Glucose concentrations of less than 3.0 mmol/L (54 mg/dL) should be reported in clinical trials
Diabetes Care. DOI: 10.2337/dc16-2215
Hypoglycaemia is a complication of diabetes that raises concern with patients and health care providers. Despite this, the threshold for hypoglycaemia varies between patients and also within the same patient depending on their frequency and overall control (HbA1c). This position statement from the ADA and EASD seeks to clarify the definition and absolute glucose values constituting an episode of hypoglycaemia. Specifically, glucose values of <3.0mmol/l, measured via self-monitoring, continuous glucose monitoring or a laboratory sample. This value was chosen as it is unequivocally a value that does not occur under physiological conditions in non-diabetic individuals. A value of <2.8mmol/l was also considered following its link to increased mortality in the ACCORD and ORIGIN studies. Three levels of hypoglycaemia have been proposed – alert if <3.9mmol/l, <3.0 indicating serious or clinically significant hypoglycaemia and severe in the presence of cognitive impairment or requiring external assistance for recovery. It is also proposed that only values of <3.0mmol/l be reported in clinical trials, rather than readings <3.9mmol/l.
HbA1c and the prediction of type 2 diabetes in children and adults
Pavithra Vijayakumar et al. Diabetes Care. DOI: https://doi.org/10.2337/dc16-1358
It is recognised that Type 2 diabetes is no longer a condition only affecting older people with increasing number of patients being diagnosed in childhood, especially in those belonging to high risk populations. Whilst most guidelines use HbA1c as a diagnostic tool for T2DM, this has not been validated in children, an issue addressed in this paper which examined glycaemic thresholds in American Indian children using HbA1c, fasting and 2hour post load glucose. Stratifying patients into T2DM (HbA1c>6.5%, FPG>7.0 and 2hr glucose >11.1mmol/l), 2095 children without diabetes aged 10-19 underwent long term review. During long-term follow-up of children and adolescents who did not initially have diabetes, the incidence rate of subsequent diabetes was fourfold (in boys) as high and more than sevenfold (in girls) as high in those with HbA1c ≥5.7% as in those with HbA1c ≤5.3%. Identifying the risk of T2DM was not different whether HbA1c, FPG or 2hr glucose was used. The study suggests that HbA1c is a predictor of risk in children and can be used as a tool to target lifestyle intervention.
Gastric bypass surgery reveals independency of obesity and diabetes melitus type 2
Mogens Fenge et al. BMC Endocrine Disorders. DOI: 10.1186/s12902-016-0140-8
Roux-en-Y gastric bypass surgery (RYGB) is the most effective form of bariatric surgery with patients permanently losing approximately 40% of their body weight whilst in patients with pre-existing T2DM, remission may occur in 40-80%. However, this remission tends to occur within days of the surgery often before any weight loss has occurred. This study examined weight loss trajectories in groups of patients who were non-diabetic, diabetic pre- and post-surgery, and those whose diabetes went into remission post-surgery. Weight loss rates varied significantly between the groups with up to 11 sub populations identified which were felt to represent different physiological states. These states were presumed to be due to a combination of genetic predisposition and the changed anatomy with further variability conferred by alterations to gut flora and hormones. Patients who lost a significant amount of weight tended to be more likely to go into remission from their diabetes probably due to improved insulin sensitivity which remained even if they regained some weight. Overall, this rather complex paper does not significantly advance understanding of the heterogeneity of response to bariatric surgery.
TRENDS in medication use in patients with type 2 diabetes mellitus a long-term view of real world treatment between 2000 and 2015
Authors: Higgins V, Piercy J, Roughley A, Milligan G, Leith A, Siddall J, Benford M
The authors collected data on type 2 diabetes (T2DM) prescribing between 2000 and 2015 in the US and five EU countries, including the UK. Clinicians completed patient record forms for their next 10 patients allowing capture of change over time in therapy usage, time to insulin and HbA1c. Data from 70,657 patients showed treatment patterns changed and the number of agents prescribed per patient increased over time, as did HbA1c levels at which physicians would introduce insulin. HbA1c improved during 2000–2008 but was stable thereafter. This type of report is often used to snipe at the use of newer, expensive anti-diabetes therapies (ADTs) and argue for a return to metformin, sulphonylurea and human insulin. However, interpretation of these real-life data is complex. It is hardly surprising that the shift of T2DM management into primary care, over a period when three new oral ADT classes were launched, has led to more complex oral regimes. It is also of note that clinicians have much higher thresholds for insulin initiation than any current guidelines. The authors are right to recommend further investigation.
Tackling variation in diabetes care
This report is published by the All-Party Parliamentary Group for Diabetes and so will hopefully carry some weight with the Clinical Commissioning Groups in England and Health Boards in Wales. It highlights that the quality of care someone with diabetes receives, and presumably the outcomes they achieve, depends on where they live. The key message is that good diabetes care is possible and the task is to make it happen everywhere.
For me, the highlights are:
. Training for healthcare professionals (HCPs) should be increased to allow them to have the knowledge and skills to give accurate advice i.e. an admission that T2DM cannot be appropriately managed by HCPs without specialist knowledge.
- A focus on structured education, which includes one-to-one advice (i.e. one group-sized education programme doesn’t fit all) and the need for psychological support.
- The need for the NHS to provide access to new technologies. The report highlights that ‘muddled funding processes make accessing technology difficult even when someone satisfies the NICE criteria for it’.
Let’s hope that this report helps push diabetes higher up the NHS priority list.