Browsing by Author "Lertwattanarak R."

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    Benefits of Long-Term Continuation of Low-Dose Methimazole Therapy in the Prevention of Recurrent Hyperthyroidism in Graves' Hyperthyroid Patients: A Randomized Prospective Controlled Study
    (2022-01-01) Lertwattanarak R.; Mahidol University
    Background. The long-term continuation of the low-dose antithyroid drug (ATD) beyond the standard duration of ATD therapy of 12-18 months to prevent recurrent hyperthyroidism (RH) is recommended with low quality of evidence. Objectives. To examine whether long-term continuation of low-dose ATD beyond the recommended duration of treatment would provide a benefit in the prevention of RH in patients with Graves' hyperthyroidism (GH) who achieved euthyroid status with a standard course of ATD therapy. Methods. A 36-month prospective randomized controlled study was conducted in 184 patients who had first diagnosed GH and were treated with a standard regimen of ATD therapy using methimazole (MMI) until achieving euthyroidism that was stably maintained for at least 6 months with a low-dose of (2.5-5 mg/day) MMI. All patients had neither a history of adverse effects from MMI, recurrent GH, severe and active ophthalmopathy nor conditions known to affect thyroid function before randomization. The patients were randomized into 2 groups: One group (92 cases) was assigned to discontinue (DISCONT-MMI) and the other (92 cases) was assigned to continue low-dose MMI (CONT-MMI) that was taken at the time of enrollment. The patients in both groups were followed up at 3, 6, 12, 18, 24, 30, and 36 months. The rate of RH was compared between both groups, and the adverse effects and risk factors of RH were also studied. Results. At the end of the 36-month study, 83 cases in CONT-MMI and 90 cases in DISCONT-MMI were eligible for analysis. The cumulative rates of RH in CONT-MMI were significantly lower than those in DISCONT-MMI at every follow-up time point (1.2% vs. 11.2%, 6.8% vs. 18.4%, 11.0% vs. 27.2%, 11.0% vs. 35.0%, and 11.0% vs. 41.2% at 6, 12, 18, 24, and 36 months, respectively; p<0.01). Cox proportional hazard multivariate analysis showed that there were 2 factors independently associated with the risk of RH, including continuation of low-dose MMI therapy, which decreased the risk of RH by 3.8 times (HR = 0.26, p=0.007, 95% CI = 0.10-0.70) and age onset of hyperthyroidism before 40 years, which increased the risk of RH by 2.9 times (HR = 2.9, p=0.015, 95% CI = 1.23-6.88). Neither minor nor major adverse effects of low-dose MMI therapy were observed during the study period. Conclusions. In Graves' hyperthyroid patients with no or nonsevere ophthalmopathy who have completed a standard course of methimazole therapy without an adverse effect and have achieved an euthyroid status that is stably maintained with low-dose methimazole, a long-term continuation of the low-dose methimazole of 2.5-5 mg daily is effective and safe in the prevention of recurrent hyperthyroidism or maintenance of euthyroid status as long as the low-dose methimazole is continued. (TCTR20170705002).
