卷 28, 编号 12 (2021)

The menopausal transition is characterized by accelerated bone loss and an increased risk of skeletal deformities and low-energy fractures. The main cause of postmenopausal osteoporosis is the persistent decline and loss of estrogen-producing function of ovaries. Clinicians who deal with the problem of osteoporosis should remember that the terms «postmenopausal osteoporosis» and «osteoporosis in postmenopausal women» cannot be equated, because postmenopausal women may have other diseases and factors that accelerate the loss of bone mineral density caused by a decrease in estrogen levels, thereby increasing the risk of osteoporosis and low-energy fractures (secondary osteoporosis).

Non-alcoholic fatty liver disease (NAFLD) is the most common liver disease that tends to annually increase in incidence along with obesity. The presence of NAFLD is associated with the development of fibrosis, cirrhosis, liver cancer, as well as a high incidence of cardiovascular diseases. At the same time, the occurrence of type 2 diabetes mellitus (DM2) is certainly associated with NAFLD; moreover, the combination of these diseases contributes to their accelerated progressive course. This review was aimed to the evaluation of the pathogenetic relationship of NAFLD, DM2 and obesity in order to develop the most appropriate tactics for the treatment of comorbidity.

The drugs of the class of sodium-glucose co-transporter type 2 (SGLT-2) inhibitors have been used for a long time as hypoglycemic drugs. The hypoglycemic effect of this class of drugs is based on the predominant selective reversible inhibition of SGLT-2, which leads to a decrease in the reabsorption of glucose and sodium from the glomerular filtrate in the renal tubules, excretion of glucose and sodium in the urine and osmotic diuresis. Dapagliflozin, the first representative of the SGLT-2 inhibitors, which was registered on the territory of the Russian Federation, has been studied in patients with type 2 diabetes mellitus (T2DM) in detail. Further evaluation of the effects of SGLT-2 inhibitors in T2DM patients showed their additional beneficial effect on cardiovascular and renal outcomes. Meta-analysis of three large randomized clinical trials, DECLARE-TIMI58 (dapagliflozin), EMPA-REG OUTCOME(empagliflozin), and CANVAS (canagliflozin), estimating the incidence of cardiovascular and renal outcomes in the pooled population of T2DM patients (n=34,322), has revealed that the use of SGLT-2 inhibitors is associated with a decrease in the relative risk of significant cardiovascular events (nonfatal stroke, nonfatal myocardial infarction, cardiovascular death) by 11%, hospitalization for heart failure by 31% and the progression of renal failure by 45%. In late April 2021, the US Food and Drug Administration (FDA) approved dapagliflozin to reduce the risk of renal and cardiovascular events in patients with chronic kidney disease (CKD) who are at risk of disease progression, regardless of the presence of T2DM. This makes dapagliflozin the first SGLT-2 inhibitor approved for the treatment of CKD in adult patients regardless of diabetic status.

Background. The relevance of the study is determined by the low efficiency of treatment of type 1 diabetes mellitus (T1DM) despite the use of various modern expensive technologies. Objective. Evaluation of the glycemic variability (GV) in T1DM patients on insulin pump therapy before and 12 months after training with the use of a new education module to increase the effectiveness of insulin pump therapy. Methods. Patients before training (group 1, n=18) and 12 months after (group 2, n=18) underwent determination of the glycated hemoglobin (HbA1c) level, GV parameters, and questionnaire survey. Results. Patients in group 1 used the capabilities of the insulin pump worse than in group 2 - 19.8±2.6 and 27.2±2.43 points, respectively (p<0.001). Before training, patients experienced a significantly greater fear of hypoglycemia than after completion of training (71.9±10.5 and 62.4±7.75 points, respectively, p=0.004). The HbAu level in group 1 was significantly higher than in group 2 and amounted to 7.38±1.12% and 6.71±0.54%, respectively, p=0.028. The postprandial glycemic index (MAGE) was significantly lower after training - in group 1 it was 3.62 [2.65; 4.77] mmol/L, in group 2 - 2.44 [2.2; 2.86] mmol/L (p=0.006). The glycemic lability index (LI) was also significantly higher in group 1 than in group 2 - 12.0 [8.35; 27.3] and 12.0[8.35; 27.3] mmol/L2/h, respectively, p=0.041. Conclusion. The HbAu level, the postprandial glycemic index (MAGE) and the glycemic lability index (LI) in T1DM patients on insulin pump therapy after enrolling in school of diabetes using education module on insulin pump therapy were significantly lower (p=0.028, p=0.006, p=0.041, respectively). After completing the training, patients used the capabilities of the insulin pump significantly better (p<0,001) and experienced significantly less fear of hypoglycemia according to the HFS-II scale (p=0,004).

Background. The development of osteoporosis (OP) is one of the most frequent and serious complications of rheumatoid arthritis (RA) and largely determines its unfavorable course and prognosis associated with a high incidence of osteoporotic fractures and death after their development. Data on the state of bone mineral density (BMD) in men with RA are still scarce and highly controversial. Objective. Assessment of the state of BMD and indicators of androgenic status in male patients with RA over 50 years of age. Methods. 96 male patients aged 59 [54; 64.75] years with a reliable diagnosis of RA and a disease duration of more than one year were examined. The control group consisted of 30 apparently healthy men of comparable age (p>0.05). Assessment of the androgenic status included the determination of blood serum total testosterone and sex hormone binding globulin (SHBG) levels, followed by the calculation of the androgenic activity index, free and bioavailable testosterone levels. BMD at the lumbar spine, femoral neck and proximal femur as a whole was assessed by dual-energy X-ray absorptiometry (DXA) (Stratos dR DMS densitometer, France). All patients included in the study have given written informed consent for participation. Results. Male RA patients showed a statistically significant increase in SHBG level and a decrease in free and bioavailable testosterone levels. In 49.2% of men with RA, the increase in SHBG was higher than normal values. Patients with seronegative RA were more likely to have a decrease in total testosterone levels. Androgen deficiency was verified in 50.8% of patients of the study group. Osteopenic syndrome was diagnosed in 71.9% of patients with RA: in 11.5% of cases, the decrease in BMD in at least one area corresponded to OP and in 60.4% of cases - to osteopenia. Androgen deficiency was detected in 70% of patients with OP, in 50% of patients with osteopenia, and in 33.3% of men with normal BMD. In patients with androgenic deficiency, the BMD of the lumbar spine was statistically significantly lower than in patients with normal indicators of androgenic status (0.85 [0.80; 0.96] g/cm2 and 0.94 [0.84; 1.08] g/cm2, respectively, p=0.036). Conclusion. Thus, a decrease in BMD in male patients with RA has a high prevalence and requires timely diagnosis in order to determine the tactics of treatment and prevention of low-energy fractures. Androgen deficiency is an additional risk factor for bone mass loss in men with RA, which makes the assessment of androgenic status an additional important examination.

Obesity is recognized by the modern medical community as a global medical, social and economic problem. First of all, this attitude is due to its significant prevalence, the scale of which is comparable to that of the epidemic. Today, this problem concerns not only the adult population: the number of obese and overweight children and adolescents is progressively increasing. More than half of obese adults begin to gain weight in childhood and adolescence. At the same time, the incidence of concomitant pathology in obesity that debuted in childhood is significantly higher than in obesity that developed in older age. Adequate diagnosis of obesity and determination of the type of distribution of adipose tissue is also an important issue. It is known that abdominal obesity has a higher prevalence in the general population. According to the ESSE-RF epidemiological study, the incidence of abdominal obesity, diagnosed by the size of the waist circumference, is significantly higher than the prevalence of obesity determined by the body mass index. The number of persons with abdominal obesity increases with age, both among men and women. The relevance and significance of this issue is largely due to the fact that obesity is one of the main modifiable risk factors for the development of a number of chronic non-communicable diseases, which are the main cause of disability and mortality in the population. They include type 2 diabetes mellitus, arterial hypertension, coronary artery disease and many others. To solve this problem, the role of not only the medical community, but also the state should significantly increase. Active prevention and timely treatment of obesity will preserve the population’s ability to work, increase life expectancy and reduce the economic costs of health care.

Diabetes mellitus (DM) and osteoporosis are two socially significant and mutual burdened diseases that have reached the scale of epidemic. These diseases are closely related and have common pathogenetic mechanisms of development. However, problems of insufficient prevention and diagnosis of both prediabetes and osteopenic conditions remain. Timely therapy for prediabetes with metformin can have a beneficial effect on both the patient’s glycemic and metabolic status, and the state of bone tissue. When choosing a hypoglycemic therapy, it should be taking into account that drugs can have both a negative effect on the state of bone tissue (insulin, thiazilidones, sulfonylureas), and neutral (glucagon-like peptide-1 receptor agonists) or a positive effect (metformin, dipeptidyl peptidase-4 inhibitors).

Background. Progeroid syndromes are a group of rare hereditary diseases characterized by accelerated aging of the body. The most striking signs of premature aging are manifested in Werner syndrome, caused by a mutation in the WRN gene. The main clinical feature of the disease is the loss of subcutaneous fat in the distal extremities. Patients are characterized by disorders of lipid and carbohydrate metabolism with the development of type 2 diabetes mellitus (T2DM) and cardiovascular diseases, hypogonadism, osteoporosis, cataracts, and oncological pathology. Currently, only symptomatic therapy of the disease has been developed. Description of the clinical case. The patient 16 years and 11 months old, from a closely related marriage. Stuntedness, gray hair, diffuse alopecia, pointed facial features, beak-shaped nose, loss of subcutaneous fat in the distal extremities were noted. Laboratory testing revealed hypercholesterolemia, hypertriglyceridemia, atherogenic dyslipidemia, high blood insulin, C-peptide levels, insulin resistance. Fatty hepatosis was confirmed. Treatment with fenofibrate led to the normalization of the child’s lipid profile. Normalization of blood insulin levels during therapy with metformin was not observed. Conclusion. At the initial examination, it is possible to suspect hereditary lipodystrophy with further genetic diagnosis. Early diagnosis of the disease makes it possible to prevent acute conditions and diseases associated with the syndrome, and allows to use reproductive technologies before the formation of hypogonadism. Correction of childhood lipid metabolism disorders with fibrates and/or statins can be successful. The first-line drugs for the correction of T2DM are metformin and/or insulin. At suspicion on Werner syndrome, it is imperative to conduct medical genetic counseling and psychological support to family members.