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PubMed1980

Diabetic ketoacidosis. Reassessment of therapeutic "truths".

The diagnosis of diabetic ketoacidosis remains, as always, a bedside clinical exercise. Rapid consideration and exclusion of other conditions associated with altered consciousness that may occur in diabetics, such as lactic acidosis, hyperosmolar states, hypoglycemia, alcohol-related ketosis, and infections, should be routine. Although recent reassessment of therapy has meant more rational and specific action, close attention to the physical and laboratory responses to treatment is equally essential for a successful outcome.

Bicarbonates↗
PubMed2002

[Disorders of lipid and glucose metabolism. Long-term adverse effects of antiretroviral therapy].

In addition to readily controllable short-term side effects, highly active antiretroviral therapy (HAART) also has long-term side effects: lipodystrophy syndrome, hyperlipoproteinemia, insulin resistance, elevated glucose tolerance sometimes leading to diabetes mellitus and lactic acidosis. The pathogenesis remains uncertain although various hypotheses have been advanced. A number of approaches for the treatment of lipodystrophy are available, the effects of which, however, have not been confirmed by study results. Hyperlipoproteinemia probably means an increased cardiovascular risk, but a final pronouncement on this is not yet possible. Fibrates and statins are currently applied for treatment, but interactions with HAART medicaments have to be considered. HAART-induced diabetes mellitus presents clinically as type 2 diabetes, and is treated accordingly.

Acquired Immunodeficiency Syndrome↗
PubMed2000

[Current role of metformin in treatment of diabetes mellitus type 2].

Metformin-associated lactic acidosis is not necessarily due to metformin accumulation. It appears that mortality in patients receiving metformin who develop lactic acidosis is mostly linked to underlying disease. It has been suggested that metformin should be the first-line agent for the treatment of obese type 2 diabetic patients since metformin was associated with a significant decrease in macrovascular events and a reduction of all-cause mortality in the United Kingdom Prospective Diabetes Study (UKPDS) in a substudy. However, in this substudy no significant decrease in microvascular complications was observed in obese subjects with intensive metformin therapy. In addition, the use of metformin in combination with sulfonylurea seemed to be associated with excess risk of diabetes-related and all-cause mortality in obese subjects. Due to the discrepant and contradictory nature of the results in the obese patients and a lack of power the UKPDS offered no decision for any drug for initial therapy of type 2 diabetes. The main message of the UKPDS is that lowering of the blood glucose to the normal range is beneficial irrespective of the hypoglycaemic agent used. A rational approach to therapy in a type 2 diabetes patient who fails to sufficiently lower blood sugar with diet and weight loss is to begin therapy with a sulfonylurea or metformin and to add another oral agent if the desired glycaemic control is not achieved.

Acidosis, Lactic↗
PubMed1990

Decreased sensitivity of contraction to changes of intracellular pH in papillary muscle from diabetic rat hearts.

1. The relationship between intracellular pH (pHi) and contractile activity was investigated in papillary muscles isolated from right ventricle of normal and streptozotocin (STZ)-induced diabetic rats. pHi changes induced by 20 mM-NH4Cl were recorded with H(+)-sensitive microelectrodes. 2. An increase in pHi of approximately 0.20 pH units on exposure to NH4Cl led to an increase of the maximum developed tension, which was 707.8 +/- 57.5% (mean +/- S.E. of mean, n = 10) of control in normal muscles and 271 +/- 16.3% (n = 10) in diabetic muscles. On the other hand, acidosis induced by NH4Cl withdrawal was associated with a fall in developed tension to 48.2 +/- 6.7% of control in diabetic muscles, as compared to 79.2 +/- 8% in normal muscles. 3. The decrease in tension associated with acidosis was rapidly followed (in approximately 2 min) by a transient redevelopment of force, which peaked at 80.2 +/- 8.6% of control in the diabetic muscles as compared to 153.5 +/- 11.7% in normal papillary muscles. The peak of this secondary positive inotropy coincided in both groups of muscles with the maximum decrease of pHi, i.e. -0.40 +/- 0.02 and -0.28 +/- 0.04 pH units in diabetic and normal muscles, respectively. 4. Caffeine (10 mM), which had a marked positive inotropic effect in both groups of muscles, abolished the transient recovery of tension occurring after NH4Cl withdrawal. Ryanodine (2 microM) which had a marked negative inotropic effect on both normal and diabetic papillary muscles, also suppressed the transient recovery of tension. 5. The presence of amiloride (1 mM) during acidosis induced by NH4Cl withdrawal abolished the observed differences in developed tension, in particular the transient recovery of tension, between normal and diabetic muscles, as it abolished the differences in the amplitude of pHi decrease and in the time course of pHi recovery. 6. The presence of 2',4'-dichlorobenzamil amiloride (40 microM) significantly and similarly delayed and reduced the amplitude of transient recovery of tension in both normal and diabetic papillary muscles. 7. We conclude that STZ-induced diabetes induces a decrease in pHi sensitivity of contractile force. This may be the consequence of a change in sarcoplasmic reticulum (SR) composition and function, and may also indirectly result from changes in Na(+)-H+ exchange activity, particularly during intracellular acidosis.

