Archive for month: May, 2024

SGLT2 inhibitors, hailed for their efficacy in managing type 2 diabetes by promoting urinary glucose excretion, have gained widespread acceptance in clinical practice. However, emerging evidence suggests a rare but severe adverse effect – euglycemic diabetic ketoacidosis (EDKA), characterized by ketoacidosis with blood glucose levels within the normal or mildly elevated range. With their increasing use in the management of type 2 diabetes mellitus due to long-term beneficial effects, there is a rise in the incidence of this complication.

The recent case, published in Cureus, signifies the importance of awareness of the link between the SGLT2 inhibitors use and EDKA and early recognition of this complication to reduce mortality and morbidity. Furthermore, it also emphasizes the need for clinicians to educate their patients taking these drugs to prevent them during the intercurrent illness to prevent them from developing EDKA.

Sangita D. Kamath, Internal Medicine, Tata Main Hospital, Jamshedpur, IND, and colleagues report the case of a 58-year-old lady with a history of type 2 diabetes mellitus (T2DM) on multiple anti-diabetes medications, including dapagliflozin for one year, who during intercurrent illness developed EDKA.

Her blood sugar on admission was 203 mg/dL, and arterial blood gas showed high anion-gap metabolic acidosis (HAGMA) with ketonemia (blood beta-hydroxybutyric (BOHB) acid level: 5.4 mmol/L) and ketonuria. This condition may have been precipitated by dehydration resulting from repeated vomiting, low carbohydrate intake, and skipping the previous two days’ dose of insulin.

She was treated with intravenous fluids, insulin, 5% dextrose infusion, and potassium supplements with complete resolution of acidosis after about 90 hours.

In conclusion, the case report adds to the existing evidence in the literature supporting the relationship between SGLT2 inhibitors use and EDKA.

“Diagnosing this condition without high blood glucose levels may be challenging, as seen in typical DKA. It is imperative to check ketone body and blood gas levels in patients on SGLT2 inhibitors as the diagnosis cannot be excluded based on blood glucose levels alone,” the researchers wrote. This dreaded complication may be excluded by unexplained HAGMA even in the setting of normal levels of blood glucose.

The report also highlights the importance of patient education on the “sick-day rules” before starting this class of drugs. Clinicians should have a high index of suspicion for detecting this complication early and avoid delay in treatment.

Reference:

Kamath S D, Kumar U, Shrivastava V (April 15, 2024) Sodium-Glucose Cotransporter 2 Inhibitor-Induced Euglycemic Diabetic Ketoacidosis: The Other Side of the Coin!. Cureus 16(4): e58341. doi:10.7759/cureus.58341

At present, in order to practice in any of the States across the Country, a graduated doctor needs to apply to the concerned State Medical Council (SMC) separately. When he applies to the SMC (independently whether he is registered in the previous medical council or not) he is given a new registration number.

When the National Medical Register (NMR) comes into force, a doctor will be entered into NMR, and on the basis of his/her application, the doctor will get a unique doctor ID.

Currently, all the doctors are applying for different registration numbers in different State Medical Councils and they are getting different numbers as well.

What information will be available in NMR?

Whenever a doctor applies for registration in the NMR, all the records of that concerned doctor will be uploaded against his/her name and unique ID. The Register, which shall be available on the website of the National Medical Commission (NMC), shall display the information of a doctor such as his/her UID, registration number, name, place of work, qualifications, speciality and name of the Institute/University from where the qualifications were obtained among other key details. These will be made public.

There will be some private information as well of the doctors (such as telephone number,email id, etc,) and that will be visible to only concerned authorities such as the doctor herself, the NMC, etc. This will be login based.

How will it end Fake Doctor Menace?

The National Medical Register (NMR) will be a public document as it will be available online on the NMC website. Therefore, the general public can easily get access to the register and verify the credentials of a doctor. This will, in turn, help to put an end to the fake doctor menace.

Atrial fibrillation is a common cardiac arrhythmia associated with increased morbidity and mortality. Traditional treatments include thermal ablation techniques, which have varying success rates and potential complications. Pulsed field ablation, a newer technique, promises to offer a safer and more effective alternative. The ADVENT trial’s initial results showed noninferiority of PFA compared to thermal ablation in achieving freedom from atrial arrhythmias at one year. The secondary analysis aimed to delve deeper into arrhythmia burden and quality of life metrics.

• In the ADVENT trial, 82% of patients treated with PFA achieved less than 0.1% residual atrial arrhythmia burden compared to 75% with thermal ablation (OR 1.5, P=0.04).

• This equates to approximately 8.6 minutes of arrhythmia over two 72-hour Holter monitoring periods.

• Atrial arrhythmia burden greater than 0.1% was associated with lower quality of life scores and higher rates of redo ablation, cardioversion, and hospitalization.

• Real-world data from the FARADISE global registry, involving 1,173 patients, showed a 4.0% rate of device or procedure-related serious adverse events, primarily minor vascular access complications.

