Journal of Diabetes, Endocrinology and Metabolic Diseases

Transcription

1 Vol. 44 No. 4 (pp ) 2015 / Zagreb, December 2016 vol. 44 no. 4 p.p Journal of Diabetes, Endocrinology and Metabolic Diseases VUK VRHOVAC UNIVERSITY CLINIC, ZAGREB, DAMA - DIABETOLOGY ALUMNI MEDICAL ASSOCIATION CONTENTS ORIGINAL RESEARCH ARTICLES PREVALENCE OF DIABETES MELLITUS AND ASSOCIATED RISK FACTORS IN KINDERGARTEN AND SCHOOL PERSONNEL IN ZAGREB, CROATIA Tamara Poljic anin, Melita Jelavic, Vanja Tešic EFFECT OF CHRONIC SLEEP DEPRIVATION ON OXIDATIVE STRESS STATUS IN ALLOXAN INDUCED DIABETIC RATS Jolaoluwa Oluwatosin Yesufu, Adesoji Adedipe Fasanmade REVIEW UDC ISSN EFFECT OF COMBINATION THERAPY IN THE TREATMENT OF PATIENTS WITH TYPE 2 DIABETES MELLITUS Ivana Antal, Spomenka Ljubic, Lea Smirc ic Duvnjak

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3 100 inzulin jedinica/ml glargin Porazgovarajmo o Abasaglaru inzulin glarginu tvrtke Eli Lilly Učinkovito smanjenje HbA1C i glukoze natašte 1 PrAktično doziranje jednom dnevno 2 dostupan U brizgalici kwikpen Ovaj je lijek pod dodatnim praćenjem. Time se omogućuje brzo otkrivanje novih sigurnosnih informacija. Od zdravstvenih djelatnika se traži da prijave svaku sumnju na nuspojavu za ovaj lijek. Upute za prijavljivanje dostupne su na ABASAGLAR 100 jedinica/ml otopina za injekciju u napunjenoj brizgalici.jedan ml sadrži 100 jedinica inzulina glargina* (što odgovara 3,64 mg). Jedna brizgalica sadrži 3 ml otopine za injekciju, što odgovara 300 jedinica. * Inzulin glargin proizvodi se tehnologijom rekombinantne DNK na bakteriji Escherichia coli. Broj odobrenja za stavljanje lijeka u promet: EU/1/14/944/008 Višestruko pakiranje: 10 (2 pakiranja po 5) brizgalica od 3 ml. Način i mjesto izdavanja lijeka: Lijek se izdaje na recept. Ime i adresa nositelja odobrenja: Eli Lilly Regional Operations GmbH, Kölblgasse 8-10, 1030 Beč, Austrija Terapijske indikacije: Liječenje šećerne bolesti u odraslih, adolescenata i djece u dobi od 2 ili više godina. Kontraindikacije: Preosjetljivost na djelatnu tvar ili neku od pomoćnih tvari. Posebna upozorenja i posebne mjere opreza pri uporabi: ABASAGLAR nije inzulin izbora za liječenje dijabetičke ketoacidoze. Umjesto njega se u takvim slučajevima preporučuje intravenska primjena običnog inzulina. U slučaju nedostatne regulacije glukoze ili sklonosti epizodama hiperglikemije ili hipoglikemije, prije razmatranja prilagodbe doze mora se procijeniti pridržava li se bolesnik propisanog režima doziranja i mjesta primjene injekcije, primjenjuje li pravilnu tehniku injiciranja te sve ostale važne čimbenike. Prebacivanje bolesnika na drugu vrstu inzulina ili inzulin drugog proizvođača treba provesti pod strogim liječničkim nadzorom. Promjene u jačini, nazivu inzulina (proizvođač), vrsti (obični, NPH, lente, dugodjelujući itd.), podrijetlu (životinjski, ljudski, analog ljudskog inzulina) i/ ili načinu proizvodnje mogu rezultirati potrebom za promjenom doze. Primjena inzulina može uzrokovati stvaranje protutijela na SAMO ZA ZDRAVSTVENE RADNIKE HRABA00011, inzulin. U rijetkim slučajevima prisutnost tih protutijela na inzulin može uvjetovati prilagodbu doze inzulina kako bi se umanjila sklonost hiperglikemiji odnosno hipoglikemiji. Kombinacija lijeka ABASAGLAR s pioglitazonom: Prijavljeni su slučajevi zatajenja srca kod primjene pioglitazona u kombinaciji s inzulinom, osobito u bolesnika koji su imali rizične čimbenike za razvoj zatajenja srca. Interakcije s drugim lijekovima ili drugi oblici interakcija: Brojne tvari utječu na metabolizam glukoze i mogu zahtijevati prilagodbu doze inzulina glargina. Tvari koje mogu pojačati učinak na snižavanje razine glukoze u krvi i povećati sklonost hipoglikemiji obuhvaćaju oralne antidijabetike, inhibitore angiotenzin konvertirajućeg enzima (ACE), dizopiramid, fibrate, fluoksetin, inhibitore monoaminooksidaze (MAO), pentoksifilin, propoksifen, salicilate, analoge somatostatina i sulfonamidske antibiotike. Tvari koje mogu smanjiti učinak na snižavanje razine glukoze u krvi obuhvaćaju kortikosteroide, danazol, diazoksid, diuretike, glukagon, izoniazid, estrogene i progestagene, derivate fenotiazina, somatropin, simpatomimetičke lijekove (npr. epinefrin [adrenalin], salbutamol, terbutalin), hormone štitnjače, atipične antipsihotike (npr. klozapin i olanzapin) te inhibitore proteaze. Beta blokatori, klonidin, soli litija odnosno alkohol mogu pojačati ili oslabiti učinak inzulina na snižavanje razine glukoze u krvi. Pentamidin može uzrokovati hipoglikemiju, nakon koje ponekad može uslijediti hiperglikemija. Osim toga, pod utjecajem simpatolitika, poput beta blokatora, klonidina, gvanetidina i rezerpina, mogu oslabjeti ili potpuno izostati znakovi adrenergičke proturegulacije. Trudnoća i dojenje: Može se razmotriti primjena lijeka ABASAGLAR tijekom trudnoće, ako je to potrebno. Dojiljama će možda biti potrebno prilagoditi dozu inzulina i prehranu. Istraživanja na životinjama ne ukazuju na izravne štetne učinke na plodnost. Utjecaj na sposobnost upravljanja vozilima i strojevima: Bolesnikova sposobnost koncentracije i reagiranja može biti Eli Lilly (Suisse) S.A. Predstavništvo u RH, Ulica grada Vukovara 269 G, Zagreb Tel: , Fax: , umanjena zbog hipoglikemije ili hiperglikemije ili, primjerice, zbog oštećenja vida. To može predstavljati rizik u situacijama u kojima su takve sposobnosti posebno važne (primjerice, vožnja automobila ili rukovanje strojevima). Nuspojave: Hipoglikemija, koja je općenito najčešća nuspojava inzulinske terapije, može nastupiti ako je doza inzulina previsoka u odnosu na potrebu za inzulinom. Doziranje i način primjene: ABASAGLAR sadrži inzulin glargin, koji je inzulinski analog s produljenim djelovanjem. ABASAGLAR se primjenjuje jedanput na dan, u bilo koje vrijeme, ali svaki dan u isto vrijeme. Režim doziranja lijeka ABASAGLAR (dozu i vrijeme primjene) potrebno je prilagoditi pojedinom bolesniku. U bolesnika sa šećernom bolešću tipa 2 ABASAGLAR se može primjenjivati i zajedno s oralnim antidijabeticima. Jačina ovoga lijeka izražena je u jedinicama. Ove se jedinice odnose isključivo na inzulin glargin te nisu istovjetne internacionalnim jedinicama (IU) ili jedinicama koje se koriste za izražavanje jačine drugih inzulinskih analoga. Datum revizije Sažetka opisa svojstava lijeka 05/2015. Ovaj promotivni materijal sadrži bitne podatke o lijeku koji su istovjetni cjelokupnom odobrenom sažetku svojstava lijeka te cjelokupnoj odobrenoj uputi sukladno članku 15. Pravilnika o načinu oglašavanja o lijekovima i homeopatskim proizvodima (NN 43/2015). Važno: informacije pripremljene samo za zdravstvene radnike. Lijek Abasaglar izdaje se na recept. Prije propisivanja lijeka Abasaglar molimo pročitajte zadnji odobreni Sažetak opisa svojstava lijeka i Uputu o lijeku. Detaljnije informacije o ovom lijeku i zadnji odobreni Sažetak opisa svojstava lijeka možete dobiti u Predstavništvu Eli Lilly (Suisse) S.A., te na web stranicama Europske agencije za lijekove: eu i Europske komisije: community-register/html/alfregister.htm. Reference: 1 Rosenstock et al: Diabetes, Obesity and Metabolism 17: , 2015; Blevins et al: Diabetes, Obesity and Metabolism 17: , Abasaglar Sažetak opisa svojstava lijeka

4 TRESIBA jednom dnevno SADA NO ODOBREEN ATA DJELOVANJE3,4 SC I KOD ADOLE BI I DJECE U DO NA3,5 DA OD GODINU DULJE OD 42 SATA Uspješno sniženje HbA1c1,2 Manji rizik od noćnih hipoglikemija u odnosu na glargin inzulin1,2,* Fleksibilno vrijeme doziranja u bilo koje doba dana, kada je potrebno3*...jednom dnevno. *Odnosi se samo na odraslu populaciju Odnosi se na glargin inzulin 100 jedinica/ml Referencije: 1. Rodbard HW, et al. on behalf of the BEGIN Once Long Trial Investigators. Comparison of insulin degludec with insulin glargine in insulin-naive subjects with Type 2 diabetes: a 2-year randomized, treat-to-target trial. DIABETIC Medicine 2013;30(11): Bode BW, et al. on behalf of the BEGIN Basal Bolus Type 1 Trial Investigators. Insulin degludec improves glycaemic control with lower nocturnal hypoglycaemia risk than insulin glargine in basal bolus treatment with mealtime insulin aspart in Type 1 diabetes (BEGIN Basal Bolus Type 1): 2-year results of a randomized clinical trial. DIABETIC Medicine 2013;30(11): Tresiba Sažetak opisa svojstava lijeka 4. Jonassen I, et al. Design of the novel protraction mechanism of insulin degludec, an ultra-long-acting basal insulin. Pharmaceutical Research. 2012;29(8): Thalange N, et al. Insulin degludec in combination with bolus insulin aspart is safe and effective in children and adolescents with type 1 diabetes. Pediatric Diabetes doi: / pedi FlexTouch, NovoFine, NovoTwist i Tresiba su zaštićena imena u vlasništvu Novo Nordisk A/S, Danska. Datum pripreme: Ovaj je lijek pod dodatnim praćenjem. Time se omogućuje brzo otkrivanje novih sigurnosnih informacija. Od zdravstvenih radnika se traži da prijave svaku sumnju na nuspojavu za ovaj lijek. Upute za prijavljivanje dostupne su na HQMMA/TB/0415/0126 SAMO ZA ZDRAVSTVENE RADNIKE U Novo Nordisku mijenjamo dijabetes. U pristupu razvoju lijekova, u predanosti da poslujemo s dobiti i etično te u potrazi za lijekom. degludek inzulin (tehnologija rdnk) injekcija

