AACE 27th Annual Scientific & Clinical Congress:

Clinical Takeaways: Microvascular Risk, Metabolic Disease, Continuous Glucose Monitoring

During a networking reception for members of the New York and New Jersey chapters of the American Association of Clinical Endocrinologists (ACCE) during the 27th annual meeting, two New Jersey endos, a mother and daughter, offered to share their personal “Ah-Ha” moments with EndocrineWeb.

Maya P. Raghwanshi, MD, is an associate professor of medicine at Rutgers Medical School in Newark, New Jersey, and co-vice chair of the AACE-NJ chapter. Dr. Raghwanshi shared some new insights gathered while attending congress sessions that will inform her clinical practice and will be shared with fellows and colleagues upon her return to Rutgers.

While she valued all of the sessions that she had attended to date, in particular, a series of poster presentations reinforced the issue that “clinical neutraceuticals, particularly biotin and selenium, might interfere with many molecular assay testing, returning a false positive reading. Biotin interference produces a biochemical finding that mimics Grave’s disease.”1,2

This has become rather common among patients who self-treat or seek care from a holistic practitioner who advises megadoses of a variety of vitamins and minerals among them biotin.

Clinicians should be aware that a false positive finding may also occur if the lab running the thyroid function immunoassay uses a biotin-strepavidin bond to measure hormones including: thyroid stimulating hormone (TSH), free thyroixxine(fT4), free triiodothryonine (fT3), and TRAbs as well as follicle-stimulating hormone (FSH), luteinizing hormone (LH), insulin, prolactin, estradiol, testosterone, progesterone, dehydroepiandrosterone (DHEA), cortisol, and parathyroid hormone (PTH).1

To lessen the possibility of inaccurate lab results, it is very important to ask patients routinely if they are taking any supplements before ordering a molecular assay to assess thyroid function or to check on other hormone levels.

“I also learned that the regular use of artificial sweeteners promotes metabolic syndrome and may lead to obesity,” said Dr. Raghwanshi. Researchers reported finding an adverse dose-response in people who consumed diet soda as well as those drinking regular, sugar-containing soda.3 The risk of metabolic syndrome as well as obesity, waist circumference, blood pressure, and blood glucose, increased with each can of soda consumed.

While short-term intake of sugar substitutes appear safe, the long-term effects appear to increase the risk for metabolic diseases including weight gain; therefore, we should approach intake of artificial sweeteners similar to that of cigarettes,3 according to Dr. Cuevas-Ramos. He also mentioned that Stevia has contraceptive properties, something that should also be shared with patients who are either on the pill or trying to become pregnant.

“The other factor of interest to me is the reversal of microvascular disease in children who have been diagnosed with metabolic syndrome.” In patients with prediabetes, adolescents who developed retinopathy progressed to diabetes. We can reduce subclinical complications not only in classic tissues but also in the vasculature, brain (early changes were seen in adolescents), and skin by screening patients who present with 4-5 METs traits.4 Screening for baseline lipids, for example, ought to be considered in children with metabolic syndrome between 9-11 years.

As for treatment, other than instituting a lifestyle modification program, there is no uniform treatment for these patients; rather, each [metabolic syndrome] component must be treated as well as treating for microvascular syndrome may delay the onset or progression of the metabolic syndrome in at-risk children [with prediabetes].4,5

Most importantly, the intervention—both behavioral and pharmacotherapy —must be initiated for the entire family.5 Treatments to consider are: statins, particularly in children with familial hypercholesterolemia or cholestyramine, and fibrates for high triglycerides (>500 mg/dL) and increased risk for pancreatitis. Bariatric surgery is also a reasonable consideration in children with severe obesity who have reached a Tanner 4/5 and near-adult height. 

Informing Clinical Care of Gastroparesis, Vitamin Utilization

Anita P. Raghwanshi, MD, an endocrinologist at the Cape Regional Health System, in Cape May Court House, New Jersey who was inducted as an ACE fellow at this meeting, shared some news clinical insights to better inform her practice, and that may be of interest to others.

