Limited information is available regarding the effects of long-acting insulin. We compared the variation in the blood glucose levels between patients treated with insulin degludec (degludec) and those treated with insulin glargine (glargine) using continuous glucose monitoring (CGM). Sixteen patients with type 2 diabetes mellitus were randomly allocated to groups who received either degludec then glargine or vice versa. The patients were hospitalized one month after the start of each drug, and CGM was performed in order to evaluate the differences in glucose variability. Identical test meals were given to all patients during hospitalization. The M-value (0: 00 to 08: 00 (90 mg/dl) ), mean glucose level (0: 00 to 08: 00), SD (0: 00 to 08: 00) and fasting blood glucose level (breakfast) were significantly lower in the patients who received degludec than in those who received glargine (P=0.005, P=0.007, P=0.03, P=0.001, respectively). These results suggest that degludec exerts a more stabilized and potent effect than glargine on glycemic control from night to morning.

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We surveyed the rate of hypoglycemic attacks in diabetic patients while driving. A questionnaire survey was distributed to 402 diabetic drivers. With respect to the frequency of having experienced a hypoglycemic attack while driving, the order of related characteristics was Type 1 disease, followed by the use of insulin treatment or sulfonylureas. Regarding the rate of having experienced a traffic accident due to hypoglycemia, the order of related characteristics was Type 1 disease, followed by the use of insulin treatment. Meanwhile, the percentage of patients taking preventive measures against hypoglycemia, such as having glucose with them while driving, was 52 %. In addition, the percentage of patients given instructions regarding coping with hypoglycemia while driving by their primary care physician was only 16 %. Furthermore, among those receiving insulin treatment, the percentage of patients who measured their blood glucose before driving was 22 %. These results show that there is room for doctors to actively intervene with regard to taking preventative measures against hypoglycemia while driving.

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The patient was a 79-year-old woman. At 71 years of age, she had developed Graves' disease. In November 2010, at 77 years of age, her plasma glucose level was 364 mg/dl and her HbA1c (NGSP) level was 9.4 %, indicating diabetes mellitus. Under medication consisting of daily glimepiride and vildagliptin, the HbA1c level improved to 7.4 %. However, the patient's glycemic control remained poor, and she was admitted to our hospital in January 2012. A blood test showed an anti-GAD antibody titer of 110,000 U/ml with positive anti-TSH receptor antibodies. The increment value of serum C-peptide after glucagon loading was 0.19 ng/ml, suggesting an exhausted insulin secretary reserve. Meanwhile, genotyping for human leukocyte antigens showed type 1 diabetes mellitus susceptible to the DRB1^*0901-DQB1^*0303 haplotype. The patient was therefore diagnosed with polyglandular autoimmune syndrome type 3 due to the presence of type 1 diabetes mellitus and Graves' disease without adrenal dysfunction. The elderly onset of disease associated with a significantly elevated titer of anti-GAD antibodies is the distinguishing characteristic of this case.

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We herein describe the case of a 63-year-old man with type 2 diabetes mellitus diagnosed eight years ago who developed a rash and hepatic dysfunction following the subcutaneous injection of insulin (i.e. insulin aspart, insulin lispro and regular human insulin). He was diagnosed with pancreatic cancer and admitted to our hospital for pancreaticoduodenectomy in May 2011. Despite the administration of oral hypoglycemic therapy, the patient's blood glucose control was poor (HbA1c: 8.5 %; non-fasting blood glucose: 355 mg/dl), which necessitated the inclusion of insulin in his perioperative blood glucose management regimen. The patient tested negative for insulin-specific IgE antibodies. Drug lymphocyte stimulation tests and intradermal skin tests for various types of insulin also yielded negative results. Subsequently, he tested positive on a zinc patch test, thus indicating that he had a zinc allergy. However, no allergic reactions were recorded following the administration of zinc-free insulin glulisine via continuous subcutaneous insulin infusion (CSII). This procedure proved efficacious in achieving perioperative glycemic control after pancreaticoduodenectomy. The findings of this case show that CSII treatment with insulin glulisine is very effective for obtaining perioperative glycemic control after pancreaticoduodenectomy in type 2 diabetes patients with zinc allergies.

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We experienced two cases of fulminant type 1 diabetes mellitus associated with Vogt-Koyanagi-Harada syndrome. The first case involved a woman who was diagnosed with Hashimoto's thyroiditis at 33 years of age and Vogt-Koyanagi-Harada syndrome at 36 years of age. Her poor eyesight recovered following the administration of steroid therapy for one year. At 44 years of age, she developed diarrhea in addition to abdominal pain, nausea, vomiting and symptoms of diabetes, with weight loss of 5 kg over one week. She was subsequently diagnosed with fulminant type 1 diabetes mellitus due to the abrupt onset of symptoms as well as a plasma glucose level of 756 mg/dl, an HbA1c of level 7.3 % (NGSP) and depletion of endogenous insulin secretion. The second case involved a man who visited a clinic with common cold symptoms and was diagnosed with fulminant type 1 diabetes mellitus by chance due to a plasma glucose level of approximately 600 mg/dl and an HbA1c level of 6.0 % at 34 years of age. At 39 years of age, he developed poor vision. The patient was ultimately diagnosed with Vogt-Koyanagi-Harada syndrome due to retinal detachment and iritis. His eyesight recovered under steroid pulse therapy, and no other symptoms specific to Vogt-Koyanagi-Harada syndrome have since been observed.

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