Testosterone treatment in men with type 2 diabetes and HH increases insulin sensitivity, increases lean mass, and decreases subcutaneous fat (Diabetes Care)
Archives for November 2015
Dapagliflozin 10 mg significantly improved blood pressure and HbA1C. Its blood pressure-lowering properties were particularly favourable in patients already receiving a β blocker or calcium-channel blocker. Dapagliflozin could benefit patients with type 2 diabetes who need a diuretic-like effect to optimise control of blood pressure (The Lancet Diabetes & Endocrinology)
The role of the healthcare professional is to empower patients with the knowledge to manage this chronic disease and understand why they need to: (Nursing in Practice)
Our idea that insulin therapy is like a basic “black dress” includes the concept that both can go well with additional accessories—in the case of insulin, other therapies used in combination (Diabetes Care)
Diabetes in children & young people (NICE 2015)
Given the epidemiology of diabetes, most Health Care Professionals spend a significant amount of time treating Type 2 adult patients, often at the expense of a very vulnerable group of patients, specifically young people. The epidemiology of diabetes in this group is also changing as, due to the rise in obesity, it is increasingly common to see a young person with Type 2 diabetes. As a result, it is timely that NICE has published guidance for this group of patients, an update from their original 2004 document. In fact, early in their guidance, the possibility of Type 2 diabetes is raised at time of diagnosis in certain groups including patients of S Asian origin or show signs of insulin resistance (e.g. acanthosis nigricans). There is also increasing recognition of different sub types of diabetes e.g. monogenic with advice around genetic testing and C-peptide measurement. Whilst most children will be managed in secondary care, there are several developments within this guidance which will impact on service delivery. Specifically, this includes enhanced patient (and family) education, a requirement to attend clinic 4 times per year as well as further advice on retinal screening. There is some advice on transition from paediatric to adult care although given the importance of this period, guidance is surprisingly brief especially the potential benefits of psychological services in diabetes care. The lack of recommendations about transition contrasts with the large detailed description on ketoacidosis management, despite DKA guidance being a summary of recommendations from the Joint British Diabetes Societies.
Unsurprisingly, the main sections refer to glycaemic control including targets and drug use. An HbA1c<48mmol/mol (6.5%) is recommended and although an individualised target is suggested, special reference is given to those whose HbA1c is>53mmol/mol. Glycaemic targets have been divided into the management of both T1 and T2 patients. For both, a patient centred approach is advised but a basal bolus regimen is recommended as first line with pump therapy another early option especially if good control is not possible. Obviously dietary modification including carbohydrate counting is required – assuming dietetic services are adequate. As a contrast to T1 management in adults, Metformin is not recommended due to lack of evidence yet the sustained release preparation is considered first line in children with T2 diabetes. Guidelines for this group of patients are the most significant change since 2004 in recognition of their growing number with extensive advice given about lipid, blood pressure and renal complications.
Overall, this new and updated guidance in an important patient group from NICE is welcome however, as ever, the challenge will be its implementation especially those sections where funding and service delivery need addressing.
Dr Mark Freeman
Empagliflozin, Cardiovascular Outcomes, and Mortality in Type 2 Diabetes
Bernard Zinman et al. NEJM. Doi: 10.1056/NEJMoa1504720
The withdrawal of rosiglitazone from European markets, following the suggestion that it increased the risk of myocardial infarction in people with type 2 diabetes (T2DM), spawned a generation of cardiovascular outcome trials (CVOTs) for new diabetes therapies. CVOTs are designed to be safety studies, aiming for so-called ‘glycaemic equipoise’; this means that any reduction in HbA1c should be similar in patients receiving the new, active therapy to those receiving placebo. They also have other facets, which make them unlikely to demonstrate CV benefit; they are usually short studies (2-3 years); they often focus on patients with advanced CV disease (where glycaemic control is least likely to provide advantage, and may cause harm) and they mandate optimal control of other CV risk factors (such as blood pressure [BP] and low-density lipoprotein cholesterol). For these reasons, many assumed that CVOTs would show no evidence of harm but also no evidence of superiority. This was largely the case for three studies, which examined the dipeptidyl peptidase-4 inhibitors (saxa-, alo- and sitagliptin) and the ELIXA trial of lixisenatide.
Imagine then, the surprise when results of the EMPA-REG study were presented at the European Association for the Study of Diabetes (EASD) meeting in Stockholm in September 2015. Not only did this CVOT of the sodium glucose co-transporter-2 (SGLT-2) inhibitor, empagliflozin, show a significant reduction in the primary end-point of ‘CV death, non-fatal myocardial infarction or non-fatal stroke’ but there was also a significant reduction in all-cause mortality. The patient cohort was at extremely high CV risk, with median treatment duration of only 3.1 years and benefits were seen within three months of the drug initiation.