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    Clinical Characteristics, Glycemic Control, and Microvascular Complications Compared Between Young-Onset Type 1 and Type 2 Diabetes Patients at Siriraj Hospital – A Tertiary Referral Center
    (2022-01-01) Preechasuk L.; Tantasuwan S.; Likitmaskul S.; Santiprabhob J.; Lertbannaphong O.; Plengvidhya N.; Tangjittipokin W.; Nitiyanant W.; Lertwattanarak R.; Mahidol University
    Purpose: This study aimed to investigate the clinical characteristics, glycemic control, and microvascular complications compared between young-onset type 1 (T1DM) and type 2 diabetes (T2DM) patients at Siriraj Hospital. Patients and Methods: We collected demographic, clinical, glycemic control, and microvascular complication data of young-onset (onset <30 years of age) T1DM and T2DM patients at our center using February 2019-December 2020 data from the Thai Type 1 Diabetes and Diabetes diagnosed Age before 30 years Registry, Care and Network (T1DDAR CN). Results: Of 396 patients, 76% had T1DM and 24% had T2DM. At diagnosis, T1DM were significantly younger (9.7±5.4 vs 16.9±6.4 years, p<0.001), had a lower body mass index (17.2±4.1 vs 30.8±7.9 kg/m2, p<0.001), higher prevalence of diabetic ketoacidosis (DKA) (66.1% vs 13.7%, p<0.001), and higher HbA1c level (12.8±2.6% vs 10.9±3.1%, p=0.002) compared to T2DM. Regarding glycemic control, the mean HbA1c at registry enrollment did not differ between groups (T1DM 8.3±1.8% vs T2DM 8.1±2.2%, p=0.303), but T1DM achieved HbA1c <7% significantly less than T2DM (19.3% vs 47.8%, p<0.001). T1DM showed deterioration of glycemic control during 10–20 years of age, and gradually improved during 20–30 years of age, whereas patients with T2DM showed progressive worsening of glycemic control over time. Concerning microvascular complications, the prevalence of diabetic retinopathy (10.6% vs 9%, p=0.92) and diabetic neuropathy (3.4% vs 5.5%, p=0.514) between T1DM and T2DM was not significantly different. However, T2DM had a significantly higher prevalence of diabetic nephropathy (T1DM 10.1% vs T2DM 40.2%, p<0.001) that developed within a significantly shorter duration of diabetes (T1DM 11.0±6.8 vs T2DM 4.3±5.1 years, p<0.001) compared to T1DM. Conclusion: T1DM had a significantly high prevalence of DKA at presentation, and most T1DM did not achieve the glycemic target, especially during adolescence. T2DM had a significantly higher prevalence of diabetic nephropathy that developed within a shorter duration of diabetes compared to T1DM.
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    Comparison of clinical characteristics and treatment outcomes between initially diagnosed type 1 and type 2 diabetes mellitus patients presenting with diabetic ketoacidosis
    (2024-12-01) Mookpaksacharoen O.; Choksakunwong S.; Lertwattanarak R.; Mookpaksacharoen O.; Mahidol University
    Objective: Patients with type 1 diabetes (T1DM) and type 2 diabetes (T2DM) can present with diabetic ketoacidosis (DKA) as the first manifestation. Differentiating types of newly diagnosed diabetes could provide appropriate long-term management. Therefore, we conducted this study to compare clinical characteristics and outcomes between initially diagnosed type 1 and type 2 diabetes mellitus patients presenting with DKA. Materials and methods: A retrospective study was conducted on adult patients who presented with DKA as the first diagnosis of diabetes in our tertiary hospital between January 2005 and December 2019. Demographic data, precipitating causes, laboratory investigations, treatment, and outcomes were obtained by chart review. The primary outcome was to compare the clinical characteristics of initially diagnosed patients with T1DM and T2DM who presented with DKA. Results: A total of 100 initially diagnosed diabetic patients who presented with DKA were analyzed (85 T2DM patients and 15 T1DM patients). Patients with T1DM were younger than patients with T2DM (mean age 33 ± 16.2 vs. 51 ± 14.5 years, p value < 0.001). Patients with T2DM had a higher body mass index, family history of diabetes, precipitating factors, plasma glucose, and lower renal function than those with T1DM. There was no difference in resolution time or DKA management between T1DM and T2DM patients. The overall mortality rate of DKA was 4%. Conclusion: In this population, most adult patients who presented with DKA had T2DM. Older age, obesity, a family history of diabetes, and the presence of precipitating factors were strong predictors of T2DM. We can implement the same clinical management for DKA in both T1DM and T2DM patients. However, T2DM patients had longer hospitalization than T1DM patients. After DKA resolution for 12 months, more than half of patients with T2DM could discontinue insulin. Therefore, the accurate classification of the type of diabetes leads to appropriate treatment.
