GLP-1As decreased risks of all-cause and CV mortality and severe hypoglycemia, whereas DPP-4Is had no effect on CV outcomes but increased risks in acute pancreatitis and hypoglycemia (Cardiovascular Diabetology)
Archives for March 2017
A Clinical Model Based on Maternal Demographic Parameters (Diabetes Research and Clinical Practice)
This study is the first to date to document that a high proportion of children hospitalized for DKA develop AKI. Acute kidney injury was associated with markers of volume depletion and severe acidosis (JAMA Pediatrics)
Among hospital-admitted individuals with diabetes, age, social deprivation, comorbidities, and ethnicity are associated with higher frequency for hospitalisation due to hypoglycaemia (Diabetes, Obesity and Metabolism)
Glyburide versus metformin and their combination for the treatment of gestational diabetes mellitus
Zohar Nachum et al. Diabetes Care. DOI: https://doi.org/10.2337/dc16-2307
Glibenclamide (or Glyburide as it is known in the US) is recommended by the 2015 NICE guidance for women with gestational diabetes who are either intolerant of Metformin or decline insulin. Despite this recommendation, its use is often avoided either due to clinical concerns about oral agents in pregnancy or its efficacy. This study examined both the efficacy and safety of the drug in comparison with, and as an addition to Metformin. Women with GDM at 13-33 weeks, poorly controlled with diet were randomised to either Metformin or Glyburide which were combined if monotherapy was insufficient. In the Glyburide group, drug failure occurred in 23% due to inadequate glycaemic control and 11% due to hypoglycaemia. For Metformin, lack of control in 28% and GI side effects in 2%. Combining the drugs reduced the requirement for insulin by 21%. There were no adverse obstetric or neonatal outcomes. Overall, the fact that this study showed comparable efficacy between the drugs along with reduced requirement for insulin suggest that Glyburide should be more actively considered with a possible advantage for Metformin over Glyburide as first-line therapy.
Comparing effects of insulin analogues and human insulin on nocturnal glycaemia in hypoglycaemia-prone people with Type 1 diabetes
L. Kristensen et al. Diabetic Medicine. DOI: 10.1111/dme.13317
Hypoglycaemia is the most common complication of treatment for Type 1 Diabetes, usually resulting from a mismatch between the blood glucose and insulin profiles. Avoiding and treating nocturnal hypoglycaemia can be more challenging especially in patients with recurrent severe episodes due to hypo unawareness. Evidence suggests that the more predictable profiles of insulin analogues reduces hypoglycaemia, a fact acknowledged by NICE guidance for T1DM. This cross over study of insulin Detemir (Levemir)/ aspart (Novorapid) and human NPH/ human regular insulin in 72 patients used hourly venous blood sampling to obtain glucose profiles for 2 consecutive nights. Mean blood glucose levels were higher in the analogue group although fasting glucose was similar. Nocturnal hypoglycaemia was less common in the analogue group (16% v 41%) Overall, the study confirms the known benefit of analogues with regard to hypoglycaemia but also demonstrates the benefit of the nocturnal glucose profile although this was only achievable with invasive testing. Newer monitors such as the freestyle libre may enable more comprehensive profiles to be obtained in order to avoid nocturnal hypoglycaemia.
Safer insulin prescribing
This document is the latest from NICE regarding hypoglycaemia. It advises: 1 Clinicians should ensure that people with diabetes who are receiving insulin therapy are given information about awareness and management of hypoglycaemia. 2 People with diabetes who use insulin and who drive should be aware of the need to notify the DVLA. 3 Clinicians should be aware of ‘sick-day’ rules and should ensure that people with diabetes who are receiving insulin therapy are given information about these. 4 They note that several new insulin products have been launched, including high-strength, fixed combination and biosimilar insulins and clinicians should be aware of the differences between these products and ensure that patients receive appropriate training on their use. 5 People should be advised to only use insulin in the way they have been trained. Finally, it recommends that adults who are using insulin therapy should receive a patient information booklet and an ‘insulin passport’ (although in the text, a safety card is seen as equivalent to the cumbersome passport). None of this is rocket science….
Managing glycaemia in older people with type 2 diabetes
Jason Gordon et al. Diabetes, Obesity and Metabolism. DOI: 10.1111/dom.12867
This study examines the health and economic outcomes of different therapeutic approaches in older patients with type 2 diabetes failing on metformin (M) monotherapy. The Clinical Practice Research Datalink (CPRD) database was used to identify 10,484 patients requiring escalation (addition or switch) to a second-line oral regimen from 01-01-2008 to 31-12-2014. Primary outcomes included time to first event (any event, myocardial infarction (MI), stroke, or composite of MI/stroke [major adverse cardiovascular event; MACE]) and total event rate. Health economic consequences were assessed using the CORE Diabetes Model (CDM). The majority of patients (42%) received a sulphonylurea (SU) as second-line treatment whilst 28% switched to SU monotherapy (28%). In multivariate adjusted analyses, total event rates for M + dipeptidyl peptidase-4 inhibitor (DPP-4) were significantly lower than M+SU for MACE (0.61, 95% confidence interval [CI]: 0.39–0.98), driven by a lower MI rate in the DPP-4 group (0.52, 95% CI: 0.27-0.99). Economic analyses estimated that M+DPP-4 was associated with the largest gain in health benefit. This study supports the use of DPP-4s in the elderly, where they are not only safe but cost-effective.
