Current consensus proposes a differentiated algorithm of initiation and intensification of antihyperglycaemic therapy in treatment patients withtype 2 diabetes mellitus. Patient-centered approach is considered a priority at any stage of diabetes care, as it ensures efficiency and safety of treatment.This document formulates guidelines for setting adequate therapeutic goals depending on vascular complications, age, life expectancy and riskof hypoglycemic events. Therapeutic options are stratified with regard to initial HbA_1c level. This Algorithm considers all classes of antidiabetic medicationsregistered in Russian Federation, rational and irrational combinations of drugs as well as contraindications.

Aim.
Evaluation of the dynamics of the markers of insulin resistance in patients with myocardial infarction with ST-segment elevation with andwithout type 2 diabetes mellitus in the acute and early recovery period of the disease.
Materials and methods.
The study included 95 patients with myocardial infarction and 60 patients with myocardial infarction and type 2 diabetes.The control group consisted of 30 persons. We all studied at 1 st and 12 th day of myocardial infarction was determined by the content of free fattyacids, glucose, C-peptide, insulin in serum and plasminogen activator inhibitor in blood plasma. In addition, the 12 th day was determined postprandialglycemic, insulin and C-peptide 2h after a standard carbohydrate breakfast.
Results.
It is established that during myocardial infarction accompanied by the development of insulin resistance, characterized by postprandialglycemia and insulinemia, as well as the presence of elevated levels of free fatty acids, plasminogen activator inhibitor.
Conclusion.
The definition of metabolic markers of insulin resistance may be of great predictive capacity for assessing the risk of both acute coronaryevents and select tactics to further treatment

The interdisciplinary service organized in the city of Barnaul provides care for patients with diabetic foot syndrome (DFS) including regular medicalexamination, diagnostics, treatment, and prophylactic measures to prevent new lesions and amputations. The service is based on the DiabeticFoot Cabinet of City Hospital No 5, Department of Wound Infections of City Hospital No 3, and Barnaul Prosthetics and Orthopedics Company,a manufacturer of prostheses and orthopedic devices for patients with DFS. These organizations have just begun cooperation with the Departmentsof Vascular Surgery of City Hospital No 5 and Regional Clinical Hospital aimed to perform vascular reconstructive surgery. The joint efforts areexpected to ensure long-term observation of the patients, their education in podiatric self-care, and introduction of the total contact cast method foroff-loading the foot at the stage of ulcer formation with the ultimate purpose of reducing it by 45-75%. Almost 3000 patients (10,000 visits) have beenexamined by specialist of Diabetic Foot Cabinet since 2005; most of them were referred to the group of high and very high risk of foot ulceration. Thenumber of patients with DFS hospitalized for the treatment of wound infections decreased from 263 in 2005 to 122 in 2010 despite a rise in overalldiabetes morbidity among the population of Barnaul. During the same period, the total number of amputations decreased from 269 to 64 and thenumber of high-level amputations from 119 to 3. The number of amputations in the patients regularly visiting the Cabinet is much lower than in thegeneral population and continues to decrease (4.7% in 2008 and 1.6% in 2010). 23% of the patients with DFS referred to the Cabinet underwentamputation in 2008 compared with 11% in 2010. In 2010, savings to the Altai region budget in direct medical expenditures for the patients with DFSamounted to 41,000,000 rubles (exclusive of management and drug costs and social benefits). The total savings to the budget in direct expendituresfor the hospital-based treatment of such patients during the last 3 years are estimated at more than 108,000,000 rubles.

Aim.
To determine the diagnostic value of urinary excretion of type IV collagen in patients with type 1 diabetes with different stages of nephropathy.Methods.
Urinary type IV collagen was determined in 60 patients with type 1 diabetes (23 with normal albuminuria, 28 with microalbuminuriaand 9 with macroalbuminuria) by an enzyme immunoassay. 10 healthy individuals were acted as the control group. Renal biopsy was performedin 22 patients. Deposits of type IV collagen were revealed by 11 individuals by immunohistochemistry.
Results.
The urinary excretion of type IV collagen increased with severety of diabetic nephropathy, correlating with the urinary albumin/creatinineratio, serum creatinine and parameters of daytime and nighttime systolic and diastolic blood pressure. Patients with excessive accumulation of typeIV collagen in the glomeruli had significantly higher level of type IV collagen in the urine.
Conclusion.
The determination of urinary type IV collagen can be used for early detection of renal fibrosis in patients with type 1 diabetes.

