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After rewriting its draft guidance on Type 2 diabetes, NICE still do not incorporate bariatric surgery in their treatment algorithm despite a plethora of evidence suggesting that it is more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.