5 Naziv lijeka: Tresiba 100 jedinica/ml otopina za injekciju u napunjenoj brizgalici. Međunarodni naziv djelatne tvari: degludek inzulin. Odobrene indikacije: Liječenje šećerne bolesti u odraslih, adolescenata i djece u dobi od 1 godine. Kontraindikacije: Preosjetljivost na djelatnu tvar ili neku od pomoćnih tvari. Posebna upozorenja i mjere opreza pri uporabi: Doze inzulina u djece potrebno je oprezno uskladiti (osobito u sklopu bazal-bolus inzulinske terapije) s unosom hrane i tjelesnom aktivnošću kako bi se umanjio rizik od hipoglikemije. U bolesnika u kojih je znatno poboljšana regulacija glikemije može doći do promjene uobičajenih upozoravajućih simptoma hipoglikemije te ih o tome treba primjereno savjetovati. U osoba koje dugo boluju od šećerne bolesti uobičajeni upozoravajući simptomi mogu nestati. Infekcije i stanja praćena vrućicom, obično povećavaju bolesnikovu potrebu za inzulinom. Bolesti bubrega, jetre, nadbubrežne žlijezde, hipofize ili štitnjače mogu zahtijevati promjenu doze inzulina. Produljeno djelovanje lijeka Tresiba može odgoditi oporavak od hipoglikemije. U teškoj hiperglikemiji preporučuje se primjena brzodjelujućeg inzulina. Obično se prvi simptomi hiperglikemije javljaju postupno. U šećernoj bolesti tipa 1 neliječena hiperglikemija u konačnici vodi u dijabetičku ketoacidozu, koja može biti smrtonosna. Zabilježeni su slučajevi zatajivanja srca kod primjene pioglitazona u kombinaciji s inzulinom, osobito u bolesnika koji su imali rizične faktore za razvoj zatajivanja srca. Ovo treba imati na umu ako se razmatra liječenje kombinacijom pioglitazona i lijeka Tresiba. U slučaju primjene ove kombinacije, u bolesnika treba pratiti znakove i simptome zatajivanja srca, porasta tjelesne težine i edema. Liječenje pioglitazonom treba prekinuti ako dođe do bilo kakvog pogoršanja srčanih simptoma. Bolesnicima se mora objasniti da prije svakog injiciranja uvijek provjere naljepnicu na inzulinu. Bolesnici moraju vizualno provjeriti odabrane jedinice na brojčaniku doze na brizgalici. Stoga je uvjet za samostalno injiciranje da bolesnik može pročitati prikazano na brojčaniku doze na brizgalici.. Primjena inzulina može uzrokovati pojavu inzulinskih protutijela. Prisutnost takvih inzulinskih protutijela može zahtijevati promjenu doze inzulina kako bi se izbjegla sklonost hiperglikemiji ili hipoglikemiji. Nuspojave: Vrlo često: hipoglikemija; često: reakcije na mjestu injiciranja; manje često: lipodistrofija, periferni edem, rijetko: preosjetljivost, urtikarija. Doziranje: Tresiba je bazalni inzulin za supkutanu primjenu jednom dnevno, u bilo koje doba dana, po mogućnosti u isto vrijeme svakoga dana. Jedna (1) jedinica (U) degludek inzulina odgovara 1 internacionalnoj jedinici (IU) humanog inzulina, 1 jedinici glargin inzulina ili 1 jedinici detemir inzulina. U bolesnika sa šećernom bolešću tipa 2, Tresiba se može primjenjivati u monoterapiji ili u bilo kojoj kombinaciji s oralnim antidijabeticima, agonistima GLP-1 receptora i s bolus inzulinom. Kod šećerne bolesti tipa 1, Tresiba se mora kombinirati kratkodjelujućim/ brzodjelujućim inzulinom radi pokrivanja potreba za inzulinom u vrijeme obroka. Tresiba se treba dozirati sukladno individualnim potrebama bolesnika. Kod primjene lijeka Tresiba 100 jedinica/ml, može se primijeniti doza od 1-80 jedinica po injekciji, u stupnjevima od 1 jedinice. U slučajevima kada primjena u isto doba dana nije moguća, Tresiba omogućuje fleksibilnost vremena primjene inzulina. Između dviju injekcija uvijek treba proteći najmanje 8 sati. Bolesnicima koji zaborave jednu dozu, preporučuje se da je primjene čim to primijete te da se nakon toga vrate uobičajenom rasporedu doziranja jednom dnevno. Bolesnici sa šećernom bolešću tipa 2: Preporučena početna dnevna doza je 10 jedinica uz naknadnu individualnu prilagodbu doze. Bolesnici sa šećernom bolešću tipa 1: Tresiba se primjenjuje jednom dnevno s inzulinom uz obrok uz naknadnu individualnu prilagodbu doze. Možda će biti potrebno prilagoditi doze i vrijeme primjene brzodjelujućih ili kratkodjelujućih inzulinskih pripravaka ili drugih antidijabetika koji se koriste istovremeno. Za bolesnike sa šećernom bolešću tipa 2 koji se liječe bazalnim inzulinom, kombinacijom bazalnog i bolus inzulina, predmiješanim inzulinom ili inzulinom kojeg bolesnik sam miješa, zamjena bazalnog inzulina lijekom Tresiba može se obaviti po načelu jedinica za jedinicu, uz naknadnu individualnu prilagodbu doze. Za većinu bolesnika sa šećernom bolešću tipa 1, zamjena bazalnog inzulina lijekom Tresiba može se obaviti po načelu jedinica za jedinicu, uz naknadnu individualnu prilagodbu doze. Za bolesnike sa šećernom bolešću tipa 1 koji prelaze s bazalnog inzulina koji se primjenjuje dva puta dnevno ili u onih koji imaju HbA 1c < 8,0% u vrijeme prijelaza, dozu lijeka Tresiba potrebno je utvrditi individualno. Potrebno je razmotriti smanjenje doze uz naknadnu individualnu prilagodbu doze na osnovi glikemijskog odgovora. Kad se Tresiba dodaje agonistima GLP-1 receptora, preporučena dnevna početna doza je 10 jedinica uz naknadnu individualnu prilagodbu doze. Kad se agonisti GLP- 1 receptora dodaju lijeku Tresiba, preporučuje se smanjiti dozu lijeka Tresiba za 20% kako bi se smanjio rizik od hipoglikemije, uz naknadnu individualnu prilagodbu doze. Tresiba se može primjenjivati u starijih bolesnika te bolesnika s oštećenjem bubrega i jetre. Treba pojačano pratiti razinu glukoze te individualno prilagoditi dozu inzulina. Tresiba se može koristiti u adolescenata i djece u dobi od 1 godine. Kad se bazalni inzulin mijenja u lijek Tresiba, potrebno je razmotriti individualno smanjenje doze bazalnog i bolus inzulina, kako bi se umanjio rizik od hipoglikemije. Način primjene: Tresiba je namijenjena samo za supkutanu primjenu. Tresiba se ne smije primjenjivati intravenski, intramuskularno niti u inzulinskim infuzijskim pumpama. Tresiba se primjenjuje supkutanom injekcijom u bedro, nadlakticu ili trbušnu stijenku. Tresiba dolazi u obliku napunjene brizgalice (FlexTouch ) namijenjene uporabi s iglama za injekciju NovoFine ili NovoTwist. Napunjena brizgalica od 100 jedinica/ml isporučuje 1-80 jedinica u stupnjevima od 1 jedinice. Nositelj odobrenja: Novo Nordisk A/S, Novo Allé, DK-2880 Bagsværd, Danska. Broj odobrenja: EU/1/12/807/004. Način izdavanja: na recept. Datum revizije sažetka: srpanj Prije propisivanja lijeka Tresiba obvezno proučite posljednji odobreni Sažetak opisa svojstava lijeka te posljednju odobrenu Uputu o lijeku. HQMMA/TB/0415/0126 SAMO ZA ZDRAVSTVENE RADNIKE U Novo Nordisku mijenjamo dijabetes. U pristupu razvoju lijekova, u predanosti da poslujemo s dobiti i etično te u potrazi za lijekom. degludek inzulin (tehnologija rdnk) injekcija

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7 MEDICAL SCIENTIFIC JOURNAL OF THE VUK VRHOVAC INSTITUTE UNIVERSITY CLINIC FOR DIABETES, ENDOCRINOLOGY AND METABOLIC DISEASES SCHOOL OF MEDICINE, UNIVERSITY OF ZAGREB CROATIAN MEDICAL ASSOCIATION, CROATIAN SOCIETY FOR ENDOCRINOLOGY AND DIABETOLOGY DIABETOLOGY ALUMNI MEDICAL ASSOCIATION VUK VRHOVAC UNIVERSITY CLINIC, ZAGREB Referred in: AGORA BIOLOGICAL ABSTRACTS (BIOSIS) BIOSIS PREVIEWS CABI Bibliographic Databases: CAB Abstracts Global Health Abstracts on Hygiene and Communicable Diseases Nutrition Abstracts and Reviews Series A: Human and Experimental Nutrition and Food Sciences Database Review of Aromatic and Medicinal Plants Tropical Diseases Bulletin VetMed Resource CIRRIE Database of International Rehabilitation Research DOAJ: Directory of Open Access Journals EBSCO Bibliographic Databases ELSEVIER SCIENCE B.V. (SEDBASE) EMBASE / Excerpta Medica GALE/CENGAGE Learning Databases: Academic OneFile Health databases: Health & Wellness Resource Center Health Reference Center Nursing Resource Center HINARI Geneva Foundation for Medical Education and Research Open Science Directory SCOPUS THOMSON REUTERS MASTER JOURNAL LIST T.I.M.B.O. Trama Interinstitucional Multidisciplinaria de Bibliografía Online ULRICH'S PERIODICALS DIRECTORY VINITI Abstracts Journal (REFERATIVNYI ZHURNAL) VOLUME 44, NUMBER 4, 1, 2015

