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Nivelreumapotilaan kortisonihoidon diabetogeeninen vaikutus

Näytönastekatsaukset
30.3.2015
Kari Puolakka

Näytön aste: C

Matala-annoksisen kortikoidihoidon epäedullinen vaikutus nivelreumapotilaan glukoosimetaboliaan lienee vähäinen.

In a Dutch study «Hoes JN, van der Goes MC, van Raalte DH ym. Glucose tolerance, insulin sensitivity and ß-cell function in patients with rheumatoid arthritis treated with or without low-to-medium dose glucocorticoids.»1 frequently sampled 75 g oral glucose tolerance tests were performed in 58 chronic GC-using and 82 GC-naive patients with RA with established disease, with no known type 2 diabetes mellitus (T2DM), and 50 control subjects of comparable age with normal glucose tolerance.

Glucose tolerance state, insulin sensitivity and beta-cell function did not differ between the two RA populations; de novo T2DM was detected in 11 % and impaired glucose metabolism in 35 % of patients with RA. Cumulative GC dose was associated with T2DM. Patients with RA had decreased insulin sensitivity and impaired beta-cell function compared with controls, and multivariate regression analyses showed a negative association between the presence of RA and insulin sensitivity.

  • Tutkimuksen laatu: kelvollinen
  • Sovellettavuus suomalaiseen väestöön: kohtalainen

Kommentti: Näytön astetta laskee poikkileikkaus-asetelma.

In a study «Toms TE, Panoulas VF, Douglas KM ym. Lack of association between glucocorticoid use and presence of the metabolic syndrome in patients with rheumatoid arthritis: a cross-sectional study. Arthritis Res»2 from the US 398 RA patients with detailed clinical and laboratory assessments were categorised into three groups according to glucocorticoid (GC) exposure: no/limited (< 3 months) exposure (NE), low-dose (< 7.5 mg/day) long-term exposure (LE), and medium-dose (greater than or equal to 7.5 mg to 30 mg/day) long-term exposure (ME).

The metabolic syndrome as defined using the National Cholesterol Education Programme III guidelines was present in 40.1 % of this population and its prevalence did not differ significantly between the GC exposure groups (NE 37.9 % vs LE 40.7 % vs ME 50 %, P = 0.241). Binary logistic regression did not demonstrate any increased odds for the metabolic syndrome when comparing ME with LE (odds ratio = 1.64, 95 % confidence interval 0.92–2.92, P = 0.094) and remained non-significant after adjusting for multiple potential confounders.

The components of the metabolic syndrome may already be extensively modified by other processes in RA (including chronic inflammation).

  • Tutkimuksen laatu: kelvollinen
  • Sovellettavuus suomalaiseen väestöön: kohtalainen

Kommentti: Näytön astetta laskee poikkileikkaus-asetelma.

In a randomized, controlled, single-blind trial «den Uyl D, van Raalte DH, Nurmohamed MT ym. Metabolic effects of high-dose prednisolone treatment in early rheumatoid arthritis: balance between diabetogenic effects and inflammation reduction. Arthri»341 patients with early active RA not been treated for their RA were randomized to begin treatment with prednisolone at 60 mg/day or 30 mg/day. Before and at the end of 1 week of treatment, a frequently sampled oral glucose tolerance test was performed. The glucose area under the curve (AUC(G)) was calculated. In addition, beta cell function and insulin sensitivity parameters were computed.

Impaired glucose tolerance at baseline was found among 56 % of the patients (mean age 55 in both groups; body mass index 25 kg/m(2)) and 7 % were found to have previously unrecognized type 2 diabetes mellitus (DM) Treatment with prednisolone at both dosages reduced CRP levels significantly. The incidence of type 2 DM increased to 24 % (P < 0.001) (evenly distributed across the groups). The mean AUC(G) did not change in either treatment arm. Beta cell function improved during prednisone treatment at 60 mg/day (P = 0.02) and at 30 mg/day (P = 0.04).

  • Tutkimuksen laatu: kelvollinen
  • Sovellettavuus suomalaiseen väestöön: kohtalainen

Kommentti: Käytetyt prednisoloniannokset eivät kuulu suomalaiseen nivelreuman hoitosuositukseen.

Chronic systemic inflammation is associated with increased cardiovascular mortality in patients with rheumatoid arthritis (RA). The aim of our study was to investigate association of glucose metabolism and inflammatory markers in a group of patients with rheumatoid arthritis free of other metabolic risk factors.

In a Czech study «Penesová A, Rádiková Z, Vlcek M ym. Chronic inflammation and low-dose glucocorticoid effects on glucose metabolism in premenopausal females with rheumatoid arthritis free of conventional metabolic ris»4 22 premenopausal RA females (11 patients on low-dose GC (< 8.5 mg/day of prednisone or equivalent), 11 patients without glucocorticoid therapy) and 15 age- and BMI-matched healthy females underwent the oral glucose tolerance test. The insulin sensitivity indices (ISIs) were calculated. Cytokines, lipid profile, non-esterified fatty acids (NEFA) and plasminogen activator inhibitor-1 (PAI-1) were measured in baseline blood samples. Despite elevated interleukin IL-6 and TNF alpha, glucose, insulin and C-peptide responses to oral glucose load as well as ISIs, PAI-1 and NEFA were comparable in both RA groups and healthy controls.

  • Tutkimuksen laatu: kelvollinen
  • Sovellettavuus suomalaiseen väestöön: kohtalainen

Tämä teksti on linkitetty seuraaviin artikkeleihin:

  • Nivelreuma 1

Kommentti: Näytön astetta laskee poikkileikkausasetelma.

Kirjallisuutta

  1. Hoes JN, van der Goes MC, van Raalte DH ym. Glucose tolerance, insulin sensitivity and ß-cell function in patients with rheumatoid arthritis treated with or without low-to-medium dose glucocorticoids. Ann Rheum Dis 2011;70:1887-94 «PMID: 21908880»PubMed
  2. Toms TE, Panoulas VF, Douglas KM ym. Lack of association between glucocorticoid use and presence of the metabolic syndrome in patients with rheumatoid arthritis: a cross-sectional study. Arthritis Res Ther 2008;10:R145 «PMID: 19091101»PubMed
  3. den Uyl D, van Raalte DH, Nurmohamed MT ym. Metabolic effects of high-dose prednisolone treatment in early rheumatoid arthritis: balance between diabetogenic effects and inflammation reduction. Arthritis Rheum 2012;64:639-46 «PMID: 21953589»PubMed
  4. Penesová A, Rádiková Z, Vlcek M ym. Chronic inflammation and low-dose glucocorticoid effects on glucose metabolism in premenopausal females with rheumatoid arthritis free of conventional metabolic risk factors. Physiol Res 2013;62:75-83 «PMID: 23173679»PubMed
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