• No deaths or severe complications like coronary spasm, persistent phrenic nerve palsy, or esophageal lesions were reported.

Lucas Boersma, MD, PhD, presented 30-day data from the FARADISE registry, which tracks real-world use of the Farapulse pentaspline PFA catheter across Europe, Asia, Australia, and the Middle East. The study found that PFA had a favorable safety profile, with serious adverse events occurring in only 4.0% of cases. Most adverse events were minor vascular access complications, and there were no fatalities or severe complications.

The MANIFEST-PF registry suggested that PFA benefits extend to patients with heart failure (HF), regardless of ejection fraction. At one year, freedom from atrial arrhythmia was significantly higher in patients without HF (79.9%) compared to those with HF with preserved ejection fraction (HFpEF) (71.3%) and those with moderately reduced or reduced ejection fraction (HFmrEF/HFrEF) (67.5%). This was consistent for both paroxysmal and persistent Afib.

The findings from these studies underscore the potential of PFA to become a preferred treatment modality for Afib, offering superior outcomes in terms of reducing arrhythmia burden and maintaining quality of life. The real-world data further reinforce PFA’s safety and feasibility, even in diverse clinical settings. Additionally, the benefits observed in heart failure patients suggest that PFA could play a crucial role in managing Afib across various patient populations.

Researchers have found that pulsed field ablation is superior to conventional thermal ablation in reducing atrial arrhythmia burden, with significant implications for patient quality of life and treatment efficacy. The ADVENT trial’s secondary analysis and real-world data from the FARADISE registry highlight PFA’s safety and effectiveness, paving the way for its broader adoption in clinical practice. Further studies are warranted to explore its long-term benefits and potential applications in different patient cohorts, including those with heart failure.

Reference:

Turagam, M. K., Neuzil, P., Schmidt, B., Reichlin, T., Neven, K., Metzner, A., Hansen, J., Blaauw, Y., Maury, P., Arentz, T., Sommer, P., Anic, A., Anselme, F., Boveda, S., Deneke, T., Willems, S., van der Voort, P., Tilz, R., Funasako, M., … Reddy, V. Y. (2024). Safety and effectiveness of pulsed field ablation for atrial fibrillation in patients with heart failure: A MANIFEST-PF sub-analysis. JACC. Clinical Electrophysiology. https://doi.org/10.1016/j.jacep.2024.05.002

The higher the blood sugar level in pregnant women when first diagnosed with diabetes, the higher the risk of complications around and after birth, according to research presented at the 26th European Congress of Endocrinology in Stockholm.

For every 5mg/L above the diagnosis threshold, the risk of newborns having low blood sugar levels, or a large birth weight, rises by 9% and 6%, accordingly, while mothers have a 31% higher risk of diabetes after birth. The findings suggest that high-risk women with gestational diabetes should be classified further to limit these complications for both mothers and newborns.

Gestational diabetes — a condition in which women have elevated blood sugar, or glucose, levels during pregnancy — affects around 20 million pregnancies worldwide and poses increased health risks for both mothers and their babies. For example, mothers are more likely to develop type 2 diabetes and to give birth to especially large babies who face a high risk of birth injuries or even obesity later in life. Women are diagnosed with gestational diabetes if their fasting (pre-meal) blood glucose levels are above 92 mg/dL in the first trimester or their 2-hour oral post-meal glucose levels (OGTT) in the second trimester is above 153 mg/dL.

In this study, researchers from the Tâmega e Sousa Hospital Center in Portugal analysed data on blood sugar levels and birth complications of 6,927 pregnant women, aged 30-37 years old, who carried one child and were diagnosed with gestational diabetes between 2012 and 2017. The researchers found that for every 5mg/L increase in their blood sugar levels, there was a 9% higher risk of low blood sugar (hypoglycemia) and a 6% higher risk of large birth weight (large for gestational age) in newborns and a 31% higher risk of maternal high blood levels (hyperglycemia) after birth.

“While it is not surprising that high glucose levels are associated with these adverse outcomes in mothers and newborns, our study shows for the first time how much increase in risk there is with 5 mg/dL of increase in the mother’s blood glucose levels when first diagnosed with gestational diabetes,” said co-lead researcher Dr Catarina Cidade-Rodrigues.

Dr Cidade-Rodrigues continued: “The magnitude of elevated risk can be calculated with our measurements and, in practice, could be used to identify and stratify women at higher risk of developing these complications.”

“We now want to evaluate if there is a benefit in further stratifying these high-risk women with gestational diabetes, who will need to be more closely monitored and to whom pharmacological interventions can be carried out appropriately. This may help reduce complications during labour and in newborns and prevent future diabetes in these women.”

Blood sugar level at gestational diabetes diagnosis linked to harmful outcomes for mothers and babies

MEETING

European Congress of Endocrinology