8 EDITORIAL BOARD OF MEDICAL SCIENTIFIC JOURNAL DUGI DOL 4A, ZAGREB, CROATIA PHONE: (385 1) FAX: (385 1) E mail: Diabetologia.Croatica@idb.hr EDITOR IN CHIEF Lea Smirčić Duvnjak EDITORIAL BOARD Spomenka Ljubić Sandra Vučković Rebrina Jozo Boras Mladen Grgurević Krešimir Martinac Ante Piljac ADVISORY BOARD Dubravka Jurišić Eržen Darko Kaštelan Velimir Altabas Ivana Pavlić Renar The journal address on WWW is: including full text articles. All manuscripts are to be forwarded to the Editorial Board's address: DIABETOLOGIA CROATICA Dugi dol 4a, Zagreb, Croatia Phone: (385 1) Fax: (385 1) E mail: Diabetologia.Croatica@idb.hr Diabetologia Croatica is published quarterly Annual subscription: 45 USD payable, as well as other reimbursements, to: ZAGREBAČKA BANKA ZAGREB SWIFT/BIS: ZABAHE2X IBAN HR Note: For Diabetologia Croatica For Croatian subscribers: Annual subscription: HRK equivalent to 45 USD to be transferred to: Diabetologia Croatica VUK VRHOVAC Institute Dugi dol 4a, Zagreb IBAN HR Note: For Diabetologia Croatica Language editing: LinguaMed, Zagreb Layout and technical editing: UVEZ Mirna d.o.o., Vučković Pepeonik Zaprešić & Bojan Pepeonik Printing house: UVEZ d.o.o., D.O.O. Zaprešić GRAFIČKA INDUSTRIJA, Zaprešić Cover photo: Igor Leskovar Exempt from sales taxes according to decision No. 3716/ of the Ministry of Education and Sport of the Republic of Croatia

9 1 Croatian Institute of Public Health, Rockefellerova 7, HR Zagreb, Croatia 2 Andrija Štampar Teaching Institute of Public Health, Mirogojska 16, HR Zagreb, Croatia Original Research Article PREVALENCE OF DIABETES MELLITUS AND ASSOCIATED RISK FACTORS IN KINDERGARTEN AND SCHOOL PERSONNEL IN ZAGREB, CROATIA Tamara Poljičanin 1, Melita Jelavić 2, Vanja Tešić 2 Key words: diabetes, prevalence, kindergarten teachers, school teachers SUMMARY Diabetes mellitus is one of the major global public health problems. Despite the importance of education from the earliest age, data on the prevalence of diabetes and related risk factors in kindergarten and school personnel are limited. The aim of this study was to determine the prevalence of diabetes and its main risk factors in kindergarten and school personnel in Zagreb, Croatia. The study included 7,908 subjects from 95 kindergartens, 118 elementary schools and 58 high schools. Diabetes was present in 8.34% of men and 3.48% of women, but only half of patients were diagnosed (47% of women and 54% of men). Additionally, 12.64% of men and 6.77% of women were found to have impaired fasting glucose. Logistic regression revealed that older age, male sex, higher body mass index, physical inactivity, high school Address for correspondence: Tamara Poljičanin, MD, PhD Croatian Institute of Public Health, Zagreb Rockefellerova 7 HR Zagreb, Croatia tamara.poljicanin@hzjz.hr employment in contrast to kindergarten employment and positive family history of diabetes were significant predictors of diabetes status (p<0.001). Diabetes mellitus is commonly unrecognized in Zagreb, Croatia, even in the population that is supposed to support health promotion and diabetes prevention among children. In order to improve their quality of life and try to influence effectiveness of health education, wider inclusion of that population in screening programs might be reconsidered. INTRODUCTION Diabetes mellitus is one of the major public health problems affecting 415 million people worldwide (1). In Croatia, there are over 400,000 persons with diabetes, although the disease was diagnosed in only 254,296 citizens in 2014 (2). Late diagnosis, on average six years after its onset (3) and a low rate of persons reaching treatment goals (4) often lead to chronic complications (4), decrease in the quality of life (5) and premature death. Although many factors play a role in the development of type 2 diabetes, the most common type of the disease is predominantly caused by sedentary lifestyle in genetically susceptible individuals, the main risk factors besides family history of diabetes thus being Diabetologia Croatica 44-4,

10 Tamara Poljičanin, Melita Jelavić, Vanja Tešić / PREVALENCE OF DIABETES MELLITUS AND ASSOCIATED RISK FACTORS IN KINDERGARTEN AND SCHOOL PERSONNEL IN ZAGREB, CROATIA physical inactivity, overweight and obesity (1). Eating and physical activity habits are learned both at home and at kindergartens and schools, where children spend a substantial amount of time. Combined diet and physical activity school-based interventions may help prevent child overweight in the long term (6) and, although school-based interventions have not been associated with physical activity rates and body mass index (BMI), specific positive effects on duration of physical activity and television watching can be observed (7). Nevertheless, kindergartens and schools are seen as a good environment for the development of healthier lifestyles and many interventions have lately been focused on greater involvement of educational personnel. Enrolment in diabetes education is not rare either; education on healthy lifestyle habits could raise awareness of secondary educators, resulting in changes in their own unhealthy habits and earlier recognition of disease. In contrast, low educators awareness could negatively influence child behaviors. Although in view of their role kindergarten and school personnel represent a very important subpopulation from the aspect of diabetes prevention and early recognition, there is little evidence on the prevalence of diabetes or its main risk factors in this group (8). The aim of this study was to determine the prevalence of diabetes and main risk factors for diabetes development in kindergarten and school personnel in Zagreb, Croatia. MATERIALS AND METHODS This study was part of the Diabetes Mellitus Screening Project conducted from 2010 to 2014 in Zagreb kindergartens, elementary and high schools, universities, police and fire stations and community screening actions (9). A total of 11,979 citizens participated in the project, and 7,908 kindergarten and school personnel were included in this study. Age, sex, weight, height, waist and hip circumference, BMI and waist-to-hip ratio were determined in each subject. Habits regarding physical activity (number of days with at least 30 minutes of physical activity), personal and family history of diabetes were also defined, and fasting plasma glucose (FPG), systolic and diastolic blood pressure measured. Glycemia was measured using blood glucose self-monitoring devices while blood pressure was measured by means of mercury manometer after 5 minutes of resting. All statistical analyses were performed using STATISTICA (version 12). Normality of distribution was tested using Shapiro-Wilks test, and homogeneity of variance was tested using Levene test. Differences between the groups of independent continuous variables were analyzed using Mann-Whitney U test while differences in the prevalence of individual conditions were compared using the χ2-test. Logistic regression analysis was performed for prediction of the probability of diabetes occurrence. The predictors included in the regression analyses were age, gender, BMI, type of organization and family history of diabetes. Statistical significance was defined as p<0.05. RESULTS The study included 7,908 subjects from 95 kindergartens, 118 elementary schools and 58 high schools with the mean response rate in the organizations of 71.63%. Respondents were mostly women (n=7114; 89.99%), median age 47 (18-68) years, weight 69 (36-162) kg, height 167 ( ) cm, BMI kg/m2, waist 76 (51-138) cm, hip circumference 101 (65-176) cm and waist-to-hip ratio 0.75 ( ). Physically active were 78.33% of subjects, median 4 (0-7) days of physical activity per week. Of all the respondents, 1.95% already had diabetes, 40.36% had positive family history of diabetes, and 7.36% had FPG level mmol/l while 3.97% had diabetes according to FPG (>7 mmol/l) or previously diagnosed diabetes. Women were significantly younger, with lower BMI and waist/hip ratio (p<0.001 all). Although family history of diabetes was significantly more frequent in women (p=0.009), personal history of diabetes was more often found in men (p<0.001), as was diabetes and impaired fasting glucose (IFG) (p<0.001). There were no sex differences in physical activity (p=0.673). Differences between men and women are presented in Table 1. 98

11 Tamara Poljičanin, Melita Jelavić, Vanja Tešić / PREVALENCE OF DIABETES MELLITUS AND ASSOCIATED RISK FACTORS IN KINDERGARTEN AND SCHOOL PERSONNEL IN ZAGREB, CROATIA Table 1. Differences between men and women Women Men p Age (yrs) ( ) ( ) <0.001 Body mass index ( ) ( ) <0.001 Waist/hip ratio 0.74 ( ) 0.90 ( ) <0.001 Physical activity Yes (%) No (%) Family history of diabetes Yes (%) No (%) History of diabetes <0.001 Yes (%) No (%) Diabetes status <0.001 FPG <6.1 mmol/l (%) mmol/l FPG <7 mmol/l (%) FPG >7 mmol/l (%) or history of diabetes Data are presented as median (minimum, maximum) unless stated otherwise; FPG = fasting plasma glucose In order to explore the influence of investigated risk factors on the occurrence of diabetes, logistic regression analysis was performed. The predictors included in the analyses were age, gender, BMI, type of organization and family history of diabetes. Multivariate logistic regression model (p<0.001, R2 adjusted = 23%) suggested that older age, male sex, higher BMI, physical inactivity, high school employment in contrast to kindergarten employment and positive family history of diabetes were significant predictors of diabetes status. Results of the multivariate logistic regression are presented in Table 2. Table 2. Multivariate logistic regression model for predicting risk of prevalent diabetes Socio-demographic descriptor/group Odds ratio 95% CI p Age <0.001 Body mass index <0.001 Gender Female 1 Male Physical activity Yes 1 No Family history of diabetes No 1 Yes <0.001 Working organization Kindergarten 1 Elementary school High school Diabetologia Croatica 44-4,

