When to Start Basal Insulin Therapy in Type 2 Diabetes Patients

Type 2 diabetes (T2D) accounts for 90% of all cases of diabetes, however, the vast majority of patients in treatment for T2D have suboptimal glycemic control, with glycated hemoglobin (AIC) levels greater than the 7%. The number of people living with diabetes mellitus in Indonesia has continued to increase over the last decade. Indonesia is ranked 7th in the world in terms of most people with diabetes. There were over 10,700,000 cases of diabetes in adults in Indonesia in 2019 (IDF Atias, 2019). Data at the Dr. Soetomo Hospital in 2007 showed that the prevalence of DM who underwent hospitalization reached 16.4% with a range of complications and mortality reached 28.8%. As the prevalence of DM is increasing, it is very important to improve glycemic control to delay microangiopathy, neuropathy and other complications of diabetes (Pranoto A et al. 2015). Traditional oral antidiabetic drugs (OADs) such as sulfonylureas (SUs). thiazolidinediones (TZDs), and metformin, have limited durability with respect to glycemic control. A 6-year survey determined that 53% of patients allocated to treatment with an SU required insulin therapy for the first time by the end of the study period. T2D is a progressive disease, characterized by gradual deterioration in pancreatic beta-cell function, decreasing insulin levels, and increasing insulin resistance, ultimately leading to chronic hyperglycemia. At diagnosis, most patients with T2D have already lost 50% of their remaining beta-cell function, which reduces rapidly over a period of just a few years. This rapid beta-cell decline means that insulin replacement quickly becomes necessary in order to achieve and maintain glycemic control, because other available therapies rely on the body's ability to produce insulin. As such, Insulin replacement is the most effective treatment for long-term control of hyperglycemia, and significant improvements in glycemic control can be achieved with this therapy in a short time.There are 3 stages to insulin therapy: initiation, optimization, and intensification. This review focuses on basal insulin initiation and optimization. The right time to initiate insulin therapy will be considered, as will suggestions for overcoming patient and physician barriers to initiating insulin therapy. Practical formula for patients Starting insulin therapy will be discussed, including the initial optimization of dose titration to achieve target Alc levels (Philis-Tsimikas, 2013)

Infarct Stroke and Blood Glucose Associated with Food Consumption in Indonesia

Stroke is the primary cause of death in adults. It is predicted that the death caused by stroke will increase twice in the next 30 years. In Indonesia, stroke is one of the diseases of the circulatory system, which has been taking the first place of causing death since 2007. Indonesia has rice as the main type of daily food consumed, which has higher glycemic index than other sources. This study aims to find the risk of blood glucose level that determines the incidence of infarct stroke. There were 164 patients enrolled in this study, 82 patients in each stroke and not stroke group. The blood examination is using the enzymatic method, which is the hexokinase method. The results of research revealed that indicators of high blood glucose level were found in infract stroke incidence, including casual blood glucose, fasting blood glucose, 2-h postprandial blood glucose, and glycated hemoglobin. These four indicators were found in a higher level in the infarct stroke than the non-stroke group. Other epidemiological studies have shown that diabetes is a risk factor for stroke. Therefore, education about food selection should be a priority in the effort to prevent infarct stroke and diabetes mellitus in Indonesia

Safety and Efficacy in Early Insulin Initiation as Comprehensive Therapy for Patients with Type 2 Diabetes in Primary Health Care Centers

Aim: to analyze the safety and efficacy of early insulin initiation therapy for patients with type 2 diabetes mellitus (T2DM) in primary health care provided by general practitioners (GPs) in Surabaya, East Java, Indonesia. Methods: pre-post study of ninety nine diabetic patients without previous insulin treatment with HbA1c levels >8% were involved in this study. The study was conducted in 10 primary health care centers in Surabaya between October 2011 to June 2012. Each patient received insulin therapy for 12 weeks. Laboratory examination was performed for each patient including fasting plasma glucose (FPG), 2 hours post-prandial plasma glucose (2hPPG) and HbA1c examination before and after the study. Self monitoring blood glucose (SMBG) examination was conducted in order to adjust the insulin dose and prevent the incidence of hypoglycemia. Data was statistically analyzed using paired-T test. Results: FPG level was decreased from baseline data (209 mg/dL) to 152.07 mg/dL at the end of the study (Δ56.93 mg/dl; p=0.0001). The average of 2hPPG level was also decreased from 313.00 mg/dl to 220.72 mg/dL (Δ 92.28 mg/dL; p=0.0001). HbA1c was reduced from 11.60% at baseline to 8.95% at the end of study (Δ 2.65%; p=0.0001). Hypoglycemia was found in 6 patients (6.06%) in this study, but all events were mild and did not need to be admitted to hospital. Conclusion: the safety of insulin therapy iniatiation might be provided by GPs at primary health centers with significant efficacy and minimal side effects. Key words: insulin, general practioner, primary health center