Association of fenofibrate therapy with long-term cardiovascular risk in statin-treated patients with type 2 diabetes
Marshall B. Elam et al. JAMA. DOI: 10.1001/jamacardio.2016.4828
There is no doubt that the ‘dyslipidaemia’ which fibrates partially reverse (low high density lipoprotein (HDL) cholesterol and increased triglycerides) is associated with adverse cardiovascular (CV) outcomes. The problem has been the difficulty in demonstrating that fibrate use reduces CV events. Dyslipidaemia is common in type 2 diabetes (as part of the ‘metabolic syndrome’), and so fibrates have been examined in two large diabetes CV outcomes studies – FIELD and the ACCORD lipid study. The latter investigated their use in addition to statins (as would be real-life practice) and both studies yielded negative results, aside from a possible reduction in progression of diabetic retinopathy. This publication presents data from a five-year passive follow-up of 4,644 patients who were treated in the original ACCORD lipid study. Only 4.3% of them continued on fenofibrate therapy and overall, the same neutral effect on CV events was seen. However, a reduction in CV outcomes in the subgroup of patients designated as having dyslipidaemia, as reported in the original trial, was maintained. Perhaps fibrates do have a role in this cohort?
Since the first National Diabetes audit in 2004, the annual data collection has increased in size and breadth and has become one of the pillars of assessing the quality of care of patients with Diabetes in England and Wales, both in primary and secondary care. Over the years, it has grown to encompass a number of work streams including the inpatient, pregnancy, foot, insulin pump and transition from children to adult audits. It is designed to ensure that all patients diagnosed with diabetes are recorded on a register (sub divided into Type 1 and Type 2) and to measure the percentage of people receiving the nine NICE care processes, the percentage of people reaching NICE defined targets, the rate of acute and long term complications. Its purpose is to assess local practice against NICE guidance, identify shortfalls in practice that are priorities for improvement and compare an areas servicewith local peers. The data for the 2015/ 2016 audit allows analysis down to CCG and practice level, comparing results to the previous year’s iteration. Several facts have emerged from this year’s audit. Encouragingly, participation has increased to 82.4% from 57.3% in 2014/15. The progressive rise in patients offered structured education continues to increase despite inconsistent recording of attendance. There continues to be a large variation among CCGs and local health boards, specialist and GP services for T1 and T2 diabetes, a situation not explained by case mix and with patients aged <65 performing worst. A drop in BMI and urinary albumin/ creatinine ratio measurements from earlier audits have not recovered. Encouragingly people with learning difficulties have similar care processes and target results compared to people without learning difficulties.
Clearly reducing the significant variability in care that exists should be the one of the main action points but other recommendations include attempts to improve the access to and recording of structured education attendance and in particular addressing the age related quality issues that have emerged. Allowing patients access to their practice results would also go some way in empowering them to address individual care issues.
Dr. Mark Freeman
The model enables a wide range of diabetes prevention interventions to be evaluated according to cost-effectiveness, employment and equity impacts over the short and long term, allowing decision-makers to prioritize policies that maximize the expected benefits, as well as fulfilling other policy targets, such as addressing social inequalities (Diabetic Medicine)
The development of alternative treatment strategies to better control residual thrombosis risk in diabetes will help to reduce vascular events, which remain the main cause of mortality in this condition (Cardiovascular Diabetology)
The Stepping Up model of care was associated with increased insulin initiation rates in primary care, and improvements in glycated haemoglobin without worsening emotional wellbeing (BMJ)
The National Diabetes Inpatient Audit (NaDIA) measures the quality of diabetes care provided to people with diabetes while they are admitted to hospital whatever the cause, and aims to support quality improvement. Data is collected and submitted by hospital staff in England and Wales (HQIP)
Current engagement with mHealth in this population appears low, although the findings from this study provide support for the use of mHealth in this group because of the ubiquity and convenience of mobile devices. mHealth has potential to provide information and support to this population, utilizing mediums commonplace for this group and with greater reach than traditional methods (JMIR)
The pharmacist-led review increased the number of key care processes administered and improved diabetic control during the year of programme delivery. The improvement abated during the year after, suggesting that such programmes should be ongoing rather than fixed term (BMJ)
This paper considers the issues surrounding orthopaedic surgery in patients with diabetes and the significance and management of hyperglycemia in the peri-operative period (Current Diabetes Reports)
Examination, Evaluation and Intervention
This is without doubt an impressive book but even more impressive is the fact that it is the work of a single author. Now of course that is not unique but this is a big book which runs to over 1670 pages and for one individual to produce this reference work is an impressive feat indeed.
In this Viewpoint, we highlight the importance of patient-centered goals for glucose-lowering therapy, the essential role of lifestyle modification, the mechanisms of action of current therapeutic options and their risks and benefits, and briefly comment on the recent cardiovascular outcomes trials mandated by the US Food and Drug Administration (JAMA)
Initiating BI with or without OADs is associated with short- and long-term suboptimal glycaemic control: the majority of patients fail to achieve HbA1c target ≤7% in the first 3 months, or after 2 years’ BI treatment (Diabetes, Obesity and Metabolism)
This analysis suggests that quality of care of hypoglycaemia varies according to diagnosis and medication. The group with the highest TTR (T2DM sulphonylurea treated) are possibly the clinical group in whom hypoglycaemia is most concerning. These data therefore suggest a need for education and raising awareness within the inpatient nursing staff (Acta Diabetologica)