12 Tamara Poljičanin, Melita Jelavić, Vanja Tešić / PREVALENCE OF DIABETES MELLITUS AND ASSOCIATED RISK FACTORS IN KINDERGARTEN AND SCHOOL PERSONNEL IN ZAGREB, CROATIA DISCUSSION Out of the total number of participants in this study, 8.34% of men and 3.48% of women were found to have diabetes, and 4.55% of men and 1.66% of women had previously been diagnosed with the disease. Therefore, only around half of the patients were diagnosed (47% of women and 54% of men), whereas the remaining half were unaware of their disease. The results were even worse than expected according to previous estimates of 42% of undiagnosed patients in Croatia (10) or recent International Diabetes Federation estimation that approximately 38% of patients in Croatia are undiagnosed (1). Additionally, 12.64% of men and 6.77% of women had FPG within the IFG range. Although diabetes status was defined as previously diagnosed diabetes or only one FPG level above 7 mmol/l, the observed proportion of participants with impaired glucose metabolism and the ratio of undiagnosed study participants call for attention. The analysis of risk factors, physical inactivity, overweight and obesity revealed better results than those observed in the Croatian Adult Health Survey (CASH), where their prevalence rates were higher (11). Since the population in this study was younger, a lower prevalence of risk factors was expected. On the other hand, physical activity was much more pronounced, which could be ascribed to the much lower criteria for activity in this study, as even one day per week with at least 30 minutes of activity was classified as activity (11). Results of logistic regression revealed that older age, male sex, higher BMI, physical inactivity, positive family history of diabetes and high school employment in contrast to kindergarten employment were significant predictors of diabetes status. Older age, obesity and physical inactivity, as well as family history of diabetes are well-known risk factors for the development of type 2 diabetes (12-16). Although a higher prevalence in men has already been observed (10), there is no evidence that could explain the higher rate of diabetes in high school teachers. Factors in the high school environment such as higher levels of stress during the workday or some other circumstances might be responsible for this observation, but further investigation is needed to explore the reasons for this finding. Rare studies in the population of teachers conducted so far have revealed a higher risk of lifetime anxiety disorders in male teachers (17) and lower levels of perceived health in secondary school teachers (18), revealing, however, no differences in lifetime prevalence of any psychiatric disorder or mean scores of psychological distress (17). The study suffered from some limitations, as diabetes status was revealed relying on only one FPG measurement using glucose self-monitoring devices. A degree of uncertainty regarding the validity of diabetes status should therefore be taken into account when interpreting the results. This study confirmed that diabetes mellitus is commonly unrecognized in Zagreb, Croatia, even in the population supposed to actively participate in health promotion and prevention among children. In order to improve the quality of life of educational personnel but also trying to improve the effectiveness of health education in kindergarten and schools, expansion of the screening project to include this specific population might be considered. As diabetes is more frequent in older age, persons with increased body weight, men and physically inactive persons, people with diabetes in their families and those who work in high schools, these groups should clearly be regularly included in screening activities. ACKNOWLEDGMENTS This research was supported by the City of Zagreb, City Office for Health. We are thankful to our colleagues from Zagreb Red Cross, especially Lovorka Kodrin, MD, Zora Matić Žigmunić, MD and Ljerka Mišura, MD, for performing the fieldwork. We thank Lovorka Perković for copyediting the manuscript. 100

13 Tamara Poljičanin, Melita Jelavić, Vanja Tešić / PREVALENCE OF DIABETES MELLITUS AND ASSOCIATED RISK FACTORS IN KINDERGARTEN AND SCHOOL PERSONNEL IN ZAGREB, CROATIA REFERENCES 1. International Diabetes Federation. IDF Diabetes Atlas, 7th edn. Brussels, Belgium: International Diabetes Federation [electronic resource], [accessed 2015 Dec 1] Available from: 2. CroDiab Report [electronic resource], [accessed 2015 Dec 1] Available from: 3. Porta M, Curletto G, Cipullo D, et al. Estimating the delay between onset and diagnosis of type 2 diabetes from the time course of retinopathy prevalence. Diabetes Care Jun;37(6): Poljičanin T. Uloga praćenja dijabetičkih bolesnika pomoću registra CroDiab u prevenciji komplikacija. Doctoral dissertation. Zagreb: School of Medicine, University of Zagreb; (in Croatian) 5. Poljicanin T, Ajdukovic D, Sekerija M, Pibernik- Okanovic M, Metelko Z, Vuletic Mavrinac G. Diabetes mellitus and hypertension have comparable adverse effects on health-related quality of life. BMC Public Health. 2010;10: Brown T1, Summerbell C. Systematic review of school-based interventions that focus on changing dietary intake and physical activity levels to prevent childhood obesity: an update to the obesity guidance produced by the National Institute for Health and Clinical Excellence. Obes Rev Jan;10(1): Dobbins M, Husson H, DeCorby K, LaRocca RL. School-based physical activity programs for promoting physical activity and fitness in children and adolescents aged 6 to 18. Cochrane Database Syst Rev Feb 28;2:CD Lone D, Thakre S, Thakre S, Borkar A, Deshmukh N. Prevalence of diabetes mellitus among school teachers in urban area of Nagpur City, Central India. Indian J Appl Res. 2014;4(9): Poljičanin T, Kodrin L, Martić Žigmunić Z, Mišura LJ, Jelavić M, Tešić V. Otkrivanje šećerne bolesti u Gradu Zagrebu. Hrvatski časopis za javno zdravstvo [electronic resource], ;11(44): [accessed 2015 Dec 1] Available from: article/view/1563 (in Croatian) 10. Metelko Z, Pavlic-Renar I, Poljicanin T, Szirovitza L, Turek S. Prevalence of diabetes mellitus in Croatia. Diabetes Res Clin Pract. 2008;81(2): Poljičanin T, Džakula A, Musić Milanović S, Šekerija M, Ivanković D, Vuletić S. The changing pattern of cardiovascular risk factors: the CroHort Study. Coll Antropol. 2012;36(Suppl 1): Horton ES. Role of environmental factors in the development of noninsulin-dependent diabetes mellitus. Am J Med. 1983;75(5B): Bays HE, Chapman RH, Grandy S; SHIELD Investigators Group. The relationship of body mass index to diabetes mellitus, hypertension and dyslipidaemia: comparison of data from two national surveys. Int J Clin Pract. 2007;61(5): International Diabetes Federation. About diabetes. Risk factors. Available from: about-diabetes/risk-factors 15. Mikus CR, Oberlin DJ, Libla JL, Taylor AM, Booth FW, Thyfault JP. Lowering physical activity impairs glycemic control in healthy volunteers. Med Sci Sports Exerc. 2012;44(2): Diabetologia Croatica 44-4,

14 Tamara Poljičanin, Melita Jelavić, Vanja Tešić / PREVALENCE OF DIABETES MELLITUS AND ASSOCIATED RISK FACTORS IN KINDERGARTEN AND SCHOOL PERSONNEL IN ZAGREB, CROATIA 16. Svensson E, Berencsi K, Sander S, et al. Association of parental history of type 2 diabetes with age, lifestyle, anthropometric factors, and clinical severity at type 2 diabetes diagnosis: results from the DD2 study. Diabetes Metab Res Rev Mar; 32(3): Bogaert I, De Martelaer K, Deforche B, Clarys P, Zinzen E. Associations between different types of physical activity and teachers perceived mental, physical, and work-related health. BMC Public Health May 30;14:534. doi: / Kovess-Masféty V, Sevilla-Dedieu C, Rios-Seidel C, Nerrière E, Chan Chee C. Do teachers have more health problems? Results from a French cross-sectional survey. BMC Public Health Apr 21;6:

15 1 Department of Physiology, 2 Department of Medicine, College of Medicine, University of Ibadan, Ibadan, Nigeria Original Research Article EFFECT OF CHRONIC SLEEP DEPRIVATION ON OXIDATIVE STRESS STATUS IN ALLOXAN INDUCED DIABETIC RATS Jolaoluwa Oluwatosin Yesufu 1, Adesoji Adedipe Fasanmade 1,2 Key words: chronic sleep deprivation, diabetes mellitus, oxidative stress, glutathione, malondialdehyde, superoxide dismutase, catalase, alloxan induced diabetes SUMMARY Oxidative stress in diabetes is significant but underexplored in sleep deprived diabetics. This study evaluated oxidative stress markers, i.e. protein, glutathione, malondialdehyde, and superoxide dismutase and catalase activity in diabetic models of sleep deprived rats. Male Wistar rats were divided into groups of normal controls, diabetic controls, sleep deprived rats without diabetes induction (SD), and sleep deprived diabetes induced rats (DM+SD). Diabetes was induced with intraperitoneal injection of alloxan 100 mg/kg, which was confirmed by hyperglycemia after 48 hours. Sleep deprivation was achieved by Correspondence to: Jolaoluwa Oluwatosin Yesufu, MB.Ch, B, MPH, MSc. P.O. Box 19979, University of Ibadan Post-Office, Ibadan, Nigeria johlah18@yahoo.com. Adesoji Adedipe Fasanmade, MD, FWACP, adesojif@yahoo.com. adaptation of the multiple platform technique and markers were determined from retro-orbital blood samples at the end of each week. There was significant (p 0.05) reduction in the levels of protein, glutathione and superoxide dismutase activity, and a significant (p 0.05) increase in malondialdehyde levels in the DM+SD group. Results of the study indicated that sleep deprivation in diabetes could be lethal in terms of oxidative stress. Therefore, sleep deprivation should be avoided in subjects with diabetes. INTRODUCTION Normal and adequate sleep is restorative, and its lack triggers deleterious physiological effects. Sleep depth and diabetes exist in a vicious cycle. Diabetes and chronic loss of sleep share the fact that both affect a large population of the world and one is detrimental to the other. The current Nigerian national prevalence of diabetes is estimated to 4.9% (1), and the global prevalence is 8.3% (2). An increased risk of diabetes has been found in people who sleep less than seven hours (3), and poor glycemic control has been found in diabetic patients experiencing poor sleep quality and insufficient sleep (4). Metabolic stress resulting from changes in the status Diabetologia Croatica 44-4,

16 Jolaoluwa Oluwatosin Yesufu, Adesoji Adedipe Fasanmade / EFFECT OF CHRONIC SLEEP DEPRIVATION ON OXIDATIVE STRESS STATUS IN ALLOXAN INDUCED DIABETIC RATS of antioxidant defense systems could lead to oxidative stress in diabetes (5). Elevated glucose levels stimulate free radical production resulting in weakening of the body s defense system, which cannot neutralize the reactive oxygen species (ROS) produced. Oxidative stress occurs when there is an imbalance between ROS and their protection (6, 7). Protein oxidation occurs in diabetics resulting in altered protein structure and function and consequential decrease in protein levels, affecting many physiological functions (8). Glutathione (GSH), a tripeptide, L-y-glutamyl- L-cysteinyl glycine, is present in all mammalian tissues at a concentration of 1-10 mm, with the highest concentration in the liver. It is the most abundant non-protein thiol that defends against oxidative stress (9). GSH can maintain sulfhydryl groups of proteins in a reduced state, participate in amino acid transport, detoxify foreign radicals, act as coenzyme in several enzymatic reactions, and also prevent tissue damage (10). It is an efficient antioxidant present in almost all living cells and is also considered as a biomarker of redox imbalance at the cellular level (11), therefore its reduction occurs in oxidative stress induced by diabetes. Peroxidation of membranes increases membrane fluidity and permeability with loss of membrane integrity (6). Malondialdehyde (MDA) is a primary biomarker of free radical mediated lipid damage and oxidative stress (12). Increased MDA levels have been reported in diabetics (13). Catalase and superoxide dismutase (SOD) are antioxidant enzymes that offer protection to cells and tissues against oxidative injury (14). This study was conducted to determine oxidative stress in terms of protein and glutathione levels, the extent of lipid peroxidation, and the activity of superoxide dismutase and catalase in diabetic models of sleep deprived rats. MATERIALS AND METHODS Twenty male Wistar rats weighing between 150 g and 280 g were kept in ventilated cages to acclimatize for two weeks, allowed free access to rat chow and water ad libitum according to guidelines and ethical standards (15), and were randomly distributed into four groups of five rats each as follows: group 1 (normal controls): non-sleep deprived rats without diabetes induction, group 2 (diabetic controls): non-sleep deprived diabetic rats, group 3: normal sleep deprived rats, and group 4: sleep deprived diabetic rats. Procedure of diabetes induction Alloxan monohydrate (Sigma Aldrich, St Quentin- Fallavier, France) 100 mg/kg body weight was dissolved in normal saline and injected intraperitoneally after 18- hour fasting to induce hyperglycemia in the experimental rats (16, 17). Effective induction of diabetes was confirmed by hyperglycemia after 48 hours (18) with blood samples obtained from the tail vein. Rats with fasting plasma glucose levels 200 mg/dl (19), as well as those with levels greater than or equal to twice their normal fasting plasma glucose levels were included in the study (20). Procedure of sleep deprivation Adaptation of the multiple platform technique (21) was employed for sleep deprivation for 18 hours daily for two weeks (22). Food and water were offered ad libitum. Control animals were maintained in the same environment but not subjected to sleep deprivation. The rats were weighed daily with the use of the Mettler-Toledo laboratory weighing balance (Mettler- Toledo International Inc.) to the nearest gram. Glucose estimation This was done weekly with the use of the Accu- Check active glucometer (Roche) from the tail vein, i.e. tail tipping method (23), and results were reported as mg/dl (24). Retro-orbital blood samples were obtained from the rats after an overnight fast on day 7 and day 14 of sleep deprivation. 104