A Prediction Model of Mortality in Patients Hospitalized with Diabetic Ketoacidosis in a Tertiary Referral Hospital in Surabaya, Indonesia

Background: The mortality rate of diabetic ketoacidosis (DKA) remains high in Indonesia. Different patterns were contributing to DKA mortality from previous studies. We aim to identify clinical and laboratory findings as mortality predictors of DKA. Methods: This retrospective study was conducted in a tertiary referral hospital in Surabaya. Medical records of DKA patients from January 2016 to December 2018 were analyzed. Clinical and laboratory data were obtained from medical records for three years period. Clinical outcome was defined as either discharged home or death. Results: Fifty-six among 116 DKA patients did not survive during hospitalized. Age of 60 or older, the depressed mental state with GCS below 13, potassium serum less than 3.5 mmol/L, and bicarbonate serum less than 15 mmol/L are found to be significant as independent factors of mortality in DKA patients. Conclusion: The mortality rate of DKA patients in this study is still high. It independently associated with the age of 60 years or older, depressed mental state, hypokalemia, and low bicarbonate level. Early stratification of these predictors would help to treat patients accordingly

Effect of Growth Hormone Deficiency on the Cardiovascular System

Growth hormone (GH) is a hormone responsible for the regulation of somatic cell growth, including the development of the heart and blood vessels, and their functions. GH deficiency is a clinical condition characterized by impaired activity, decreased quality of life, as well as the impaired composition of substances in the body. GH improves cardiac metabolism, reduces oxygen consumption and energy requirements, even in patients with heart failure who have increased wall stress and impaired glucose metabolism that is characterized by insulin resistance and fasting hyperinsulinemia. Patients with GH deficiency also suffer from abnormalities in coagulation factors, such as increased levels. In another study, young adult patients with GH deficiency were found to experience a decrease in left ventricular mass, decreased ejection fraction, as well as abnormal diastolic filling patterns. GH therapy significantly reduces low-density lipoprotein (LDL) cholesterol but does not affect triglyceri de (TG). Growth hormone deficiency can increase the risk of cardiovascular disease by affecting the prevalence of risk factor-related events, such as central obesity, fat, and carbohydrate metabolism disorders, increased proinflammatory cytokines, endothelial dysfunction and oxidative stress, and morphological and cardiac dysfunction

In-Vitro Differentiation Adipose-Derived Mesenchymal Stem Cells into Pancreatic Progenitor Cells

Background: Adult stem cells are currently reliable sources of mesenchymal stem cells for regenerative therapy, include diabetes mellitus. The aim of this study is to develop endocrine pancreatic progenitor cells characterized by Pdx1 and insulin expression from rat adipose-derived mesenchymal stem cells using two steps in-vitro differentiation. Methods: In this experimental study, ADMSCs were isolated from rat adipose tissue and exposed to insulinogenic differentiation medium containing nicotinamide, activin A and glucagon-like peptide-1 (GLP1). After induction, the existence of pancreatic progenitor cells (PPCs) was confirmed by immune-staining assay of Pdx1 and insulin. Results: After three weeks of in-vitro differentiation, expression of Pdx1 and insulin proteins showed up as green in the immunofluorescence assay. Immunofluorescence intensity of Pdx1 was higher in PPCs than in ADMSCs control (p<0.05). Immunofluorescence intensity of insulin was also higher in PPCs than in ADMSCs control (p<0.05). Therefore, in-vitro differentiation was successful to develop PPCs from rat ADMSCs Conclusion: This study has demonstrated the in-vitro differentiation of ADMSCs into PPCs that expressed Pdx1 and insulin

