Two indices termed urinary C-peptide corrected value (UCC) and CPR index (CPI) mean [24 hour-urinary C-peptide (U-CPR)/fasting plasma glucose (FPG)] and [serum C-peptide (S-CPR)/FPG×100]. We examined validation for a clinical decision of whether insulin treatment is required for type 2 diabetes and compared these indices. Subjects were 180 type 2 diabetic patients with HbA₁c less than 8% if treated with either oral medication or diet therapy, and without severe complications. They were divided into three groups by therapy at the end of observation: insulin treatment (I), oral medication (O), and diet therapy (D). Both CPI and UCC of group I were significantly (p<0.001) lower than those of group O and D on admission. From ROC curves, both CPI and UCC were more useful than U-CPR and S-CPR, and CPI and UCC were almost comparable. In conclusion, both CPI and UCC prove to be equally useful indices for a clinical decision or whether insulin was required for treatment of type 2 diabetic patients 2 years in the future.

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[in Japanese]

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A 55-year-old woman undergoing neurosurgery for pituitary adenoma at age 19 underwent hormone replacement therapy that she later quit. She was diagnosed with diabetes mellitus at 48 years but declined routine medical care. At 55 years, she was hospitalized to control poorly controlled diabetes (HbA₁c 10.8%).
On admission, she had hyperlipidemia and liver dysfunction. Hormone stimulation tests showed low GH, T₃, PRL, LH, and FSH response and she was diagnosed with hypopituitarism. Concerning liver dysfunction, abdominal ultrasonography and computed tomography showed liver deformation, splenomegaly, and splenorenal shunt. Viral hepatitis and alcoholic and autoimmune liver disease were excluded as liver dysfunction etiology. Liver biopsy, yielded a diagnosis of non-alcoholic steatohepatitis (NASH) with liver cirrhosis. Glycemic control improved in diet therapy and insulin aspart injection before each meal. Inadequate long-term hormone replacement therapy after pituitary surgery appeared to cause NASH and progressive liver cirrhosis.

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[in Japanese]

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We diagnosed a 17-year-old woman whose subcutaneous adipose tissue began to decrease in her late elementary school days as a case of acquired and generalized lipoatrophic diabetes. She had extreme insulin resistance, fatty liver, hyperlipidemia, elevation of basal metabolism, and decreased subcutaneous fat mass, white hair, hyperkeratinized skin, and arachnodactylia. Insulin binding capacity to her EBV-transformed lymphocytes was about half that of control lymphocytes. Her serum insulin gradually decreased, and her glycemic control worsened even with 1,000 units of insulin per day. To overcome this severe insulin resistance, we added pioglitazone hydrochloride to insulin therapy. Her glycemic control improved with the increase in serum leptin and adiponectin. After the start of pioglitazone, bilateral subcutaneous axillary lipoimas were found, and her liver enlarged.

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A 64-year-old man admitted for poor glycemic control and diagnosed with diabetes 20 years earlier at age 44 had been treated with glucose-lowering agents such as gliclazide and voglibose. At age 63, insulin therapy with insulin analog aspart was started due to poor glycemic control. At that time, his HbA₁c was 8.0%. Following insulin therapy, his glycemic control improved, with HbA₁c decreasing to 6.2%.
In June 2006, he reported fasting hypoglycemia and daytime hyperglycemia. We monitored glucose for 24 hours using CGM, and found an insulin antibody (NSB) of 84% with a large amount of total insulin. Scatchard analysis of the patient's insulin antibodies showed low affinity and high capacity, and it was plausible that these antibodies were the cause of his fasting hypoglycemia and daytime hyperglycemia. Analysis of insulin antibodies also showed that they could bind to both human insulin and aspart. He was diagnosed as having type 1 diabetes because his fasting serum Cpeptide was 0.65 ng/ml and anti-GAD antibody and anti-IA-2 antibody were positive. His glycemic control improved with aspart twice a day and voglibose. CGM was thus useful tool in brittle diabetes treatment as in this case.

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[in Japanese]

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