Treatment persistence after initiating basal insulin in type 2 diabetes patients
Stefan Pscherer et al. Primary Care Diabetes. Doi: http://dx.doi.org/10.1016/j.pcd.2015.01.011
In the management of type 2 diabetes, treatment intensification is often delayed, a phenomenon labeled ‘clinical inertia’. It is regarded as a collusion between patients and clinicians and thought to highlight inadequacies of current therapy options. Thus, a retrospective cohort study in the UK in 2013, revealed the median time to intensification with a third oral antidiabetic agent was almost seven years in patients with an HbA1c >8% (64 mmol/mol) and median time to insulin in those on triple oral therapy was six years. This is not because patients were hitting target (currently 7.5% – 58mmol/mol – NICE 2009); the mean HbA1c for patients on triple therapy was 9.7% when insulin was started. Now a manuscript from Germany suggests that things may be worse than we thought since at two years, less than two thirds of patients were persisting with the basal insulin that had been added to their oral regimen. Germany has had a different therapy algorithm to the UK with much earlier introduction of basal insulin. An accurate examination of UK practice would be of interest.
Expedited biliopancreatic juice flow to the distal gut benefits the diabetes control after duodenal-jejunal bypass
Haifeng Han et al. Obesity Surgery. Doi: 10.1007/s11695-015-1633-7
It is clear that malabsorptive bariatric procedures rapidly reverse hyperglycaemia in type 2 diabetes (T2DM) with patients going from massive pre-operative insulin requirements to zero within days. This demonstrates that pancreatic beta-cells are not irreversibly lost or shut down and implies that something other than weight loss induced by the operation is leading to their reinvigoration. This article shows that an operation that leads to rapid delivery of bile and pancreatic secretions to the distal part small bowel (rather than via the duodenum) enhances the secretion of Glucagon-like peptide-1 (GLP-1). Since GLP-1 receptor agonists are now established therapies for T2DM, it suggests a mechanism for the rapid impact of some bariatric procedures. But beware. This is an animal study (performed in rats) and it seems that GLP-1 works differently in rodents. For example, a study of lixisenatide showed beneficial effects on glucose control in patients, despite no increase in insulin secretion – suggesting that the impact of gastric emptying (largely thought of as a side-effect) may be an important mechanism of action.
Improving diabetes prevention with benefit based tailored treatment
Sussman J. Kent D. et al. British Medical Journal. Doi: http://dx.doi.org/10.1136/bmj.h454
According to this paper “The American Diabetes Association now recommends intensive lifestyle interventions or metformin to prevent diabetes for people at high risk.” But the problem is targeting the correct group of people and giving them the appropriate intervention which may not be the same for everyone. In fact, this paper showed that by identifying the highest risk patients and concentrating treatment then maximal impact can be made compared to those at lower risk. The researchers showed that the highest risk people in the study group accounted for most of the total benefit of metformin. Whilst the lower risk people derived little and even no benefit from the intervention. Concentrating on the people most at need, not only is an efficient use of scarce healthcare resources but the treatment can be indivualised to the specific patient with the lower risk patients avoiding exposure to metformin and it’s possible side effects. A potential big issue is finding a validated risk stratification tool that is relevant to the population requiring the intervention.
Weight-based hypoglycaemia treatment protocol for adults with Type 1 diabetes
L. McTavish et al. Diabetic Medicine. Doi: 10.1111/dme.12730
Hypoglycaemia is the acute complication of diabetes management most disliked by patients with many making decisions about their control to avoid it. However, once a hypo occurs, the treatment used by patients does vary with many consuming as much carbohydrate as possible with the resultant swing to significant hyperglycaemia. This over treatment is recognised during patient education where there is a move to individualise treatment in a similar way to insulin dose calculation via carbohydrate counting. At present, standard advice is either to take 15g glucose (possibly in the form of dextrose tablets or 3 ‘jelly babies’) or 0.2g/ kg glucose. This small study of only 34 patients found that a weight based protocol of 0.3g/kg was more effective than the other two with post treatment levels rising further into the normoglycaemic range. Whilst increased weight based calculations may be more effective, a patient suffering from hypoglycaemia will still require this translating into specific amount of food/ drink – perhaps 4 jelly babies instead of 3.
New thresholds for diagnosis of diabetes in pregnancy
Gestational diabetes (GDM) is one of the commonest medical complications of pregnancy and, as demonstrated in the HAPO study, is associated with a number of complications including large babies, shoulder dystocia and a small increased risk of still birth/ miscarriage. NICE’s previous guidance from 2008 predates this study and as a result, its updated guidance has been greatly anticipated. The main (and most controversial) change to this is the adoption of a fasting glucose value of 5.6mmol/l or above or a 2 hour glucose of 7.8mmol/l or above. Whilst the value of 5.6mmol/mol is higher than many international guidelines based on WHO/ IADSPG criteria, it will still result in many more women being diagnosed with diabetes than with its 2008 guidance. Given that many clinics are already saturated with GDM patients following previous guidance, this change will increase numbers even further – but less so than if the more stringent targets were used and is probably a reasonable compromise.