Explanation of this unexpected finding will generate more studies, no doubt with focus on non-glycaemic effects of SGLT-2 inhibitors (such as BP and weight reduction and their diuretic action). It will also be of great interest to see if the other two SGLT-2 inhibitor CVOTs show similar results, although they will not complete until after 2017.
Professor Steve Bain
Bariatric–metabolic surgery versus conventional medical treatment in obese type 2 diabetes
Geltrude Mingrone et al. Lancet. Doi: http://dx.doi.org/10.1016/S0140-6736(15)00075-6
After rewriting its draft guidance on Type 2 diabetes, NICE still do not incorporate bariatric surgery in their treatment algorithm despite a plethora of evidence suggesting that it is more effective than medical treatment. However, a caveat may be because many studies are short term with regards to diabetes remission. This study to assess 5 year outcomes of medical versus surgical treatment was designed to look at outcomes up to and beyond 5 years in a total of 60 patients. It is worth mentioning that the surgical procedures were either Roux-en-Y gastric bypass or bilipancreatic diversion, the latter not being a common procedure in the UK. More of the surgical patients reached HbA1c levels of <6.5%. This group also demonstrated more significant improvement in their lipid profiles and blood pressure. In those patients who went into remission from diabetes, after 5 years, 53% of the bypass and 37% of the biliopancreatic diversion patients relapsed. So, despite significant weight loss and early remission from diabetes, the glycaemic control of these patients should still be monitored because of the potential to relapse.
Earlier intensified insulin treatment of T1D – association with long-term macrovascular & renal complications
Rathsman et al. Diabetic Medicine. DOI: 10.1111/dme.12897
As with the UKPDS and DCCT legacy studies, this study re-examined patients originally enrolled into the Stockholm Diabetes study. Patients originally recruited in 1982-84 were prospectively re-evaluated until 2011 with regard to all cause mortality and composite mortality including MI, stroke and end stage renal failure. Despite 28 years of follow up, there was no difference in the incidence of macro vascular disease or end stage renal disease between the previously intensive and conventionally treated groups. These groups had shown differences in HbA1c which disappeared after the original study. This study contrasts significantly with the DCCT (Type 1) and UKPDS (Type 2) which reinforced the concept of metabolic memory where early intervention lead to sustained long term effects although this study looked at a mere 102 patients.
Association between hyperglycaemia and adverse perinatal outcomes in south Asian and white British women
Dr Diane Farrar et al. The Lancet Diabetes & Endocrinology. Doi: http://dx.doi.org/10.1016/S2213-8587(15)00255-7
Gestational diabetes (GDM) has a significant impact on babies including them being large for gestational age (LGA) and having a future risk of obesity. This has been recognised in the 2015 NICE guidance which has changed the threshold for diagnosis. However, it is well recognised that S Asian women have a higher risk of GDM, complicated by the fact that their babies tend to have a lower risk of LGA but have increased adiposity. The Born in Bradford study has collected a significant amount of information from a large cohort of women including large numbers of S Asian origin and assessed the association between maternal glucose and adverse perinatal outcomes to assess whether the threshold to diagnose GDM should vary depending on ethnicity. A fasting glucose concentration of 5·4 mmol/L or a 2 h post-load level of 7·5 mmol/L identified white British women with 75% or higher relative risk of LGA or high infant adiposity; in south Asian women, the cutoffs were 5·2 mmol/L or 7·2 mmol/L. The data suggests that current NICE guidelines may be diagnosing too few S Asian women with GDM and that lower thresholds should apply to this group. This is in keeping with IADSP and WHO guidance for GDM but would have a major impact on already stretched diabetes services if it was introduced.