Amiloride↗
PubMedDate not supplied

The ventilatory response in uncomplicated diabetic ketoacidosis.

The ventilatory response to uncomplicated sub-acute metabolic acidosis was studied by measuring arterial blood CO2 tension (PaCO2) and pH in 27 episodes of diabetic ketoacidosis without coexisting lactic acidosis. From those data, regression equations and 95% confidence bands were calculated for the relations between PaCO2 and pH. These relations were very similar to those previously described by others in patients with chronic uremic acidosis.

Adolescent↗
PubMed1990

[Sodium dichloroacetate--a substance with manifold therapeutic potential].

The therapeutic potential of sodium dichloroacetate (DCA) formerly called vitamin B 15, has already been under investigation for the past few years. The predominant property of DCA underlying its therapeutic action is activation of pyruvate dehydrogenase. The potential therapeutic use of DCA in the treatment of lactic acidosis and type II diabetes mellitus related directly to its stimulatory effect on this enzyme. Additional favourable effects of DCA on cardiac performance in states such as ischaemia, where glucose becomes a major energy-yielding substrate, have also been demonstrated. Treatment of lipid disorders might become further indications for the implementation of this substance. DCA inhibits hydroxy-methyl-glutaryl CoA reductase, thus lowering cholesterol and triglyceride levels. Earlier suggestions that DCA produced a major degree of acute toxicity were not confirmed in recent studies using DCA of established purity and homogeneity. These findings and recent evidence suggesting a potentially important role of DCA in the treatment of lactic acidosis are the reason and basis for a review of the established actions of this substance.

Acetates↗
PubMed2004

Increased cardiac troponin I concentration in diabetic ketoacidosis.

OBJECTIVE: To examine the hypothesis that diabetic ketoacidosis may be associated with some degree of induced injury to heart muscle, related either to acidosis or hyperglycemia. METHODS: Nineteen diabetic patients with acute ketoacidosis and 19 healthy children were enrolled in this study. Cardiac troponin I (cTnI), creatine kinase (CK)-MB and myoglobin levels were analyzed soon after admission and after 24 h. Patients were subdivided into two groups according to blood pH. RESULTS: At the time of admission, the diabetic patients had significantly higher values than the controls for cTnI (0.193+/-0.008 vs 0.176+/-0.006 ng/dl; p <0.001), CK-MB (24.1+/-2.1 vs 22.7+/-1.2 U/l; p = 0.02), and myoglobin (85.5+/-7.4 vs 52.5 +/-8.3 microg/dl; p <0.001). The diabetic patients also had significantly higher values than the controls for CK-MB (24+/-2.1 vs 22.7+/-1.2 U/l; p = 0.02) and for myoglobin (78.5+/-2.5 vs 52.5+/-8.3 microg/dl; p <0.001) at 24 h. cTnI had normalized in patients at 24 h. All parameters were significantly different between patients with pH > or =7.0 and patients with pH <7.0. In addition, serum cTnI levels correlated negatively with blood pH (r = -0.57, p = 0.026) and HCO3- (r = -0.65, p = 0.008) in the patients with diabetic ketoacidosis on admission. CONCLUSION: Our findings suggest that diabetic ketoacidosis, particularly when severe, has a detrimental effect on the myocardium.

Adolescent↗
PubMed1989

[Biguanides in the treatment of diabetes mellitus].

Biguanides are useful drugs in diabetes but their indications are very precise. The danger of lactic acidosis can be avoided with the use of metformin, the less toxic of biguanides, and strict respect for contraindications. All biguanides have a similar action, through different pharmacokinetics, and besides their hypoglycemic effect, have a favourable action on blood lipids, which increases their usefulness. Haemorheological effects, recently studied in animal research, may open a new field in the employment of biguanides.

Acidosis, Lactic↗
PubMedDate not supplied

Treatment of non-insulin-dependent diabetes mellitus with metformin.

BACKGROUND: Metformin alleviates hyperglycemia of non-insulin-dependent diabetes mellitus (NIDDM) by inhibiting hepatic glucose production and improving peripheral insulin sensitivity. In contrast to sulfonylureas, metformin does not stimulate insulin-secretion, promote weight gain, exacerbate hyperinsulinemia, or cause hypoglycemia. It also favorably affects serum lipids. METHODS: A comprehensive review of the medical literature from 1968 to the present was conducted using the key words "metformin" and "non-insulin-dependent diabetes mellitus." RESULTS: Metformin monotherapy was superior to placebo and comparable to sulfonylureas in reducing fasting plasma glucose and glycosylated hemoglobin levels in patients with NIDDM uncontrolled by diet. Metformin and sulfonylureas, however, had diverse effects on body weight and fasting plasma insulin levels; both weight and insulin levels remained unchanged or decreased with metformin and increased with sulfonylureas. In patients with secondary sulfonylurea failure, the combination of metformin and a sulfonylurea synergistically improved glycemic control better than either drug alone and was comparable to insulin plus sulfonylurea. When hyperglycemia is uncontrolled by insulin after secondary sulfonylurea failure, limited data suggest the efficacy of metformin plus insulin. The mild, transient, self-limited gastrointestinal side effects that sometimes occur can be minimized by gradually increasing the doses and by taking metformin with food. Risk of metformin-associated lactic acidosis is low if prescribing guidelines are adhered to. Potential adverse drug interactions include hypoglycemia during concurrent sulfonylurea therapy and elevated metformin plasma concentrations when metformin is taken concomitantly with cimetidine. CONCLUSIONS: Metformin can be used safely and effectively as first-line monotherapy in NIDDM or in combination with a sulfonylurea when monotherapy with either agent fails. It can be particularly suitable when weight gain, hyperlipidemia, and hypoglycemia are clinically important issues.