MEDICATION ADHERENCE IN TYPE 2 DIABETES MELLITUS PATIENTS WITH CORONARY HEART DISEASE

Highlights                                                                                                                                      • Type 2 diabetes mellitus (T2DM) that is not appropriately handled can result in macro- or micro-complications. • Medication adherence is one of the most important efforts to do to prevent complications in chronic diseases such as T2DM. Abstract Background:  Diabetes medication non-adherence can aggravate the patient's condition and raise the chance of acquiring diabetes complications such as coronary heart disease. Medication adherence can help prevent micro- and macrovascular problems. Objective: This study aimed to investigate the medication adherence of type 2 diabetic patients with coronary heart disease. Material and Method: This research used a systematic literature review for the research design, with a PRISMA chart as a guideline. Researchers searched 3 databases using predefined keywords: PubMed, Google Scholar, and ScienceDirect. Result:  The search yielded 3.373 pieces of literature, and six pieces that fit the requirements were chosen. The total number of people who responded was 9.950. More men over 60 years old who have had diabetes for more than 5 years, who are taking oral medication, insulin, or combination treatment, and who are ex-smokers were shown to have characteristics of people with type 2 diabetes mellitus and coronary heart disease. Results from a systematic literature review revealed five kinds of literature with low medication adherence levels and one literature with a high medication adherence rate. Conclusion:  Medication adherence differs among type 2 diabetic patients with coronary heart disease. More research, however, has revealed that the level of medication adherence in type 2 diabetic patients with coronary heart disease remains low

A Prediction Model of Mortality in Patients Hospitalized with Diabetic Ketoacidosis in a Tertiary Referral Hospital in Surabaya, Indonesia

Abstract Background: The mortality rate of diabetic ketoacidosis (DKA) remains high in Indonesia. Different patterns were contributing to DKA mortality from previous studies. We aim to identify clinical and laboratory findings as mortality predictors of DKA. Methods: This retrospective study was conducted in a tertiary referral hospital in Surabaya. Medical records of DKA patients from January 2016 to December 2018 were analyzed. Clinical and laboratory data were obtained from medical records for three years period. Clinical outcome was defined as either discharged home or death. Results: Fifty-six among 116 DKA patients did not survive during hospitalized. Age of 60 or older, the depressed mental state with GCS below 13, potassium serum less than 3.5 mmol/L, and bicarbonate serum less than 15 mmol/L are found to be significant as independent factors of mortality in DKA patients. Conclusion: The mortality rate of DKA patients in this study is still high. It independently associated with the age of 60 years or older, depressed mental state, hypokalemia, and low bicarbonate level. Early stratification of these predictors would help to treat patients accordingly

Correlation between Neutrophil-to-Lymphocyte Ratio with Disease Severity in Diabetic Patients with COVID-19 at Tertiary Referral Hospital in Indonesia

Coronavirus disease 2019 (COVID-19) is highly transmissible and spreads quickly with the clinical presentation varies from asymptomatic to severe respiratory symptoms, even leading to death. Diabetes mellitus is one of the main comorbidities contributing to worsening the COVID-19 cases. Increased Neutrophil-toLymphocyte Ratio (NLR) is considered as an early warning of COVID-19 severity. This study evaluated the correlation between NLR with disease severity at admission in diabetic patients with COVID-19 at a tertiary referral hospital in Indonesia. The authors performed a retrospective study using secondary data from medical records of diabetic inpatients with COVID-19 from May to September 2020. The demographic data were collected from the medical record and the hematologic parameter from the laboratory. NLR was calculated by dividing the absolute neutrophils counts by the absolute lymphocyte counts. The data was analyzed with a significance level of p 6.15; p < 0.001) with sensitivity 91%, specificity 64%, negative predictive value 16%, and positive predictive value 75.82%. NLR had a significant positive correlation with disease severity at admission in diabetic patients with COVID-19. As simple, rapid, and cost-effective biomarkers, NLR can help clinicians identify potentially severe cases early, conduct early triage, and initiate effective management in time so the progress of disease severity should be possibly prevented