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    Determinants of Glycemic Control in Thai Adults with Insulin-Treated Type 2 Diabetes Mellitus: A Cross-Sectional Study
    (2025-01-01) Riangkam C.; Sanguanthammarong S.; Lertwattanarak R.; Riangkam C.; Mahidol University
    Introduction: Insulin is an effective treatment for achieving glycemic control and delaying diabetes-related chronic complications. Even with receiving insulin therapy, adults with type 2 diabetes (T2DM) may still struggle to reach their glycemic targets. Objective: This study aimed to determine factors associated with glycemic control in Thai adults with insulin-treated T2DM. Methods: A cross-sectional study was conducted among adults with insulin-treated T2DM between July 2021-May 2022. Glycemic control is measured by Hemoglobin A1C (HbA1C), and good glycemic control was defined as HbA1C < 7%. Characteristics of adults with T2DM were analyzed using descriptive statistics. Determinant factors of glycemic control, including diabetes self-management, attitude toward insulin treatment, social support, patient-healthcare providers communication, self-monitoring blood glucose (SMBG), insulin injection technique, self-reported hypoglycemia, and lipohypertrophy, were analyzed using binary logistic regression. Results: Of the 273 participants, the mean age was 62.1 (SD = 10.7) years, 60.8% were females, and 41.8% achieved good glycemic control. Binary logistic regression analyses after adjusting for gender, age, BMI, education level, and health benefits show that performing better diabetes self-management (Adjusted odds ratio (AOR) = 1.15; 95% CI: 1.10–1.21, p < 0.001), had a less negative attitude toward insulin treatment (AOR = 0.92; 95% CI: 0.89–0.96, p < 0.001), demonstrated better insulin injection techniques (AOR = 1.35; 95% CI: 1.13–1.60, p < 0.001), and performed SMBG at least 3 times per week (AOR = 9.80; 95% CI: 2.88–33.33, p < 0.001) were more likely to achieve good glycemic control in Thai adults with insulin-treated T2DM. Conclusion: Diabetes self-management, attitude toward insulin treatment, insulin injection technique, and SMBG were significantly associated with glycemic control in Thai adults with insulin-treated T2DM.
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    Efficacy of insulin and C-peptide suppression test using a rapid-acting insulin analog to induce hypoglycemia in the diagnosis of insulinoma: A comparison to the supervised prolonged fast test
    (2024-09-30) Lertwattanarak R.; Laotaveerungrueng N.; Sriussadaporn S.; Lertwattanarak R.; Mahidol University
    Background: The efficacy of insulin and C-peptide suppression (ICPS) test using a rapid-acting insulin analog to induce hypoglycemia in the diagnosis of insulinoma has never been studied. Objective: To compare the efficacy of using plasma C-peptide (PCP) and plasma insulin (PI) responses to the ICPS test using insulin aspart and the supervised prolonged fast (SPF) test in the diagnosis of insulinoma. Methods: The ICPS test was performed in 15 patients with insulinoma (IN) and 6 patients with non-insulinoma causes of hypoglycemia (non-IN) by intravenous infusion of insulin aspart to induce hypoglycemia. Plasma glucose (PG), C-peptide (PCP), and insulin (PI) levels were measured before and at the end of the test (end-ICPS) when the patients had hypoglycemia, defined by the presence of either PG ≤50 mg/dL with hypoglycemic symptoms or PG ≤40 mg/dL regardless of hypoglycemic symptoms. PCP and PI were measured by an immunoassay system that does not cross-react to insulin aspart (Cobas Modular Analytics e801). The SPF test was also performed in IN. Results: IN had a higher median end-ICPS PI (34.77 versus 0.58 μIU/mL, p < 0.001), lower magnitude of PI suppression (−24.28 % ± 35.5 % versus −93.67 % ± 2.7 %, p < 0.001), higher mean end-ICPS PCP (4.62 ± 3.02 versus 0.49 ± 0.21 ng/mL, p < 0.001), and lower magnitude of PCP suppression (−25.51 % ± 22.2 % versus −70.28 % ± 19.4 %, p < 0.001) than non-IN. In IN, end-ICPS PI was significantly correlated to end-ICPS PCP (r = 0.724, p = 0.002). There were high correlations between end-ICPS PCP and end-SPF PCP (r = 0.882, p < 0.001) and between end-ICPS PI and end-SPF PI (r = 0.794, p < 0.001). The ICPS had a sensitivity and specificity of 93 % and 83 %, respectively, when using an end-ICPS PCP cut-off level of 0.6 ng/mL and 93 % and 100 %, respectively, when using an end-ICPS PI cut-off level of 3 μIU/mL. The ICPS test was terminated in a shorter time than the SPF test (1.01 ± 0.58 versus 7.80 ± 4.10 h, p < 0.001). Conclusion: In the diagnosis of insulinoma, the ICPS test using insulin aspart is practical, safe, less time-consuming, and as effective as the SPF test. The responses of PI to hypoglycemia are more obvious and consistent, without overlap, than the responses of PCP in IN and non-IN. The use of end-ICPS PI is better than end-ICPS PCP in the evaluation of the ICPS test. The ICPS test using a rapid-acting insulin analogue such as insulin aspart can be used instead of the conventional CPS test using recombinant human insulin and should be considered an alternative first-line test to the SPF test.
