In women with gestational diabetes mellitus who smoke at the beginning of pregnancy, the shape of the OGTT is consistent with accelerated glucose absorption, and HbA1c is higher than expected for glycaemic values (Diabetic Medicine)
Archives for September 2015
In sum, genetically predisposed individuals for T2D with deteriorating glucose tolerance exhibit insulin resistance as well as beta-cell and signs of adipose tissue dysfunction, emphasizing the multifactorial pathophysiology in the development of IGT and T2D (BMC Endocrine Disorders)
Total energy intake remains the dietary predictor of body weight. A LCD appears no different from a high-carbohydrate diet in terms of metabolic markers and glycaemic control (Diabetic Medicine)
Our results support the use of AP at home as a safe and beneficial option for patients with type 1 diabetes. The HbA1c results are encouraging but preliminary (Lancet)
4th Edition Published 2015
Jim Cassidy, Donald Bissett, Roy Spence, Miranda Payne, Gareth Morris-stiff
Published by Oxford University Press
Oncology is a very fast moving, scientifically based discipline and our personal knowledge bases constantly need updating to keep up with all these ongoing changes. It is also a very big subject area with a substantial amount of literature around it and is ever growing. If oncology is not your main discipline and yet you want to keep up-to-date with the latest thinking as it may constitute a part of your everyday clinical workload, then this is the type of book which may interest you.
Preliminary evidence suggests a dose-response relationship between metformin use and increases in height in children and adolescents (JAMA Pediatrics)
When two parameters are analyzed together, the risk stratification ability improves … the use of two tests identified subset of patients who can derive the most benefit from the intensive prevention measures (Cardiovascular Ultrasound)
In this article, the authors present their findings and question the role of dietary CHO in the aetiology of abnormal liver biochemistry and diabetes (Diabesity in Practice)
Novo Nordisk announce that the US Food and Drug Administration (FDA) has approved Tresiba® and Ryzodeg® 70/30 for the treatment of diabetes mellitus in adults after review of the class II resubmissions of the New Drug Applications (NDAs)
Saxagliptin was effective in lowering blood glucose levels and generally well tolerated in GADA-positive patients. Interestingly, saxagliptin appears to improve β-cell function in these patients, although a longer treatment duration may be needed to confirm this finding (Diabetes/Metabolism Research and Reviews)
Tighter glycemic control was associated with ADL physical dependency losses, especially in those using sulfonylureas and mitiglinides (Metabolism – Clinical and Experimental)
This study adds further evidence to the proposed causal relationship between sulfonylureas and adverse cardiovascular events by observing a significant difference in infarct size among type 2 diabetes patients presenting with STEMI (International Journal of Cardiology)
Metformin monotherapy may be associated with a reduction in the risk for cancer development compared with sulfonylurea monotherapy. Moreover, the use of an average defined daily dose of >0.25 of metformin when compared to lower dose will contribute to a reduction of 80% risk (Therapeutics and Clinical Risk management)
Relatively tight glucose control has some cardiovascular benefits. HbA1c below 7.0 % as the goal to maximize the cardiovascular benefits remains suspended (Cardiovascular Diabetology)
The relationship between HbA1c and FPG changed according to the different FPG ranges. When FPG was higher, the relationship was stronger. HbA1c and FPG were highly consistent in diagnosing diabetes, but they were not in predicting intermediate hyperglycemia (Journal of Clinical Investigation)
We found similar rates of amputation at 1 year for patients treated medically or revascularized. However, at 5 years, the amputation-free survival rate was markedly higher in revascularized patients compared to those medically managed (Diabetes Therapy)
Diabetic nephropathy patients are more susceptible to H. pylori infection. Our data support an association between H. pylori infection and diabetic nephropathy (Diabetes Research and Clinical Practice)
Bariatric surgical procedures that modify the upper gastrointestinal tract anatomy (RYBP and SG) are more successful in producing weight loss and remission of T2D than those that simply restrict stomach capacity (LAGB). Younger age, short duration of diabetes and better glucose control confer higher probability of achieving remission of diabetes (Acta Diabetologica)
Numerous alterations in the distribution of enteroendocrine cells and their expression of hormonal genes are seen after RYGB and include increased density of GLP-1-, PYY-, CCK-, GIP- and PC2-positive cells, reduced gene expression of GHRL, SCT and GIP and increased expression of GC (Diabetologia)
Admission blood glucose predicts mortality and length of stay in patients admitted through the emergency department
Martin WG, Galligan J et al. Internal Medical Journal. Doi: 10.1111/imj.12841
The need to control blood glucose levels in patients with acute illness in hospital is well established and has lead to the development of guidelines for these patients especially the recognition that referral to the inpatient diabetes team is necessary. However, patients without a diagnosis of diabetes often present with hyperglycaemia, possibly due to unrecognised diabetes or stress hyperglycaemia. This retrospective observational study showed that an admission glucose >11.5mmol/l was significantly associated with increased 90 day mortality in those patients without a diagnosis of diabetes. This was not the case in those patients with a diagnosis – although their length of stay was longer. There is a need to recognise the importance of glycaemic control in all patients, not just those with diabetes – as well as to review their glycaemic status after discharge because of the long term implications of missing a diagnosis of diabetes.
