori a 126 mg comporta la mancata identificazione di una elevata percentuale di soggetti affetti. (Livello della prova VI, Forza della raccomandazione D) La diagnosi di diabete mellito indotto da steroidi dovrebbe essere effettuata clinicamente sulla base della glicemia 2 ore dopo il pranzo. (Livello della prova VI, Forza della raccomandazione A) I soggetti diabetici, sottoposti a trattamento con steroidi, dovrebbero essere educati alla rilevazione della glicemia capillare soprattutto dopo pranzo e prima di cena. (Livello della prova III, Forza della raccomandazione A) La terapia insulinica rappresenta l’opzione terapeutica più sicura ed efficace nei pazienti con iperglicemia associata a terapia steroidea. (Livello della prova VI, Forza della raccomandazione A) I farmaci agenti sull’asse incretinico, per il loro meccanismo d’azione e il loro profilo di sicurezza, potrebbero rappresentare un’opzione terapeutica efficace nei pazienti con iperglicemia associata a terapia steroidea. (Livello della prova V, Forza della raccomandazione B) COMMENTO L’iperglicemia indotta da glucocorticoidi è comune in soggetti diabetici e non diabetici.
Management of Steroid-Induced Hyperglycemia in Hospitalized Patients With Cancer: A Review Veronica J. Brady, Oncology Nursing Forum • November 2014
Dietary modifications and physical activity often are not feasible for hospitalized patients with cancer. Nausea, vomiting, decreased appetite, mucositis, and altered taste frequently impair dietary intake, whereas fatigue and scheduled tests can affect patients’ ability to participate in physical activities.
Glucocorticoid-induced hyperglycemia
A Perez, Journal of Diabetes 6 (2014) 9–20
Evaluation of the Effects of Exenatide Administration in Patients with Type 2 Diabetes with Worsened Glycemic Control Caused by Glucocorticoid Therapy
Koji Matsuo
Intern Med 52: 89-95, 2013
Our findings therefore indicate that exenatide may be a suitable option for the treatment of GC-induced diabetes mellitus.
Glucocorticoids and GLP-1 receptor agonists D H. VAN RAALTE DIAB CARE, 34, 2011
Hwang Weiss 2014
Fourteen-day treatment with high-dose prednisolone impaired postprandial glucose metabolism in subjects with the metabolic syndrome. Concomitant treatment with sitagliptin improved various aspects of pancreatic islet-cell function, but did not prevent deterioration of glucose tolerance by GC treatment.
Does dipeptidyl peptidase-4 inhibition prevent the diabetogenic effects of glucocorticoids in men with the metabolic syndrome? A randomized controlled trial
Il diabete indotto da steroidi nei pazienti in cure palliative 30 al 60% dei pazienti in cure palliative ricevono steroidi,
prevalenza molto elevata e simile a quella del diabete metasteroideo in altri contesti clinici: 31%
In a retrospettive analysis in the UK, 50.6 of patients were receiving corticosteroids on terminal admission
and 61.1% day of death (Gannon 2002),
Karen Quinn
Corticosteroid-Induced Diabetes in Palliative Care Jana Pilkey, JOURNAL OF PALLIATIVE MEDICINE 2012
Gli autori propongono un monitoraggio della
glicemia 2 volte la settimana con un target glicemico tra 10 e 20 mmol/l (180-360 mg)
con il contributo non condizionante di: