Letters

Nolan JJ: A model-based method for as- ease, rheumatoid arthritis, and colonic in which exenatide appears to be the eti- sessing insulin sensitivity from the oral polyposis. He was taking metformin at ologic agent. A review of the literature glucose tolerance test. Diabetes Care 24: 500 mg p.o., a.c., b.i.d.; pioglitazone at 30 failed to reveal any previously reported 539–548, 2001 mg p.o. daily; NPH insulin at 45 units cases of exenatide-induced acute pancre- 20. Mita S, Kobayashi N, Yoshida K, Nakano s.q., a.c., in the morning, and 20 units atitis. An occult etiology for the pancre- S, Matsuoka H: Cardioprotective mecha- nisms of Rho-kinase inhibition associated s.q., a.c., in the evening; insulin aspart on atitis cannot be completely discounted. with eNOS and oxidative stress-LOX-1 a sliding scale; metoprolol at 50 mg p.o. Pancreatitis has been reported with meva- pathway in Dahl salt-sensitive hyperten- daily; gabapentin at 1,200 mg p.o. daily; cor, infliximab, and gabapentin, but their sive rats. J Hypertens 23:87–96, 2005 lovastatin at 40 mg p.o. daily; irbesartan protracted use without change in dose 21. Martin D, Rojo AI, Salinas M, Diaz R, Gal- at 150 mg p.o. at bedtime; clopidogrel at mitigates their being the etiologic agent. lardo G, Alam J, De Galarreta CM, 75 mg p.o. daily; infliximab at 3 mg/kg The temporal relation of the symptoms to Cuadrado A: Regulation of heme oxygen- i.v. every 8 weeks; ezetimibe 10 mg p.o. the onset and cessation of therapy along ase-1 expression through the phosphati- daily; and esomeprazole at 40 mg p.o. with the normalization of laboratory pa- dylinositol 3-kinase/Akt pathway and the daily. Remarkable findings on examina- rameters on drug withdrawal implicates Nrf2 transcription factor in response to tion were exogenous obesity, bilateral ret- exenatide as the cause. Caution should be the antioxidant phytochemical carnosol. J Biol Chem 279:8919–8929, 2004 inal dot hemorrhages, trace pitting exercised when prescribing exenatide 22. Avogaro A, Pagnin E, Calo L: Monocyte bipedal edema, hyperpigmentation of the with agents known to cause pancreatitis NADPH oxidase subunit p22(phox) and legs, and a symmetric distal stocking and in patients at high risk. inducible hemeoxygenase-1 gene expres- polyneuropathy. The patient was 6 ft tall sions are increased in type II diabetic pa- and weighed 268 lb. HbA1c level was PAUL S. DENKER, MD, FACE tients: relationship with oxidative stress. 10.5%. PAUL E. DIMARCO, MD J Clin Endocrinol Metab 88:1753–1759, Treatment options were discussed, 2003 and exenatide at 5 mg s.q. b.i.d. was ini- From the Largo HCA Diabetes Center, Clearwater, 23. Pagnin E, Fadini G, de Toni R, Tiengo A, Florida. tiated. The pioglitazone and the met- Address correspondence to Dr. Paul S. Denker, Calo L, Avogaro A: Diabetes induces formin were discontinued. Within 24 h of p66shc gene expression in human pe- MD, FACE, Largo HCA Diabetes Center, 1300 South Fort Harrison, Clearwater, Florida 33756. E- ripheral blood mononuclear cells: rela- initiating the exenatide, the patient devel- oped a midepigastric abdominal pain that mail: [email protected]. tionship to oxidative stress. J Clin © 2006 by the American Diabetes Association. Endocrinol Metab 90:1130–1136, 2005 radiated through to the back. As he con- tinued with the exenatide therapy the ●●●●●●●●●●●●●●●●●●●●●●● pain intensified. There was no fever or References chills. He denied alcohol use or exposure 1. Kendall DM, Riddle MC, Rosenstock J, Exenatide to new medication. There was no previ- Zhuang D, Kim DD, Fineman MS, Baron (Exendin-4)–Induced ous history of pancreatitis or gallstones. AD: Effects of exenatide (Exendin-4) on The patient presented to the emer- glycemic control over 30 weeks in pa- Pancreatitis gency room on the 5th day of therapy. He tients with type 2 diabetes treated with was noted to have a glucose level of 309 metformin and a sulfonylurea. Diabetes Care 28:1083–1091, 2005 A case report mg/dl, creatinine of 1.0 mg/dl, and CO2 of 27, and ketones were negative. Aspartate aminotransferase was 25 IU/l and alanine xenatide is a 39–amino acid peptide aminotransferase 25 IU/l. Serum triglyc- approved for the adjunctive treat- erides were 150 mg/dl, serum calcium The Use of Insulin E ment of type 2 diabetes. It is an in- was 8.6 mg/dl, white blood cell count was Glargine With cretin mimetic agent that is consistent in 11,000, and hemoglobin was 13.8 g/l. Se- Gestational Diabetes activity with the actions of glucagon-like rum amylase was 384 IU/l and serum peptide 1. Proposed mechanisms of ac- lipase 346 IU/l. Computed axial tomogra- Mellitus tion include enhanced glucose- phy scan of the abdomen revealed no ev- dependent insulin secretion from idence of cholelithiasis. The presumptive e agree with the recent letter by pancreatic ␤-cells, restoration of first- diagnosis of acute pancreatitis was made. Woolderink et al. (1) that insulin phase insulin response, suppression of Intravenous fluids along with intravenous W glargine use during pregnancy glucagon secretion, and delay of gastric pantoprazole were started. He was made may be appropriate. In contrast to that emptying. Kendall et al. (1) found no ev- NPO (nothing to eat), and a gastroenter- letter, which described the use of insulin idence of cardiovascular, pulmonary, he- ologic consultation was obtained. The glargine in pregnant women with type 1 patic, or renal toxicities with exenatide. NPH and the exenatide were withheld. A diabetes, we detail the use of insulin Nausea (39–48%) and hypoglycemia weight-based sliding scale of insulin was glargine in four patients with gestational (19–27%) were the most common side started using aspart. diabetes mellitus (GDM). Target blood effects reported. On subsequent days the lipase was glucose levels set by the American College A 69-year-old man with type 2 diabe- 106, 27, and 17 IU/l. The abdominal pain of Obstetricians and Gynecologists for tes of 15 years’ duration presented for fol- resolved by day 3. Clear fluids were women with GDM include fasting glucose low-up. He had known diabetic started, and the diet was advanced with- Յ95 mg/dl and 1-h postprandial glucose neuropathy and retinopathy. His medical out difficulty. The patient was discharged Յ130–140 mg/dl or 2-h postprandial history was remarkable for coronary ar- home without sequelae. glucose Յ120 mg/dl (2). These criteria tery disease, gastroesophageal reflux dis- We report a case of acute pancreatitis are used by the Maternal-Fetal Medicine

DIABETES CARE, VOLUME 29, NUMBER 2, FEBRUARY 2006 471