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    Pioneering robotic-assisted surgery for insulinoma during pregnancy: The first case report and literature review
    (2024-07-30) Taweerutchana V.; Choksakunwong S.; Lerwattrakarn A.; Chalermwai W.V.; Intralawan T.; Lertwattanarak R.; Taweerutchana V.; Mahidol University
    Introduction: Insulinoma during pregnancy is a rare condition with vague clinical symptoms, making diagnosis challenging. The standard treatment for insulinoma is surgical tumor removal, preferably using a minimally invasive method. However, there have been no recorded examples of employing a robotic platform in pregnant women with insulinoma. In this report, we present the first successful case of robotic enucleation for insulinoma during pregnancy. Case presentation: A 30-year-old pregnant woman presented with recurrent hypoglycemic symptoms throughout her first trimester that were relieved by food intake. After confirming endogenous hyperinsulinemia, an abdominal magnetic resonance imaging scan was performed to locate the tumor. A well-defined 2-cm mass was found in the pancreatic body. Robotic enucleation was performed at week 18 of gestation, and the patient experienced relief from hypoglycemic episodes postoperatively. Her blood glucose levels returned to normal, and she had an uneventful pregnancy. The patient eventually delivered a healthy baby via cesarean section without any complications. Conclusions: For a subset of pregnant individuals with insulinoma, a minimally invasive approach as robotic-assisted surgery is safe and feasible. This innovative technique has the potential to both mothers and fetuses.
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    Vitamin D and calcium prevent bone loss in vitamin D-deficient chronic hepatitis B patients treated with tenofovir disoproxil fumarate: A randomized controlled trial
    (2026-01-01) Atthakitmongkol T.; Chotiyaputta W.; Lertwattanarak R.; Sritippayawan S.; Bandidniyamanon W.; Tanwandee T.; Atthakitmongkol T.; Mahidol University
    Background: Tenofovir disoproxil fumarate (TDF) is an important drug to treat chronic hepatitis B (CHB) patients. However, long-term TDF therapy decreases renal function and bone mineral density (BMD). This study compared bone turnover markers, BMD, and renal function in TDF-treated CHB patients with and without vitamin D2 and calcium supplementation. Methods: This 48-week, open-label, randomized controlled trial assigned TDF-treated CHB patients to either a supplement group (n = 32) or a control group (n = 32). Results: At baseline, the mean age was 54.2 years, 57.8% were male, and 17.2% had cirrhosis. Demographic data were comparable in both groups, except body mass index, AST, and ALT were higher in the control group. At 48 weeks, there were no differences in parathyroid hormone, serum creatinine, procollagen-1 N-terminal peptide, and tubular reabsorption of phosphate in both groups. The BMD T score of the total hip did not decrease in the supplement group but significantly decreased in the control group. The C-terminal telopeptide of type 1 collagen increased in only the control group. Subgroup analysis was performed in participants with low baseline vitamin D, the result showed that the median difference in the T score for the total hip in the supplement group also showed a smaller decrease than in the control group. Conclusions: In TDF-treated CHB patients, 48-week vitamin D2 and calcium supplementation did not meet the primary endpoint of PTH change. However, it was associated with a trend toward preserving BMD, particularly in those with baseline vitamin D deficiency. Trial registration: This study protocol was registered on ClinicalTrials.gov as NCT05313477 on 6/4/2022.