17 Jolaoluwa Oluwatosin Yesufu, Adesoji Adedipe Fasanmade / EFFECT OF CHRONIC SLEEP DEPRIVATION ON OXIDATIVE STRESS STATUS IN ALLOXAN INDUCED DIABETIC RATS Biochemical assays Assays of protein, reduced glutathione (GSH), malondialdehyde, superoxide dismutase and catalase were carried out on the blood samples of all four groups of Wistar rats by the methods of Gornal et al. (25), Beutler et al. (26), Rice-Evans et al. (27), Misra and Fridovich (28), and Claiborne (29), respectively. Statistical analysis Statistical analysis of the results of the experiment was achieved with the aid of the Microsoft Excel (2010) and Statistical Package for Social Science software (SPSS) version 15. Data were expressed as mean ± SEM. Values were compared using Student s t-test and analysis of variance (ANOVA), and differences in the values were considered statistically significant at p<0.05. RESULTS Figure 1a shows the increasing weight pattern of the normal and healthy controls that were not subjected to diabetes nor deprived of sleep throughout the 14 days of the experiment, with a minimal decline in weight on days 8 and 9. Figure 1b shows the weight pattern of the Wistar rats in different experimental groups on days 0, 7 and 14. On day 0, the mean weight of rats allocated into all experimental groups was as shown. The weights of diabetic controls, sleep deprived only and diabetic and sleep deprived (DM+SD) rats showed a steady decline, although this was not statistically significant. Figure 2a shows the blood glucose levels of the rats 48 hours after induction with alloxan. Figure 2b shows the baseline fasting blood glucose levels and differences in blood glucose levels on days 7 and 14 of sleep deprivation for different groups. The blood glucose levels of both diabetic and DM+SD rats decreased from previous hyperglycemic levels, even though there was no administration of any other substance(s). Figure 3 shows that compared to normal healthy controls, there was a significant (p 0.05) reduction in protein levels in diabetic control group (DM) and DM+SD group, where this reduction was more pronounced. Figure 4 shows reduced GSH (mg/ml) levels in different groups of rats on day 7 and day 14 of sleep deprivation. Compared to normal healthy controls, a significant (p 0.05) decrease was recorded in all three groups only on day 14, but there was no significant decrease on day 7. However, there was a more marked reduction in the DM+SD group. Figure 5 shows the level of lipid peroxidation in terms of MDA) produced (U/mg protein). Compared to normal healthy controls, there was a significant (p 0.05) increase in MDA levels in all experimental groups, with a more marked increase in the DM+SD group on day 14. Figure 6 shows SOD activity (U/mg protein) in different groups of rats. Compared to normal healthy controls and diabetic controls, there was a significant reduction in SOD activity in the DM+SD group on days 7 and 14. Figure 7 shows catalase activity (U/mg protein) in the four groups of rats. Compared to normal healthy controls, this experiment showed the increase in CAT activity to be more marked in the sleep deprived group on day 14 and in DM+SD group on both days 7 and 14. However, it was not statistically significant. Diabetologia Croatica 44-4,

18 Jolaoluwa Oluwatosin Yesufu, Adesoji Adedipe Fasanmade / EFFECT OF CHRONIC SLEEP DEPRIVATION ON OXIDATIVE STRESS STATUS IN ALLOXAN INDUCED DIABETIC RATS Rat body weight (g) Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7 Day 8 Day 9 Day 10 Day 11 Day 12 Day 13 Day 14 Days of sleep depriva7on Figure 1a. Mean body weights of normal male Wistar rats (healthy controls) Body Weight (g) Day 0 Day 7 Day Normal Control Diabe5c Control Sleep Deprived Diabe5c Sleep Deprived Experimental Groups Figure 1b. Mean body weights of rats in all groups. Data are expressed as mean± SEM (n=5) 106

19 Jolaoluwa Oluwatosin Yesufu, Adesoji Adedipe Fasanmade / EFFECT OF CHRONIC SLEEP DEPRIVATION ON OXIDATIVE STRESS STATUS IN ALLOXAN INDUCED DIABETIC RATS 450 Post Induction Blood Glucose (mg/dl) * Blood Glucose (mg/dl) Diabe-c Control Experimental Groups Diabe-c Sleep Deprived Figure 2a. Mean blood glucose levels after diabetes induction. Data are expressed as mean± SEM (n=5) 120 * * 100 * 80 * Blood Gucose (mg/dl) Baseline Fas5ng DAY 7 DAY Normal Control Diabe5c Control Sleep Deprived DM + SD Experimental Groups Figure 2b. Mean blood glucose levels in all groups of rats before (baseline fasting), during (day 7) and at the end of the experiment (day 14). Data are expressed as mean± SEM (n=5); *significantly different from control (p 0.05); DM = diabetic; SD = sleep deprived Diabetologia Croatica 44-4,

20 Jolaoluwa Oluwatosin Yesufu, Adesoji Adedipe Fasanmade / EFFECT OF CHRONIC SLEEP DEPRIVATION ON OXIDATIVE STRESS STATUS IN ALLOXAN INDUCED DIABETIC RATS Figure 3. Mean protein levels in rat groups. Data are expressed as mean± SEM (n=5); *significantly different from control (p 0.05); DM = diabetic; SD = sleep deprived * * * GSH (mg/ml) GSH DAY 7 GSH DAY Normal Control Diabe9c Control Sleep Deprived Animal groups DM + SD Figure 4. Mean glutathione levels in rat groups. Data are expressed as mean± SEM (n=5); *significantly different from control (p 0.05); DM = diabetic; SD = sleep deprived 108

21 Jolaoluwa Oluwatosin Yesufu, Adesoji Adedipe Fasanmade / EFFECT OF CHRONIC SLEEP DEPRIVATION ON OXIDATIVE STRESS STATUS IN ALLOXAN INDUCED DIABETIC RATS 0,04 MDA DAY7 MDA DAY14 0,035 * 0,03 * MDA (U/mg protein) 0,025 0,02 0,015 * * 0,01 0,005 0 Normal Control Diabe6c Control Sleep Deprived DM + SD Animal groups Figure 5: Malondialdehyde levels showing extent of lipid peroxidation in all rat groups. Data are expressed as mean± SEM (n=5) * Significantly different from control (p 0.05) DM= Diabetic. SD= Sleep deprived. 0,5 0,45 0,4 0,35 * SOD (U/mg protein) 0,3 0,25 0,2 ** SOD DAY 7 SOD DAY 14 0,15 0,1 0,05 0 Normal Control Diabe/c Control Sleep Deprived Animal groups * ** DM + SD Figure 6. Superoxide dismutase activity in rat groups. Data are expressed as mean± SEM (n=5); *significantly different from control (p 0.05); **significantly different from diabetic control (p 0.05); DM = diabetic; SD = sleep deprived Diabetologia Croatica 44-4,

22 Jolaoluwa Oluwatosin Yesufu, Adesoji Adedipe Fasanmade / EFFECT OF CHRONIC SLEEP DEPRIVATION ON OXIDATIVE STRESS STATUS IN ALLOXAN INDUCED DIABETIC RATS 1,4 1,2 CAT (U/mg protein) 1 0,8 0,6 0,4 CAT DAY 7 CAT DAY 14 0,2 0 Normal Control Diabe/c Control Sleep Deprived Animal groups DM + SD Figure 7: Catalase activity in rat groups. Data are expressed as mean± SEM (n=5) DM= Diabetic alone. SD= Sleep deprived alone. DISCUSSION The main objective of this study was to determine or evaluate the effect of chronic sleep deprivation on the oxidative stress status (in terms of the levels of protein and reduced glutathione, extent of lipid peroxidation, and activities of superoxide dismutase and catalase), in the rat model of diabetes induced by alloxan, i.e. to determine any derangement or multiplying effect on the oxidative stress status. The percentage mortality was 25% in the diabetic control group and 20% in the diabetic and sleep deprived group (DM+SD). The affected rats were noted to have died during sleep deprivation in the sleep chambers and also during the 6-hour sleep recovery period within the first 4 days of chronic sleep deprivation. In this experiment, strong proposition is that alloxan induced diabetes was a contributory factor to rat mortality. Another study has also reported mortality in rats with alloxan induced diabetes to which no treatment was given (30). However, four major aberrations were identified as the causes of death in sleep deprived rats, namely: 1) a deep negative energy balance and associated malnutrition; 2) heterogeneous reductions in cerebral function; 3) low thyroid hormone concentrations; and 4) decreased resistance to infection (31). The rats that were sleep deprived lost weight, and weight loss has also been reported as being progressive in laboratory rats subjected to sleep deprivation (32). However, there was a gradual increase in the weights of normal control rats in this experiment, as they suffered no acute stress in terms of sleep deprivation or diabetes. It has been shown that the onset of diabetes in rats is diagnosed as blood glucose being higher than the expanded normal upper level and that the criteria for rats are close to that for humans (20). In humans, diabetes is diagnosed at a fasting plasma glucose level of 7 mmol/l or 126 mg/dl (33). The reduction from previously hyperglycemic blood glucose levels and 110