The review addresses the questions of history, clinical features and outcomes of simultaneous pancreas-kidney transplantation in patients with diabetesmellitus type 1. This approach was shown to have positive aspects, such as improvement of glycemic control, rapid normalization and long-termmaintenance of glycated hemoglobin levels, disappearance of hypoglycemic events, and deceleration of coronary artery disease progression resultedin reduced incidence of cardiovascular mortality. Operative risk and post-transplantation complications are also described in details.

This review analytically considers the results of clinical trials on efficacy and safety and clinical perspectives of GLP-1 analog liraglutide

Current possibilities for the use of ultra-short acting insulin analogs are discussed. The importance of control of postprandial hyperglycemia is emphasized.Pharmacological properties of insulin glulisine are described with special reference to its advantage over human ultra-short acting insulin.An important characteristic of glulisine is the possibility of its efficacious use for the treatment of obese patients. The results of GINGER and CHOinternational studies suggest high efficacy and safety of glulisine used for intensive insulin therapy according to both flexible and fixed regimens.

Necrobiosis lipoidica (NL) is a chronic skin disease (dermatosis) associated with various metabolic disorders including carbohydrate metabolism.In the last years, NL has been increasingly frequently diagnosed by practitioners probably due to the rise in type 2 diabetes mellitus morbidity in thegeneral population. Moreover, association of NL with autoimmune thyroid diseases, Crohns disease, ulcerative colitis, sarcoidosis, and vitiligo hasbeen documented. Such cases may be attributed to phenotypic and functional defects of cellular immunity.

Recently, researchers started to pay increasingly more attention to the role of gastrointestinal hormones in regulation of insulin secretion, i.e. glucosehomeostasis. To-day, there are two approaches to the treatment of DM based on the use of GLP-1 effects. One takes advantage of DPP-4 inhibitorsthe other is combination of these agents with various drugs necessitated by heterogeneity of pathophysiological factors responsible for the developmentof DM2. The latter approach ensures multiple therapeutic effects on DM2 and its complications. Many on-going studies are focused on the use ofcombination of DPP-4 inhibitors and insulin. Vildagliptin (Galvus, Novartis Pharma, Switzerland) is presently the sole DPP-4 inhibitor approvedfor application with insulin in Russia.Aim.
To estimate the efficacy and safety of DPP-4 inhibitor combined with long-acting insulin in the treatment of DM2.
Materials and methods.
The study group included 18 patients (2 men and 16 women) with DM2 treated with long-acting insulin (glargine, humulinNPH) for at least 3 months at a mean daily dose of 31.96?4.95 U. The age of the patients averaged 59.9?2.84 years (46-75), DM2 duration8.9?1.18 years (2-15). Parameters of comprehensive glycemic control (FG, PPG, HbA_1c, LMWH - low-molecular weight heparins CGM-continuousglucose monitoring) were measured using a CGMS system in the beginning and end of the study. Functional activity of pancreatic betbeta-cells and insulinresistance (HOMA-IR), lipid metabolism, and anthropometric characteristics were estimated.
Results.
Combined therapy resulted in positive dynamics of carbohydrate metabolism within 12 weeks after onset. The functional activity of pancreaticbetbeta-cells significantly (by 157.96 U) improved by the end of the study. Changes of HOMA-IR were insignificant. CGM showed that prescription ofvildagliptin to the patients who failed to reach compensation of DM2 with long-acting insulin alone significantly improved glycemic control. Variabilityof glycemia remained unaltered during the entire period.
Conclusion.
Combined therapy of DM2 patients with vildagliptin and long-acting insulin for 12 weeks improved parameters of carbohydrate metabolismwithout hypoglycemic episodes changes, in fluctuation amplitude and body weight. The functional activity of pancreatic betbeta-cells was likewiseimproved.