Use of an α-Glucosidase Inhibitor and the Risk of Colorectal Cancer in Patients with Diabetes
Yao-Hsien Tseng et al. Diabetes Care. Doi: 10.2337/dc15-0563
It has previously been suggested that there may be an association between diabetes therapies and malignancy. Inhaled insulin was reported to increase the incidence of lung cancer and this was followed by concerns regarding the incretin therapies (pancreatic cancer) and bladder cancer, with both pioglitazone and dapagliflozin. Fortunately, none of these have been confirmed, nevertheless examination of cancer risk for diabetes therapies has become a legitimate activity. This publication from Japan examines the risk of colorectal cancer in patients being treated with acarbose. Less than 2% of acarbose is systemically absorbed and so the potential for alteration in malignancy risk is limited to the bowel. They conducted a nationwide, population-based study using the Taiwan National Health Insurance Research Database. Over one million patients with newly diagnosed diabetes were enrolled between 1998 and 2010. There were 1,332 incident cases of colorectal cancer with a rate was 89.6 cases per 100,000 person-years. Patients treated with acarbose had a 27% reduction in risk with a dose-dependent manner. Unfortunately, the bowel-related side-effects of acarbose mean that few patients in the UK will benefit…
Statins and the Risk of Pancreatic Cancer in Type 2 Diabetic Patients – A Population-Based Cohort Study
Mei-Jyh Chen et al. International Journal of Cancer. Doi: 10.1002/ijc.29813
Pancreatic cancer is the fourth leading cause of cancer deaths in the United States; only 4% of patients survive 5 years due to late diagnosis. Type 2 diabetes (T2DM) is a risk factor for pancreatic cancer with duration of T2DM greater than 5 years associated with a 50% increased relative risk. Several studies have suggested that statins possess anti-cancer potential through inhibition of cell cycle proliferation, induction of apoptosis and suppression of tumor progression. This study was another retrospective population-based cohort study using the National Health Insurance Research database (NHIRD) in Taiwan. This time patients diagnosed with a first-time diagnosis of T2DM between 1997–2010 were examined and the event of interest was newly diagnosed pancreatic cancer. In the 450,282 patients defined as ‘statin users’ 0.14% developed pancreatic cancer whereas in the 690,335 patients labelled as ‘statin nonusers’ this event occurred in 0.25%. Statin use significantly decreased the risk of pancreatic cancer with a significant dose-effect – the higher the exposure to statin, the lower the risk.
A correctible and even preventable contributing component in diabetes care corresponds to physicians’ performance. After 3 years of implementation, coaching was found to be worth the effort to improve type 2 diabetes control in primary care (Primary Care Diabetes)
Higher lactation intensity and longer duration were independently associated with lower 2-year incidences of DM after GDM pregnancy (Annals of Internal Medicine)
Among eyes with proliferative diabetic retinopathy, treatment with ranibizumab resulted in visual acuity that was noninferior to (not worse than) PRP treatment at 2 years. Although longer-term follow-up is needed, ranibizumab may be a reasonable treatment alternative, at least through 2 years, for patients with proliferative diabetic retinopathy (JAMA)
In this large, real world study, progressive uptitration with gliclazide MR 60 mg once daily appears to be efficacious and safe in individuals with suboptimal glycemic control at various stages of the diabetes continuum (Diabetes Research and Clinical Practice)
Using personal and microbiome features enables accurate glucose response prediction (Cell)
Testosterone levels are not associated with CAN among men with type 1 diabetes (Journal of Sexual Medicine)
Liraglutide was safe, well tolerated, and led to histological resolution of non-alcoholic steatohepatitis, warranting extensive, longer-term studies (The Lancet)
Comorbid stress and/or depressive symptoms are common in individuals with diabetes and together are associated with progressively increased risks for adverse CV outcomes (Diabetes Care)
Among women with a history of GDM, a low-carbohydrate dietary pattern, particularly with high protein and fat intake mainly from animal-source foods, is associated with higher T2DM risk, whereas a low-carbohydrate dietary pattern with high protein and fat intake from plant-source foods is not significantly associated with risk of T2DM (Diabetes Care)
Second Edition Published 2015
Published by Oxford University Press
Reassuringly, when I took this book in my hand it felt like a handbook – this is not a redundant tautology but an often overlooked prerequisite for this genre. I will take this manual with me as a habitual prop. It fits comfortably in the pocket. The information flows intuitively – the chapters, sections, subsections, succinct tables and chapter summaries are of a perfect size for a handbook / manual. All books can be interrogated via Contents or Index, but when you arrive at a given topic does it answer your query in one or two small pages? – probably not – but this book does! Be it signs and symptoms, investigations, diagnosis, or treatment, they are all dealt with in a practical way. This is a user-guide for healthcare professionals of all complexions who are treating a growing number of patients with diabetes. It is a singular achievement to produce a handbook that caters for all audiences. Diabetic nurses will find it an essential resource. It will enable interested patients to better understand their condition and treatment, along with the role of healthcare professionals in their care. Physicians will find within a concise presentation of diagnostic and therapeutic parameters, goals and outcomes, both for the disease process itself and of its sequelae. For all it will provide a handy and continual perspective of where their particular care paradigms, both global and local, sit in the panoply of diabetes pathology and treatment, which is the basis of the interplay between patient and care giver.
These results demonstrate that MDT and maggot ES can promote diabetic foot wound healing by up-regulating endothelial cell activity (Journal of Diabetes and Its Complications)
England, Wales and the Isle of Man (HQIP)
NAFLD might be a risk factor for DN. Elevated liver fat content could be associated with higher DN burden (PLoS ONE)