23 Jolaoluwa Oluwatosin Yesufu, Adesoji Adedipe Fasanmade / EFFECT OF CHRONIC SLEEP DEPRIVATION ON OXIDATIVE STRESS STATUS IN ALLOXAN INDUCED DIABETIC RATS variations noted had no reverse impact on the oxidative stress parameters that were measured. Furthermore, in in vivo and in vitro studies, glycemic variability has been shown to be associated with greater ROS production and vascular damage as compared with chronic hyperglycemia (34). Oxidative and glycooxidative protein damage It has been reported in subjects with pre-diabetes and type 2 diabetes mellitus (35). This study showed a marked decrease in protein levels at the end of 7 and 14 days of chronic sleep deprivation in alloxan induced diabetic rats. This decrease exceeded that found in diabetic group which had not been deprived of sleep. Therefore, this is the first known study demonstrating that a combination of sleep deprivation and diabetes and/or glycemic variability causes more protein damage than diabetes alone. Reduction in glutathione levels It indicates oxidative stress, i.e. the lower the levels of GSH, the more pronounced the oxidative stress is. Reduced GSH plays several roles as a cellular antioxidant defense because its main function is to remove hydrogen peroxide and organic peroxides (36). Hence, it is a major detoxifier. On day 7, GSH levels were lower than those recorded on day14, although a decrease as compared to normal controls was recorded on day 14. The increase in GSH levels on day 14 demonstrates again that the host enzymatic and nonenzymatic antioxidant defense system is not in total decline, and still possesses the capacity of regulation, although it was not sustained. On day 14, there was a significant decrease in blood GSH levels of diabetic and sleep deprived group (DM+SD) as compared with normal control group, showing aggravated oxidative stress. Even though decreased levels of GSH have been reported in diabetes mellitus (37), the current study is the first known in rats demonstrating that blood GSH levels are markedly reduced in the combined disease state of chronic sleep deprivation and diabetes mellitus and/or glycemic variability and may also transiently increase without any intervention or treatment. Hence, oxidative stress is aggravated in the combined disease entity of sleep deprivation and diabetes mellitus in rats. Lipid peroxidation It is a cascade of events resulting from the action of ROS on polyunsaturated fatty acids (PUFA) present in cell membranes (38), which occurs in oxidative stress. Oxidized lipids produce MDA as a decomposition product with the possible mechanism being the formation of prostaglandins and endoperoxides from PUFA (39). Studies have reported increased levels of MDA in plasma, serum, and many others tissues in diabetic patients (40, 41).The results from this study are the first known to show that there is a significant increase in blood MDA levels in the combined disease state of sleep deprivation and diabetes mellitus and/or glycemic variability in rats. Superoxide dismutase It facilitates conversion of superoxide radicals into hydrogen peroxide, and in the presence of other enzymes it is converted into oxygen and water (42). Elevated levels of SOD have been shown to reduce oxidative stress; decrease mitochondrial release of cytochrome C and apoptosis in neurons; and in mice, prevent diabetes-induced glomerular injury, thus suggesting a major role of SOD in the regulation of apoptosis (43). A decline in the level of SOD in diabetic tissue and blood has been reported in many studies (44), and there are also reports on its increased activity (45). SOD activity was significantly decreased in diabetic group and DM+SD group on day 7 of sleep deprivation. There was also a significant decrease in DM+SD group on day 14 as compared with diabetic control group. This reduction in SOD activity was more marked in the DM+SD group, thus confirming more marked oxidative stress in this group. Similarly, a study on diabetic patients showed that the activities of both cytoplasmic and mitochondrial SOD were decreased in diabetic polymorphonuclear leukocytes as compared with those from normal subjects, the effect being more pronounced in the cytoplasmic fraction (46). To corroborate this result, studies have shown Diabetologia Croatica 44-4,

24 Jolaoluwa Oluwatosin Yesufu, Adesoji Adedipe Fasanmade / EFFECT OF CHRONIC SLEEP DEPRIVATION ON OXIDATIVE STRESS STATUS IN ALLOXAN INDUCED DIABETIC RATS that in diabetes, oxidative stress causes mitochondrial superoxide overproduction, i.e. a decrease in SOD activity in endothelial cells of both large and small vessels, as well as in the myocardium (47). Furthermore, studies have reported that sleep deprivation decreases SOD activity in rat hippocampus and brainstem (48). Inconsistent reports exist about the activity of various antioxidant enzymes. Cytosolic Cu 2+ /Zn 2+ SOD (SOD1) and mitochondrial Mn 2+ SOD (SOD2) are lower in human diabetic neutrophils. Renal SOD1 is increased in diabetic rat kidneys, while SOD2 shows no change. Genetic enhancement of SOD1 activity has been shown to be a reno-protective therapy in diabetes (45). Catalase activity In this experiment, catalase activity was found to be increased across all the experimental groups compared to the normal control group. The sleep deprived and diabetic group had increased catalase activity both on days 7 and 14 as compared with normal controls. This increased catalase activity may compensate for other antioxidant deficiencies of diabetic and sleep deprived rats reported in this study. Similarly, it has been reported that the increases in serum catalase activity in HIV-infected individuals may reflect and/ or compensate for systemic glutathione and other antioxidant deficiencies present in the disease (49). In contrast, a study that examined the influence of dietary intervention on oxidative stress parameters in patients with metabolic syndrome found that it was only catalase that showed no improvement in terms of increased activity, which was expected after the intervention (50). Catalase is usually located in a cellular organelle called peroxisome (51). It is a very important enzyme in reproduction. Catalase catalyzes oxidation, by hydrogen peroxide, of various metabolites and toxins, including formaldehyde, formic acid, phenols, acetaldehyde and alcohols. Hydrogen peroxide is a harmful by-product of many normal metabolic processes; to prevent damage to cells and tissues, it must be quickly converted into other, less dangerous substances (52). Hence, the importance of catalase cannot be overemphasized. This study is, however, the first known study to show that catalase activity is increased in a combination of the sleep deprived and diabetic state. This increase may, however, be a compensation for other antioxidant deficiencies, which proves that the decline in defense mechanisms of enzymatic and non-enzymatic antioxidants is not a completely total one, as has been widely believed. CONCLUSION Sleep is a significant factor in physiological restoration, but it has been relegated by humans due to a complexity of factors for competitive survival and relevance in the present century. Sleep deprivation has been defined as a failure to get enough sleep, and an average of seven to eight hours of normal sleep is considered adequate (53). It was shown in this study that in diabetic state, sleep deprivation could be more hazardous than predictable, in terms of oxidative stress. This study, which examined the effect of chronic sleep deprivation on oxidative stress status in the rat model of diabetes, has shown that several factors may affect survival and health of sleep deprived diabetics, such as mortality, marked weight loss, glycemic variability, and altered antioxidant and enzyme levels specific to the length of the sleep deprivation period. Therapeutic modification of oxidative stress has been proposed as a type of management for the complications of diabetes mellitus such as diabetic neuropathy, but effective therapy is yet to be discovered and established for the management of sleep deprived diabetics. Diabetics may experience poor sleep quality and insufficient sleep. Moreover, the importance of normal sleep in mammalian species and especially in patients with diabetes mellitus cannot be overemphasized. Acknowledgment. The support and help of the Department of Physiology and Department of Biochemistry, College of Medicine, University of Ibadan, were invaluable in the execution of this study. 112

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29 1 School of Medicine, University of Zagreb, Zagreb, Croatia 2 Vuk Vrhovac Clinic for Diabetes, Endocrinology and Metabolic Diseases, Merkur University Hospital, Zagreb, Croatia Review EFFECT OF COMBINATION THERAPY IN THE TREATMENT OF PATIENTS WITH TYPE 2 DIABETES MELLITUS Ivana Antal 1, Spomenka Ljubić 1,2, Lea Smirčić Duvnjak 1,2 Key words: type 2 diabetes mellitus, combination therapy, treatment of diabetes mellitus, insulin resistance, microvascular complication SUMMARY Diabetes mellitus is the most common chronic metabolic disorder. There are four basic forms of diabetes: type 1 diabetes mellitus, type 2 diabetes mellitus (DMT2), gestational diabetes, and other specific types of diabetes. The most common form is DMT2, and 90% of patients suffering from diabetes have this type. The core pathophysiological mechanisms disrupted in DMT2 are increased insulin resistance, increased endogenous hepatic gluconeogenesis, and impaired secretion of insulin from the pancreas. Skeletal muscle and liver are most affected by insulin resistance. There is increased endogenous gluconeogenesis in the liver and decreased glucose Corresponding author: Ivana Antal, MD School of Medicine, University of Zagreb Šalata 3 HR Zagreb Croatia ivana.antal91@gmail.com utilization in muscle. Advancing age, a variant of the gene for the transcription factor TCF7L2, lipotoxicity, glucotoxicity, and amyloid deposition result in damage to pancreatic β-cells. Treatment of hyperglycemia is important because hyperglycemia increases the risk of developing complications, especially microvascular complications. Combination therapy is a logical therapeutic approach because it acts on the underlying pathophysiological mechanisms. The optimal value of glycated hemoglobin (HbA1c) is less than 6.5%. There is an increasing emphasis on the individualized approach to DMT2 treatment. INTRODUCTION Diabetes mellitus (DM) is one of the most common chronic disorders of today s mankind. It occurs due to impaired secretion and/or impaired action of insulin leading to hyperglycemia and disturbances in the metabolism of carbohydrates, fats and proteins. Longterm hyperglycemia is the cause of chronic vascular complications of diabetes. According to the American Diabetes Association (ADA) classification, diabetes occurs in the four basic forms: type 1 diabetes mellitus (DMT1), type 2 diabetes mellitus (DMT2), gestational diabetes, and other specific types of diabetes. The most Diabetologia Croatica 44-4,