Aims.
The aim of this study was to estimate the prevalence rate of concomitant pathology and its influence on leading causes of death in patients withtype 2 diabetes mellitus according to clinical charts and pathologist's reports.
Materials and methods.
We have studied the database of Moscow City Hospital №50 in order to pick out confirmed cases of type 2 DM, treated inthe period from 2006 to 2008 years (302 patients, 9,97%). Prevalence rate of concomitant pathology and leading causes of death were then carefullystudied on this ground.
Results.
We examined clinical charts of 302 patients with type 2 DM - 219 female (72.5%) at the age of 76 [70;80] and 83 male at theage of 75 [68;80]. Cardiovascular pathology and cerebrovascular disease (acute cerebrovascular event and/or postinfarction encephalic cysts,discirculatory encephalopathy) (50.66%) showed high prevalence. Respiratory system diseases (25.8%), excessive body weight and obesity (21.5%),gallstone disease (19.86%), malignant neoplasm (16.2%), prostatic hyperplasia (found in 35 male patients, 42.17%), gynecologic pathology (foundin 23 female patients, 10.5%) and infectious inflammatory diseases of kidneys and urinary tract (8.6%) were also disclosed. Leading causes of deathwere found to be acute cerebrovascular events (28.8%), postinfarction cardiosclerosis (23.18%), acute/recurring myocardium infarction (19.54%)and malignant neoplasm (14.57%). High polypathy prevalence was discovered in studied cohort, and in one third of cases patients perished fromcombination of concurrent diseases.Conclusion: High prevalence rate of intercurrent diseases and polymorbidity in patients with type 2 diabetes mellitus substantiate the need for thoroughexamination at different stages of medical care, treatment of existing malfunctions, as well as preventive measures against complications.

Aims.
The article addresses incidence and causes of belated diagnostics of pancreatogenic diabetes mellitus (DM).
Materials and methods.
In 367 patients with chronic biliary or alcoholic pancreatitis (CP) glycemia and glycated hemoglobin HbA_1c levels were testedin order to detect a metabolic disorder (DM or impaired glucose tolerance).
Results.
We observed positive correlation between duration of CP (1 to 10 years) and incidence of DM, with the latter being 3 to 5 times greater inpatients with 10 years of CP experience. During remission period 44,8% of patients were not aware of development of DM. In more than 80% ofpatients CP was diagnosed during admission for exacerbation of DM.
Conclusion.
Low detection rates of pancreatogenic DM is largely due to insufficient risk awareness of patients as well as inadequate attention of medicalpractitioners to the problem of CP and DM comorbidity.

Aim.
To elucidate peculiar features of the clinical course of gastroesophageal reflux disease (GERD) in patients with type 1 and 2 diabetes mellitus(DM1 and DM2).
Materials and methods.
The study included 258 patients (68 DM and 190 DM2) undergoing 24-hour pH-metry, gastric and oesophageal endoscopy,and evaluation of H.pylori (Hp) infestation.
Results.
Based on the results of pH-metry and complaints of the patients, GERD was diagnosed in 23.5 and 33.6% of DM1 and DM2 patients respectively.GERD in DM patients is frequently asymptomatic, with fewer complaints of oesophageal problems but more pronounced endoscopic changesin patients with GERD alone. Patients with GERD + DM more frequently present with erosive oesophagitis and oesophageal ulcers than those withGERD without DM. Patients with GERD + DM are characterized by a higher occurrence of H.pylori in gastric mucosa than patients with DM alone.
Conclusion.
GERD is a frequent pathology in DM1 and DM1 patients characterized by a peculiar, frequently asymptotic, clinical course; it requiresthorough attention of endocrinologists and gastroenterologists.

