Sulfonylurea use and the risk of hospital readmission in patients with type 2 diabetes
Pamela C. Heaton et al. BMC Endocrine Disorders. Doi: 10.1186/s12902-016-0084-z
Sulphonylureas (SUs)have been a mainstay of glycaemic control for many years and as a result, reinforced by multiple iterations of guidelines which placed them early in the treatment pathway, clinicians are comfortable with using them. However, their well-documented side effects, specifically hypoglycaemia are increasingly recognized as problematic. Furthermore, hypoglycaemia is a common cause for hospital admission especially in the elderly, with some patients being admitted on multiple occasions. This US study compared the risk for diabetes–related hospital readmission in patients with type 2 diabetes treated with sulphonylureas compared to those treated with other oral hypoglycaemic agents (OHAs). In this readmission cohort, 23.2% were taking SUs whilst 16.1% of readmitted patients were taking other OHAs – a 30% increase. Although other OHAs such as gliptins and SGLT2 inhibitors are relatively expensive compared to SUs, this cost may be offset if only a handful of admissions are prevented. Indeed, the risk of hypoglycaemia is now mentioned in the recent NICE guidance on hypoglycaemic agents in Type 2 Diabetes.
Effect of diabetes and glycemic control on ischemic stroke risk in AF patients
Jeffrey M. Ashburne et al. Journal of the American College of Cardiology. Doi: 10.1016/j.jacc.2015.10.080
Atrial fibrillation is a well recognised risk factor for ischaemic stroke, a risk that is increased in patients with diabetes. Duration of diabetes is also a documented risk for stroke, risk increasing by 3% per year and tripling after 10 years. This study examined both of these risks by examining the association between duration of diabetes and elevated HbA1c and ischaemic stroke in a US community based cohort of AF patients. Duration of diabetes was divided into <3 years or >3 years whilst an HbA1c of 9% and 7-9% were the glycaemic control groups. Neither glycaemic control groups were found to be associated with an increased risk of stroke. However, duration of diabetes >3 year was associated with an increased risk (hazard ration 1.74), this relationship being independent of the patients age. Potential mechanisms for this include the enhanced thrombin generation and impaired fibrinolysis which occur in diabetes. This study reinforces the benefit of using duration of diabetes rather than just the diagnosis when calculating risk – an example being the UKPDS risk engine which uses both duration of diabetes and the presence of atrial fibrillation in its algorithms.
The UK NSC recommendation on Diabetic Retinopathy screening in adults
UK National Screening Council
Annual retinal screening has been a cornerstone of diabetes care in the UK for over a decade and is now part of the 9 NICE diabetes care standards. However, the epidemiology of diabetes is increasingly putting screening programs under pressure as they struggle with creating the capacity to screen ever rising numbers of patients within the required period. Until recently, retinal screening guidance has been a ‘one size fits all’ process which is not in keeping with individualised care now recommended by NICE. As a result, many patients at low risk of developing sight threatening retinopathy (defined as patients having two successive clear eye screening appointments) have regular screening sessions making it harder to find appointments for those for whom more regular and targeted screening is required. Following an observational study following > 350000 patients for four years which looked at progression of retinopathy in seven screening programs, the UK National Screening Council has changed its guidance in January 2016 to recalling low risk patients every 2 years. However, it continues to recommend that annual screening should remain for those at higher risk of sight loss.
Glucose test provenance recording in UK primary care: was that fasted or random
P. McGovern et al. Diabetic Medicine. Doi: 10.1111/dme.13067
The authors report the effect of provenance recording on the interpretation of glucose tests requested in primary care. ‘Provenance’ indicates that the nature of the test (e.g. fasting, oral glucose tolerance test, random, none specified) has been documented with its result and the presumption is that absence of provenance indicates failure by the requesting clinician, rather than laboratory omission. A cross-sectional analysis was conducted of glucose measurements from the Royal College of General Practitioner Research and Surveillance Centre database, which includes primary care records from more than 100 practices across England and Wales. All glucose results recorded during 2013 were identified. Over two million people were included in the cross-sectional analysis. Of 203 350 recorded glucose measurements the majority (117 893; 58%) did not have any provenance information. Analysis of data from a single practice showed that this caused unnecessary repeated testing, delayed diagnosis and wasted clinician time. This lends support to the current recommendation that diagnosis of type 2 diabetes should be made by testing HbA1c, where provenance is immaterial.
The renal threshold for glucose re-absorption predicts diabetes improvement by sodium glucose co-transporter 2 inhibitor therapy
Aya Osaki et al. Journal of Diabetes Investigation
There are currently eight classes of glucose-lowering medicines in the UK and various guidelines as to how to combine them. Guidelines generally advocate individualisation of therapy using patient characteristics (e.g. weight, hypoglycaemia risk) but not according to whether a subject is likely to respond to an individual treatment. This is because for the newer classes, such as gliptins and GLP-1RA injectables, it has not been possible to identify clinical features of ‘responders’ versus ‘non-responders’. Hence therapy is based on ‘suck it and see’. To this point, the same applied to the sodium-glucose co-transport 2 inhibitor (SGLT2i) class, however, this publication might change that. The authors assessed the renal threshold for glucose re-absorption using a simple spot urine test and then examined the patient response to ipragliflozin (an SGLT2i not available in the UK). They revealed a negative correlation between HbA1c improvement and the renal glucose threshold, suggesting that this test will identify responders to SGLT2i treatment. Simple means of targeting therapy to those who will respond is potentially time and money-saving. Confirmatory data from a UK population are needed.