30 Ivana Antal, Spomenka Ljubić, Lea Smirčić Duvnjak / EFFECT OF COMBINATION THERAPY IN THE TREATMENT OF PATIENTS WITH TYPE 2 DIABETES MELLITUS common type is DMT2, which occurs in 90%-95% of patients. The number of patients is growing daily and is connected with the increase in obesity (1, 2). PATHOPHYSIOLOGY OF TYPE 2 DIABETES MELLITUS Type 2 diabetes mellitus is a complex metabolic disorder the pathogenesis of which involves genetic and external factors. Heredity has a greater role in DMT2 than in DMT1. The main disorders in DMT2 are insulin resistance, impaired insulin secretion, and increased rate of endogenous gluconeogenesis in the liver (3). Knowledge of the pathophysiology of DMT2 is important because the choice of therapy is based on the correction of disturbed mechanisms in the regulation of blood glucose (4). Insulin resistance Insulin resistance is a condition in which the biological effect of insulin is reduced. In DMT2, it is mostly manifested by reduced glucose utilization in skeletal muscles and reduced suppression of endogenous glucose production in the liver (5). Pancreatic β-cells compensatory increase insulin secretion in the beginning of the disease, so in the initial stage of the disease patients have hyperglycemia with hyperinsulinemia. As the disease progresses, insulin secretion is decreased and as a result of insulin resistance and increased hepatic glucose output there are hypoinsulinemia and hyperglycemia. Hyperglycemia is at first reflected in the postprandial period, and then in fasting state during later stages of the disease (4, 6). Besides insulin resistance manifesting mostly in the liver and skeletal muscles, it also affects other organs (7). Liver. It is observed that in patients with DMT2 hepatic production of glucose during overnight fast (average 2.5 mg/kg per min) is higher than in persons without diabetes (average rate 2 mg/kg per min) and patients with DMT2 have elevated glucose levels and fasting plasma insulin. This argues in favor of severe hepatic insulin resistance and consequently increased gluconeogenesis, which is responsible for fasting hyperglycemia in people with DMT2 (7). Increased concentrations of glucagon (8, 9), lipotoxicity (10), and glucotoxicity (11) contribute to the increased endogenous hepatic production of glucose. Skeletal muscle. According to some studies, insulin resistance in skeletal muscle is responsible for 85%- 90% of impaired glucose utilization in the body of DMT2 patients. Disrupted insulin signal transmission is the core disorder of insulin resistance in the muscle (7). Adipose tissue. Adipocytes secrete the proinflammatory cytokines tumor necrosis factor α (TNFα) and interleukin-6 (IL-6) that contribute to insulin resistance and vascular endothelial dysfunction. On the other hand, the concentration of the protective adipokine adiponectin is reduced (12, 13). Increased lipolysis and elevated plasma free fatty acids (FFAs) are due to the resistance of adipocytes to insulin action (14). FFAs enhancing gluconeogenesis (15) induce insulin resistance in the muscle and liver (16), and damage the pancreatic β-cell in obese people who are at risk of developing DMT2 (7, 17). Gastrointestinal tract. The glucose-dependent insulinotropic polypeptide (GIP) and glucagon-like peptide 1 (GLP-1) are responsible for the incretin effect (18). The incretins stimulate insulin secretion, reduce glucagon release, slow gastric emptying, and decrease food intake. They are inactivated by the dipeptidyl peptidase-4 (DDP-4) enzyme (19). Postprandial secretion of GLP-1 is reduced in patients with DMT2 (20). Secretion of GIP is increased, but pancreatic β-cells do not respond by secreting insulin, i.e. the insulinotropic effect of GIP is absent (21). Pancreatic α-cells. In patients with DMT2, pancreatic α-cell function is increased and consequently the concentration of fasting glucagon is elevated (22). Kidneys. Sodium-glucose co-transporter 2 (SGLT2) is situated in the convolute segment of the proximal tubule and reabsorbs 90% of the filtered glucose. Sodium-glucose co-transporter 1 (SGLT1) in the straight segment of the descending proximal tubule reabsorbs the remaining 10% of the filtered glucose 118

31 Ivana Antal, Spomenka Ljubić, Lea Smirčić Duvnjak / EFFECT OF COMBINATION THERAPY IN THE TREATMENT OF PATIENTS WITH TYPE 2 DIABETES MELLITUS (7). It is assumed that in patients with DMT2, glucose reabsorption is increased due to the increased reabsortive capacity for glucose. There is a significantly increased expression of SGLT2 in patients with DMT2 (23). Brain. A study on rodents showed that insulin reduced appetite. However, in obese people in which compensatory hyperinsulinemia exists due to insulin resistance, food intake is increased. This supports the note about resistance of brain tissue to insulin action (7). Pathogenesis of pancreatic β-cell destruction Age. Advancing age is a precipitating factor for the development of impaired glucose tolerance (IGT) and DMT2 (24). Genetic inheritance. Variants of the transcription factor 7-like 2 (TCF7L2) gene are associated with impaired insulin secretion, disrupted incretin effect, and increased hepatic gluconeogenesis (25). Variants of this gene lead to changes in the Wnt signaling pathway, which is responsible for the regulation of β-cells (26). Insulin resistance. β-cells increasingly secrete insulin in the beginning of the disease due to insulin resistance and they wear out with time (7). Lipotoxicity. The effects of FFAs are decrease of islet insulin content, inhibition of insulin mrna expression, and decreased insulin secretion (7). Glucotoxicity. Hyperglycemia stimulates production of reactive oxygen species that damage cellular components in the production of insulin (5). Amyloid deposition. Amyloid deposition in the pancreatic islets leads to β-cell damage (7). PHARMACOLOGICAL THERAPY Most patients fail to keep the disease under control with lifestyle changes only, so they need pharmacological treatment. The groups of drugs used in the treatment of DMT2 include sulfonylureas (SUs), sulfonylurea analogs, biguanides, thiazolidinediones (TZDs), incretin mimetics, DDP-4 inhibitors, alphaglucosidase inhibitors (AGIs), SGLT-2 inhibitors, and insulin preparations. Sulfonylureas Sulfonylureas bind to the SU receptor (on the cell membrane of β-cells) that is associated with ATP dependent potassium channels. Closure of potassium channels leads to depolarization and opening of voltage-dependent calcium channels through which calcium enters β-cells and increases the release of insulin from the pancreas (27). Tolbutamide, chlorpropamide, tolazamide, and acetohexamide are representatives of the first generation SUs. The second generation SUs (glyburide, glipizide, glimepiride) are more potent and with less adverse effects than the first generation SUs (4). Sulfonylurea analogs Repaglinide and nateglinide are sulfonylurea analogs. Their mechanism of action is similar to the way of SUs acting. Biguanides The main effect of metformin is reduction of gluconeogenesis in the liver (28). Metformin increases insulin sensitivity in peripheral tissues, especially muscles, but has no direct effect on the function of β-cells (29). Metformin is the gold standard as initial therapy of DMT2 along with lifestyle modifications. Thiazolidinediones Thiazolidinediones or glitazones are oral hypoglycemic drugs that decrease insulin resistance. Rosiglitazone and pioglitazone bind to the peroxisome proliferatoractivated receptor gamma (PPARγ) receptor in the cell nucleus. The activated PPARγ receptor changes expression of the genes involved in the regulation of carbohydrate and lipid metabolism (4). Incretin mimetics Exenatide, liraglutide, lixisenatide, albiglutide, and dulaglutide are the incretin mimetics that bind to the GLP-1 receptor and activate it. DDP-4 do not degrade them due to the different molecular structure compared to the endogenous GLP-1 (30). DPP-4 inhibitors Sitagliptin, vildagliptin, linagliptin, alogliptin, and saxagliptin are antidiabetic drugs of the DPP-4 inhibitor class. These drugs inhibit the enzyme DPP- 4 and thus increase the concentration of endogenous Diabetologia Croatica 44-4,

32 Ivana Antal, Spomenka Ljubić, Lea Smirčić Duvnjak / EFFECT OF COMBINATION THERAPY IN THE TREATMENT OF PATIENTS WITH TYPE 2 DIABETES MELLITUS incretins GLP-1 and GIP (31). Alpha-glucosidase inhibitors Acarbose and miglitol are competitive inhibitors of the α-glucosidase enzyme, which is situated in the brush border membrane of the proximal small intestine epithelium. α-glucosidase is the enzyme which breaks down complex carbohydrates and disaccharides into monosaccharides. AGIs slow the breakdown and absorption of carbohydrates and reduce the postprandial rise in glucose levels (4). SGLT2 inhibitors SGLT2 inhibitors are the newest class of diabetes drugs. Canagliflozin, dapagliflozin, and empagliflozin increase excretion of glucose in urine, so the blood glucose concentration falls (32, 33). Insulin preparations There are four different groups of insulin formulations: rapid-acting insulin, short-acting insulin, intermediate-acting insulin, and long-acting insulin. They are produced by recombinant DNA technology. They vary in amino acid sequence, concentration, solubility, onset time, and effective duration. Insulin analogs have replaced human amino acid sequence, thus preventing aggregation in the solution and leading to faster absorption after subcutaneous administration (34). Insulin lispro, insulin aspart, and insulin glulisine are rapid-acting insulin analogs. They are prandial insulins. Regular insulin is short-acting insulin. Neutral protamine Hagedorn (isophane insulin; NPH) insulin is intermediate-acting insulin. Insulin glargine, insulin detemir, and insulin degludek (35) are long-acting insulin analogs that act as basal insulin (34). Premixed insulin analogs consist of a single formulation that covers the needs for both basal and postprandial insulin (36). HbA1c GOALS The main goal in the management of diabetes patients is achieving the desired glycemic control. Glycated hemoglobin (HbA1c) is an important indicator of adequate disease control and a good predictor of the development of diabetes complications, especially microvascular complications (1). HbA1c should be measured routinely at least twice a year in patients that have achieved stable glycemic values. In patients that have not achieved adequate glycemic targets or therapy has changed, HbA1c testing should be performed every 3 months (37). The ADA/European Association for Study of Diabetes (EASD) position statements recommend optimal glycemic targets, but decisions on targeting values should be made according to each individual patient. ADA/EASD guidelines propose HbA1c <7% for most patients. It is possible to set a more stringent HbA1c target (HbA1c 6.0%-6.5%) in appropriate patients (patients with short duration of disease, DMT2 treated with lifestyle modifications and metformin only, no significant cardiovascular disease, long life expectancy). Less stringent disease control (HbA1c 7.5%-8%) is a possible option for more complicated patients (38). According to the algorithm of the American Association of Clinical Endocrinologists (AACE) and American College of Endocrinology (ACE), it would be optimal to achieve HbA1c 6.5% in patients with no concurrently present severe illness and with a low risk of hypoglycemia. Values of HbA1c >6.5% are satisfactory in patients who have a severe illness and are at risk of developing hypoglycemia (39). The level of HbA1c and duration of DMT2 are associated with the incidence and prevalence of microvascular complications (nephropathy, retinopathy and neuropathy) in diabetic patients. The United Kingdom Prospective Diabetes Study (UKPDS 35) showed that 1% decrease in HbA1c led to a reduction of microvascular complications by 37%. It was believed previously that microvascular complications occurred only after years of active DMT2. It is clear today that the development of complications can start before the criteria for the diagnosis of DMT2 are reached (e.g., in patients with impaired glucose tolerance and during transient increase of plasma glucose concentrations). Microvascular complications linearly correlate with HbA1c levels, whereas macrovascular complications (coronary heart disease, peripheral vascular disease, 120