Metformin versus insulin for gestational diabetes mellitus: a meta-analysis
Zhao LP, Sheng XY et al. British Journal of Clinical Pharmacology. Doi: 10.1111/bcp.12672
Gestational diabetes is associated with an increased risk of a variety of maternal and perinatal complications including macrosaomia, shoulder dystocia and respiratory distress. Until comparatively recently, the only drug used to manage hyperglycaemia in gestational diabetes was insulin. However, in keeping with clinical practice, recent NICE guidance promotes the use of Metformin in the treatment of hyperglycaemia even though it crosses the placenta and reaches pharmacological levels in the foetus. As such, there is always a nagging doubt about its safety despite studies suggesting otherwise. Its safety is reinforced by this meta-analysis of 8 studies which showed no clinically relevant safety or efficacy difference when compared to insulin although it was associated with a lower incidence of pregnancy induced hypertension. It also has the advantage of being an oral agent as well as being weight neutral. However, its use should also accompany lifestyle changes – often harder to prescribe.
Case–control study of second-line therapies for type 2 diabetes in combination with metformin and the comparative risks of myocardial infarction and stroke
Floyd JS, Wiggins JL et al. Diabetes, Obesity & Metabolism. DOI: 10.1111/dom.12537
After lifestyle modification, it is universally accepted that Metformin is the drug of choice. However the second line agent of choice remains a subject for discussion with sulphonylureas appearing prominently. Since the concerns about Rosiglitazone, there has been an increasing emphasis on the cardiovascular safety of anti-diabetic drugs. Pioglitazone and the DPP 4 inhibitors have been shown to have no negative CV impact with studies examining SGLT2 inhibitors and GLP1 analogues in progress. Insulin has been considered a ‘clean drug’ from a CV point of view. The issue with sulphonylureas has been debated for many years and indeed a metanalysis in 2013 suggested that sulphonylurea use may elevate the risk of cardiovascular disease among patients with diabetes. However, this study suggests that there may not be large differences in cardiovascular risk associated with the use of insulin or sulphonylureas when used in combination with Metformin. Whatever the current evidence, large prospective studies are unlikely and given the decades of experience with sulphonylureas, they seem set to remain in guidelines of all varieties.
Inhaled Technosphere insulin compared with injected prandial insulin in type 1 diabetes
Bruce W. Bode et al. Diabetes Care. Doi: 10.2337/dc15-0075
Inhaled insulin was available for use in the UK in 2006 when Pfizer launched ‘Exubera’ but it did not do well. NICE quickly limited its use by recommending that it should only be considered for people with an injection phobia (confirmed by a psychiatrist or psychologist!) or those with ‘severe persistent problems with injection sites’. In addition, the inhaler device was large and clumsy and then came lawsuits in the US suggesting that it might be linked with lung malignancy. Exubera was withdrawn from the market in 2007 and phase 3 trials of similar (but better) products from Lilly and Novo Nordisk were promptly terminated. However, all was not lost. Mannkind continued the development of inhaled insulin and, following an agreement with Sanofi, this was launched in the US last year as ‘Afrezza’. This paper describes how the inhaled insulin provides equivalent glycaemic control to meal-time injections, with less hypoglycaemia and weight gain. Cough was an expected side-effect. Initial sales of Afrezza in the US have been disappointing and so its future is uncertain. It remains to seen whether a UK launch will happen.
Estimated glomerular filtration rate and albuminuria for prediction of cardiovascular outcomes
Kunihiro Matsushita et al. Lancet Diabetes & Endocrinology. Doi: http://dx.doi.org/10.1016/S2213-8587(15)00040-6
Although eGFR is regarded as a test for chronic kidney disease (CKD), the chance of a person with T2DM and stage 3 CKD progressing to end-stage renal failure is vanishingly small. Reduced eGFR is highly correlated with CV disease and should be regarded a CV marker. The second ‘CKD screening’ tool, until recently enshrined in GMS diabetes practice, is urinary albumin excretion, assessed by a urine albumin-to-creatinine ratio (UACR) on a first voided sample. The presence of microalbuminria (elevated albumin excretion but below that detectable by routine dipstick testing) was reported to predict diabetic nephropathy in patients with T1DM and quickly adopted for renal screening in all diabetes populations. However, in T2DM, it predicts CV risk much better than renal deterioration. So, the two major CKD screeners are actually CV screening tests. The does mean that their annual assessment in patients with established CVD is of questionable value.