In particular, during the Demystifying Autonomic Imbalance meet the expert session,7 “Aaron I. Vinik, MD, PhD, made it clear that using Reglan (metoclopromide) on an intermittent (or as needed) basis for gastroparesis flares can help avoid the dreaded neurologic side effects known to arise with chronic, consistent use. This less intensive approach will make it safer and more effective for our patients over the long-term,” she told EndocrineWeb.

"Another clinical takeaway is that as with irritable bowel syndrome, diabetic gastroparesis may be characterized by chronic constipation alternating with diarrhea.7 This diarrhea, however, is not something most of us think to associate with diabetic gastroparesis but it is more common than most of us likely realize. Since the diarrhea is due to bacterial overgrowth, it should be treated with a 10-day course of Flagyl (metronidazole, 750 mg).

In another pre-conference session, Laura Shane-McWorter, PharmD, professor emeritus at the University of Utah College of Pharmacy revealed that the over-the-counter alpha lipoic acid (1800 mg) that many of us have been recommending for diabetic neuropathy has the added benefit of being one of the few safe and effective weight loss supplements with good clinical trial data, “something that I know will be welcomed by many of my patients,said Dr. Raghwanshi.

“And, of course, we were reminded that patients on metformin may benefit from supplemental vitamin B12.8 In fact, a low vitamin B12 may increase the risk for neuropathy in those taking metformin long-term,” she said.

Elevating  Our Effectiveness with the Evolving  Diabetes Technology 

In the Diabetes Technology session, the focus was on how continuous glucose monitoring is revolutionizing how endocrinologists approach diabetes care.

“Having noticed a change in the device reports for the FreeStyle Libre professional version that I use extensively, I learned that the estimated hemoglobin A1c column has been removed by FDA mandate due to patient confusion,” said Dr. Raghwanshi, “because this calculated estimation of A1c often did not match their lab-measured A1c.”

“It was also interesting to learn that one little-known reason for a “falsely low” Hb A1c in some patients may be due to mitral valve prolapse, which is especially common in women,” according to Dr. Hirsh. Similar to what happens when someone has a metallic heart valve replacement, in mitral valve prolapse, the blood cells become sheared and so the average red cell life is much shorter than the usual 90 days, which produces the “falsely low” A1cs in these patients.9 “So Dr. Hirsh said he is still using his stethoscope to be sure and listen for this condition to better inform his patient care, regarding appropriate expectation of Hb A1c levels.”

Another way in which CGM is revolutionizing diabetes care is the movement away from our reliance on Hb A1c as the primary determinant of glucose control toward a greater focus on time-in-range as a better indicator of glucose control.9

"We are learning how limited the Hb A1c numbers are. An A1c in you could have a very different average glucose on GGM than an A1c on me. In addition to its limited utility, Time-in-Range (TIR), Time-Below-Range (TBR), and Time-Above-Range (TAR) give a much broader picture of diabetes control," Dr. Hirsh told EndocrineWeb. The terminology for Hb A1c is under review,; "the new metric [replacing the estimated A1c] will give the same number just a different name."

"We also learned that a consensus has now labeled a blood glucose level of 70-180 mg/dL as the target range and the percentage of the day spent with a patient’s glucose level within those bounds is called “Time-in-Range,” ideally this would be > 70%. As important as time-in-range is, “we also need to consider the “time-below-range” which should be minimized as hypoglycemia raises the risk for cardiovascular concerns and neurologic damage.”

When viewing CGM reports, “we can view each 1% of the day as about 15 minutes, so we’ll want to aim to get Time-Below-Range to less than 4% for patients with type 1 diabetes (= < 1hr per day of hypoglycemia) and as close to zero as possible for those with type 2 diabetes since these patients still have intact glucagon to keep them from becoming hypoglycemic,” according to Dr. Hirsh.

 

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Evolving Care of Thyroid Nodules: Improving Cancer Detection, Determining Need for Active Surveillance
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