33 Ivana Antal, Spomenka Ljubić, Lea Smirčić Duvnjak / EFFECT OF COMBINATION THERAPY IN THE TREATMENT OF PATIENTS WITH TYPE 2 DIABETES MELLITUS cerebrovascular disease) do not. Glycemic control has a more significant result in reducing microvascular disease than in reducing macrovascular complications (40). THE TRADITIONAL STEPWISE APPROACH TO DMT2 MANAGEMENT The traditional approach to DMT2 treatment consists of therapeutic steps ( stepwise approach ) in the control of glycemia (41). This approach does not target underlying pathophysiological disorders of DMT2, but aims to reduce plasma glucose concentration (7). Diet, increased physical activity (exercise), and weight loss are the first steps of treatment. These lifestyle modifications contribute to better regulation of diabetes, but they are often insufficient, so treatment with one of oral antidiabetic drugs (OAD) is required. That is often not enough, so the next step is drug titration to the maximal recommended doses. The last step is the introduction a combination therapy (combination of OAD, combination of OAD and insulin). The problem with this conservative approach is delay in achieving and maintaining target parameters in the regulation of blood glucose, i.e. achieving a satisfactory level of HbA1c. The multidisciplinary group consisting of institutions and diabetes organizations from all over the world, The Global Partnership for Effective Diabetes Management (The Global Partnership) has issued recommendation stating that the aim of good glycemic control is achieving HbA1c <6.5%, or fasting plasma glucose concentration of 6.0 mmol/l in the case where assessment of HbA1c is not possible. There are several studies showing the effectiveness of lifestyle modifications in the regulation of blood glucose, but it is not a successful method of treatment in clinical practice and target glycemic parameters are rarely achieved. This approach is less used because it takes long before proceeding to the next step of treatment. During this period, patients have poorly regulated disease and are exposed to longer periods of hyperglycemia, which increases the risk of developing microvascular and macrovascular complications. It was found that even short periods of hyperglycemia increased the risk of developing complications (41). COMBINATION THERAPY IN THE TREATMENT OF DMT2 To avoid periods of poor glycemic control that are present in the traditional stepwise approach, this treatment approach has been replaced with combination therapy in early treatment of DMT2. Combination therapy is a proactive approach the goal of which is targeting the parameters of desired glycemic control as early as possible. In fact, the combination therapy approach consists of the same steps as the conservative stepwise approach, but they follow one after the other more quickly. Glycemic control is achieved quickly and care for patients is improved. Stepwise approach has an increased frequency of adverse effects (hypoglycemia and gastrointestinal disturbances) because of up-titration to maximal recommended doses, which increases adverse effects but has no additional improvements in glycemic profile in comparison to the maximal effective dose. In contrast, early administration of combination therapy in submaximal doses of drugs has impact on better control of the disease and reduces the number of side effects (41). According to data from the Kaiser Permanente Northwest database between 1994 and 2002, it passed more than a year in the stepwise approach to switch from OAD monotherapy to OAD combination therapy. During that period, HbA1c was not within the target values. Thus, patients were on metformin monotherapy for a mean of 14.5 months and on sulfonylurea monotherapy for a mean of 20.5 months with HbA1c value of 8% until therapy was replaced or the second OAD added in the treatment (42). Physician should individualize therapy to the patient, thereby improving the care of patients. Patient phenotype, age, HbA1c values, duration of disease, long life expectancy, presence of complications, comorbidities, risk of hypoglycemia, efficacy of drugs, cost of drugs, and possible adverse effects should be considered when choosing drugs for treatment. For Diabetologia Croatica 44-4,

34 Ivana Antal, Spomenka Ljubić, Lea Smirčić Duvnjak / EFFECT OF COMBINATION THERAPY IN THE TREATMENT OF PATIENTS WITH TYPE 2 DIABETES MELLITUS example, in patients with long duration of diabetes, management by insulin secretagogues should be avoided because it is more likely that β-cells are quite damaged (41). The Global Partnership proposes to initiate treatment with monotherapy and lifestyle changes together in patients with HbA1c <9% at the time of DMT2 diagnosis. The introduction of combination therapy should be considered if HbA1c <6.5% is not achieved within 3 months. In the case of HbA1c 9% at the time of DMT2 diagnosis, initial therapy is combination therapy or insulin therapy along with lifestyle modifications. Patients should be treated intensively to achieve optimal blood glucose control, i.e. HbA1c <6.5% within a period of 6 months from diagnosis (41). Patients whose initial HbA1c <8% and who have no cardiovascular disease will have the best outcome and will benefit most from the intensified and aggressive approach with tighter regulation of blood glucose. Elderly patients with long duration of diabetes, comorbidities, and advanced stage of disease will not achieve significant benefits from an intensified approach. The importance of individualized approach in which both the benefits of successful glycemic control and the risks of treatment are balanced is emphasized (43, 44). Significant predictors of cardiovascular events are increased levels of cholesterol and triglycerides, high blood pressure, and smoking. Besides the treatment of hyperglycemia, it is necessary to treat comorbidities associated with DMT2 that contribute to the development of severe complications. A holistic, multidisciplinary approach in the management of hyperglycemia, dyslipidemia, and hypertension should be adopted to achieve the best outcome for patients (41). EFFECT OF COMBINATION THERAPY IN CROATIA Even 72.27% of patients with diabetes in Croatia did not achieve optimal glycemic control (HbA1c less than 6.5%) according to data from the National Diabetes Registry CroDiab in Only 58.74% of patients had good regulation of systolic blood pressure (<130 mm Hg) according to previously recommended target values 130/80 mm Hg (45). The new target values of blood pressure for patients with diabetes and hypertension are 140/90 mm Hg from 2015 (46). Also, total cholesterol less than 4.5 mmol/l was only achieved in 34.49% of patients (45). These parameters (blood glucose, blood pressure, total cholesterol) are risk factors for the development of chronic complications of diabetes. In Croatia, 60% of patients with DMT2 have chronic complications. The most common complication is retinopathy, which leads to blindness. Peripheral neuropathy is the next most frequent complication, and it is a risk factor for developing diabetic ulcers, diabetic foot, and amputation. Diabetes is a major cause for loss of kidney function, therefore these patients need dialysis. The worst consequence of diabetes is death. Diabetic patients live 5-10 years shorter than people without diabetes. Also, these patients have up to six fold greater risk of developing cardiovascular diseases, which are the cause of death in 50% of patients. Diabetic complications are a social burden for patients, and economic burden for the health care system and the society. The consequences of complications are inability to work, disability, and reduced quality of life. The cost of treating complications accounts for the largest proportion of costs in the treatment of diabetes. Complications are also the most common cause of hospitalization. Analysis has shown that the cost of treatment of diabetes in 2009 accounted for 11.5% of the Croatian Health Insurance Fund budget. According to analysis, 85.72% of the funds were spent for treating complications, 8.75% for medication (OAD and insulin) and 5.53% for regular physician checkups. The aim of a study conducted in Croatia was to examine whether the effectiveness of intensified supervision of patients with DMT2 had an impact on reducing the cost of treatment. Health-economic models of development of chronic complications and mortality were developed. Two treatment strategies 122

35 Ivana Antal, Spomenka Ljubić, Lea Smirčić Duvnjak / EFFECT OF COMBINATION THERAPY IN THE TREATMENT OF PATIENTS WITH TYPE 2 DIABETES MELLITUS were simulated over a 10-year period, and then longterm outcomes related to complications and costs were assessed. The simulation used data from One strategy was previous approach to treatment, which was based on the regulation of metabolic parameters. Another strategy was intensified approach, which promptly introduced the treatment of hyperglycemia, along with blood pressure and lipid regulation. As expected, the analysis revealed that earlier and intensified initiation of diabetes treatment led to less complications and deaths. Consequently, treatment costs were reduced by about 2 billion HRK, with greatest savings achieved by reducing the cost of hospitalization, rehabilitation and dialysis (47). THE MANAGEMENT OF DMT2: GENERAL RECOMMENDATIONS Metformin is the gold standard for initial drug therapy. Patients also should take care of diet, physical activity, and body weight. They need to be educated about their disease. Metformin is optimal for initial therapy because of its effects on gluconeogenesis, low risk of hypoglycemia, favorable effects on body weight, and low cost (43). If this strategy of treating diabetes fails to put the disease under control within 3 months, then consider metformin combined with one drug of the following groups (TZD, DPP-4 inhibitors, GLP-1 receptor agonists, SGLT2 inhibitors, SU/SU analogs, basal insulin) as dual therapy with complementary mechanisms of action. If the patient has a contraindication for metformin or does not tolerate metformin, initial drug can be some medication from the groups above. Emphasis is on the patient centered approach. Dual therapy should be considered as initial therapy when HbA1c 9% (43). If glucose control remains poor after 3 months of treatment with dual therapy, consider introduction of a third medication as triple therapy (43). According to DeFronzo et al., a combination of metformin, pioglitazone and GLP-1 analog is a rational treatment option owing to their reversing the underlying pathophysiological mechanisms of DMT2 (48). Some patients do not achieve good control of the disease despite triple therapy. After 3 months of unsuccessful triple combination, basal insulin should be taken in consideration as an essential component of the treatment strategy. Addition of one to three injections of rapid-acting insulin analog before meal has been approved. A combination of basal insulin (along with metformin) with agonist GLP-1 receptor or prandial insulin preparations could be considered as a logical treatment regimen. This combination injectable therapy should be considered as initial therapy when HbA1c 10%-12% and/or glucose concentration mmol/l (43). CONCLUSION People in the early stages of the disease should be looked for and intensified treatment initiated. Good glycemic control and prevention of other risk factors such as high blood pressure and increased lipids reduce the risk of complications. Initiation of combination treatment is a better approach because this approach can reverse the pathophysiological sequels of DMT2. Glycemic regulation is under control and uncontrolled periods of hyperglycemia are avoided if DMT2 is started to be treated with combination therapy. Thus, the risk of organ damage and chronic complications is reduced. Since medical profession progresses, more emphasis is placed on individualization of both treatment targets and treatment strategies. The goals of treatment and drug selection should be tailored to individual patient needs. Diabetologia Croatica 44-4,

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(Poster #949) presented at EASD, Vienna, September Available from: org/resources/ Date accessed: April Yki-Jarvinen H, et al. Diabetes Care 2014;37: Becker RH, et al. Diabetes Care 2015;38(4): Toujeo Sažetak opisa svojstava lijeka. Detaljnije informacije o ovom lijeku dostupne su na web stranici Europske agencije za lijekove: 7. Ritzel R et al. Diabetes, Obesity and Metabolism 17: , Gerstein HC, et al. 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