Acidosis, Lactic↗
PubMed2004

Biotin responsive multiple carboxylase deficiency presenting as diabetic ketoacidosis.

Multiple carboxylase deficiency (MCD) is a rare inherited metabolic disease of biotin dependency due to deficiency of holocarboxylase synthetase (HCS) or biotinidase deficiency. A 30-month-old female patient who presented with the initial features of diabetic ketoacidosis (severe metabolic acidosis, ketosis, and hyperglycemia), lactic acidemia, moderate hyperammonemia, and generalized organic aciduria is described. Associated symptoms and signs included erythematous skin rashes, alopecia and developmental delay. The patient responded dramatically to treatment with biotin (10 mg/day) showing normalization of clinical symptoms and most biochemical abnormalities. Based on the urine organic profile by gas chromatography/ mass spectrometry (GC/MS), the diagnosis of MCD was made. A plasma tandem mass study confirmed this diagnosis. The biotinase activity in serum was normal, indicating that this was a rare case of late-onset HCS deficiency.

Biotin↗
PubMed1964

DIABETES MELLITUS AND ITS COMPLICATIONS IN AN ELDERLY POPULATION.

The planning of a diabetic control program in a home and hospital for the aged prompted a survey of the incidence, severity and number of complications of diabetes mellitus in this population. Twenty-eight per cent of the total population of 265 persons were found to be diabetic. In most of them the onset of diabetes was late in life and in the majority the disease was controlled by dietary measures alone. Of interest was the low incidence of gallbladder disease, hypercholesterolemia, ocular disease, myocardial and peripheral vascular disease. Neurological complications were minimal. The measures adopted to achieve biochemical stabilization in diabetes mellitus are discussed and the absence of acidosis and ketosis in this group is noted. The high incidence of diabetes, the need for detection of undiagnosed cases, and the low rate of complications are discussed.

Acidosis↗
PubMed1987

Renal substrate utilization in normal and acidotic rats.

Renal arteriovenous (A-V) concentration differences of the major potential respiratory substrates were measured in whole blood of control, NH4Cl-acidotic and diabetic ketoacidotic (DKA) rats. Net renal substrate extractions were calculated from A-V differences and renal blood flows. In fed control rats lactate accounted for 78% of the total substrate extracted. Small amounts (10-12%) of citrate and the ketone bodies 3-hydroxybutyrate and acetoacetate were also extracted. There was no significant extraction of either free fatty acids, glucose, glutamine, or pyruvate. In NH4Cl-acidotic rats lactate extraction was lower (40%) than in controls, but glutamine extraction increased (28%). The amount of extra glutamine extracted approximated the fall in lactate extraction. In DKA rats, ketone bodies accounted for the major portion of the extracted substrates (56%) but a significant part of the net extraction was due to urinary excretion of these compounds. Glutamine extraction represented 23% of the total. Lactate extraction was low (14%) in DKA rats, probably as a result of the low arterial lactate concentration. In vitro studies done on renal cortical slices suggest that each of the three major substrates extracted by the kidneys of normal, NH4Cl, and DKA rats could serve as major respiratory fuels.

Acid-Base Equilibrium↗
PubMed1990

[Effect of biguanides on the indicators of thrombelastography and the level of lactic acid in diabetes mellitus].

The authors analyze the results of examinations of 232 patients with diabetes mellitus; 48 of these suffering from type I diabetes and 64 from type II diabetes were treated with biguanides. Thromboelastograms were recorded in the presence of hyperglycemia and repeatedly during stable compensation of diabetes, and their values were analyzed with due consideration for therapy administered. Since biguanides are known to induce lactate acidosis, blood serum lactic acid levels were measured when the patients were hospitalized, in the presence of hyperglycemia, and then after a standard exercise test (to detect latent acidosis). When stable compensation of diabetes mellitus was achieved, the examination scheme described before was repeated, i. e. lactic acid measurements before and after exercise test, with due consideration for the therapy administered. Biguanides were found to be conducive to normalization of thrombelastogram values, not elevating the blood serum content of lactic acid even after exercise test.

Adolescent↗