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    Young-onset diabetes patients in Thailand: Data from Thai Type 1 Diabetes and Diabetes diagnosed Age before 30 years Registry, Care and Network (T1DDAR CN)
    (2022-05-01) Dejkhamron P.; Santiprabhob J.; Likitmaskul S.; Deerochanawong C.; Rawdaree P.; Tharavanij T.; Reutrakul S.; Kongkanka C.; Suprasongsin C.; Numbenjapon N.; Sahakitrungruang T.; Lertwattanarak R.; Engkakul P.; Sriwijitkamol A.; Korwutthikulrangsri M.; Leelawattana R.; Phimphilai M.; Potisat S.; Khananuraksa P.; Kunsuikmengrai K.; Nitiyanant W.; Sahakitrungruang T.; Aroonparkmongkol S.; Supornsilchai V.; Ngarmukos C.; Nimitphong H.; Korwutthikulrangsri M.; Khlairit P.; Mahachoklertwattana P.; Poomthavorn P.; Jerawatana R.; Pongratanakul S.; Sriwijitkamol A.; Santiprabhob J.; Preechasuk L.; Lertbannaphong O.; Lertwattanarak R.; Thongpaeng S.; Likitmaskul S.; Patjamontri S.; Tanathornkirati N.; Panpitpat P.; Engkakul P.; Dermkhuntod N.; Rawdaree P.; Sinsophonphap T.; Sunpakaew W.; Kiatpanabhikul P.; Suksantilirs S.; Kongkanka C.; Boonkong N.; Somsaen S.; Vansaksri A.; Deerochanawong C.; Chairat C.; Chanchalam K.; Siangruangsang S.; Tantichattanon W.; Nganlasome C.; Pichetsin K.; Boonpakdee K.; Wongjitrat N.; Nuphonthong J.; Sathavarodom N.; Numbenjapon N.; Keamseng C.; Wongsa D.; Limpijankit L.; Phimphilai M.; Densriwiwat M.; Sony K.; Mahawongsanan O.; Maneerat P.; Tangngam H.; Nirach T.; Pongchaiyakul C.; Panamonta O.; Wiromrat P.; Suesirisawad C.; Sanguanwongwichit P.; Tantiwong P.; Setthalak S.; Jindamaneemas A.; Suwansaksri N.; Petchkul J.; Jeerawongpanich K.; Tongmeesee S.; Roonghiranwat T.; Sornsiriwong C.; Piriyabanjong N.; Kongvitayanon T.; Leelawattana R.; Jaruratanasirikul S.; Dissaneevate P.; Nakkaew S.; Nantarakchaikul P.; Mahidol University
    Aims/Introduction: There is a lack of current information regarding young-onset diabetes in Thailand. Thus, the objectives of this study were to describe the types of diabetes, the clinical characteristics, the treatment regimens and achievement of glycemic control in Thai patients with young-onset diabetes. Materials and Methods: Data of 2,844 patients with diabetes onset before 30 years-of-age were retrospectively reviewed from a diabetes registry comprising 31 hospitals in Thailand. Gestational diabetes was excluded. Results: Based on clinical criteria, type 1 diabetes was identified in 62.6% of patients, type 2 diabetes in 30.7%, neonatal diabetes in 0.8%, other monogenic diabetes in 1.7%, secondary diabetes in 3.0%, genetic syndromes associated with diabetes in 0.9% and other types of diabetes in 0.4%. Type 1 diabetes accounted for 72.3% of patients with age of onset <20 years. The proportion of type 2 diabetes was 61.0% of patients with age of onset from 20 to <30 years. Intensive insulin treatment was prescribed to 55.2% of type 1 diabetes patients. Oral antidiabetic agent alone was used in 50.8% of type 2 diabetes patients, whereas 44.1% received insulin treatment. Most monogenic diabetes, secondary diabetes and genetic syndromes associated with diabetes required insulin treatment. Achievement of glycemic control was identified in 12.4% of type 1 diabetes patients, 30% of type 2 diabetes patients, 36.4% of neonatal diabetes patients, 28.3% of other monogenic diabetes patients, 45.6% of secondary diabetes patients and 28% of genetic syndromes associated with diabetes patients. Conclusion: In this registry, type 1 diabetes remains the most common type and the prevalence of type 2 diabetes increases with age. The majority of patients did not achieve the glycemic target, especially type 1 diabetes patients.