This review presents a comprehensive analysis of actual ambulatory care in patients with type 2 diabetes mellitus provided in 10 federal subjects withinthe period of 1 year. The analysis is based on results from non-interventional open label prospective observational study DIA-CONTROL, whichincluded 9844 patients with DM type 2. The study was aimed to assess the initial level of glycated hemoglobin and its further dynamics according tomeasurements repeated every 3 months. Composition and efficiency of hypoglycemic therapy were also estimated in these patients.Inclusion visit showed 38.5% of patients to have adequate HbA_1c levels (<7%). 17% of patients were treatment, 41% remained on monotherapy,19% received combined treatment and 23% - insulin therapy (with or without oral hypoglycemic agents). Metformin and DPP-4 inhibitors,as well as their combination, were most common choices for initiation of treatment - with aforementioned combination (as more safe in respect ofhypoglycemic events) being preferred to traditional combination of metformin and sulphonylurea derivatives. Insulin therapy was actively prescribedin cases of inadequate glycemic control.Naturally, positive correlation was observed between HbA_1c levels and therapy correction frequency. However, more than 20% of physicians preservedthe therapeutic scheme unchanged in case of HbA_1c>8%, which is quite disturbing and suggests a more careful approach to instruction of healthcarespecialists.

Aim.
The aim of this study is to assess the therapeutic efficacy of alpha-lipoic acid in patients with type 2 diabetes mellitus (DM) and non-proliferativediabetic retinopathy.
Materials and methods.
47 patients with mild to moderate non-proliferative diabetic retinopathy were included in this trial. Dynamics of ophthalmologicparameters were assessed by means of stereoscopic photography of ocular fundus. Patients were examined every 6 months in order to registernew cases of clinically significant macular oedema.
Results.
During 24 months follow-up period, patients treated with 600 mg of alpha-lipoic acid showed stabilization in development of diabetic retinopathy.New cases of macular oedema, as well as transition into a more severe stage of retonopathy were less common in those patients. Vision andcontrast sensation also remained stable in the majority of participants from experimental group.Conclusions. 600 mg of alpha-lipoic acid may be recommended for patients with type 2 DM as part of complex therapy

This article addresses modern approach to diabetic retinopathy management. Administration of an agent, not included in the list of evidence basedmethods, such as thioctic acid, is not considered to be an appropriate practice.

Some chronic systemic diseases, including diabetes mellitus, require the life-long use of biotechnological medical products, of which quality,effectiveness and safety depends the duration and quality of life for patients.Patent protection expiry of many original biological agents has assumed the key role in development of biosimilars (replica versions of originalbiotechnological products) and their broad entrance to the pharmaceutical market. Because of structural complexity of biological products andimpossibility of precise reproduction of patented processing, biosimilars are not ideal duplicates of original substances. Despite numerous evidence oftherapeutic nonequivalence, danger of mechanical substitution of original agents still exists in Russia due to lower price of biosimilars - and lackof legislative acts, regulating registration and circulation of such drugs.In this article we characterize biosimilars in great detail and review major problems of their use, that is: aspects of quality control; disparity withoriginal bio-agents in efficacy and safety; clinical trial requirements, registration procedures and subsequent safety control.

The article presents a clinical example of integrated surgical management in patient with multifocal atherosclerosis, chronic kidney disease andneuro-ischemic form of diabetic foot syndrome

It is known that hypoglycemia is associated with an increased risk of cardiovascular adverse events including death. ACE-inhibitors, when taken withantidiabetic drugs, can cause hypoglycemic episodes by improving insulin sensitivity. This clinical case illustrates the necessity to monitor plasmaglucose in the early phase of the treatment by the ACE-inhibitors in diabetic patients.

Individualization of treatment goals is a modern trend in diabetology. During 47th Annual Meeting of European Association for the Study of Diabetesthis very problem was addressed repeatedly. The Sanofi Satellite Symposium under the name A step towards individualizing care to achieve earlyand sustained glycemic control presented lectures of worlds leading experts, giving priority to the problem of early diagnosis and early interventionfor individuals with T2DM, as well as potential benefits of early insulinisation, significance of adequate self-monitoring and pharmacoeconomicaspects of diabetes care.