Effectiveness of peer support for improving glycaemic control in type 2 diabetes
Li Qi, Qin Liu et al. BMC Public Health. Doi: 10.1186/s12889-015-1798-y
This fascinating paper from China offers an impressive non pharmacological approach to improving diabetic control in type 2 diabetes. Utilising peer support, this study showed that “a pooled mean reduction of 0.57% in HbA1c levels compared with usual care”. This meta-analysis managed to find 13 randomised controlled trials which covered over 2300 patients. Interestingly, those less well controlled seemed to benefit more than their better controlled counterparts. As well as being innovative, this may provide a cost effective contribution to the management of diabetes in some groups of people. Most of the 13 trials were based within the United States, which means more research is needed to assess its suitability in other countries such as the UK. Not only that, we need to be more precise on what is the most effective form of peer support. The paper also mentions telephone based peer support and this could be another suitable intervention. I would guess peer support could offer an attractive option as a relatively low cost solution to manage the ever expanding diabetic workload. But we need more proof of effectiveness.
A decade in diabetes specialist services, 2000 to 2011, in England
C.A. Gosden, K. Barnard et al. Diabetic Medicine. Doi: 10.1111/dme.12786
As a GP witnessing perpetual change in our NHS working environment, I find fascinating to observe the view from specialist services. The results are not that surprising but good to see that efforts have been made to verify staff views and this was obtained through interviews. Analysis of the results concluded that people are prepared to accept change and admire the workings of a multidisciplinary team. However the ongoing organisational working pattern changes have had a corrosive effect on morale, as working relationships and team building are disrupted. Admittedly these results are based on a relatively small sample but they make sense and probably chime with many NHS workers’ feelings. Lack of resources was quoted as an issue and I am sure that remains relevant to today’s climate. I am sure these results apply not to just diabetic services but it would be good to see this work replicated elsewhere in other specialities with greater numbers. From my perspective as a GP, I can see many similarities in primary care to the concerns expressed by the diabetic team.
MicroBiome therapeutics receives positive response from FDA for diabetes drug NM505
There is increasing interest in how changes in bowel microbiota might be linked to metabolic diseases such as obesity, cardiovascular disease and type 2 diabetes (T2DM). This has been fuelled by publication of a genetic analysis of bowel microbes showing differences in women with normal, impaired and glucose intolerance and the intriguing report of a patient becoming obese after receiving a faecal transplant for treatment of Clostridium difficile infection. There have been suggestions that the epidemic of T2DM can be explained by changes in the bowel microbiome (i.e. it is a major environmental factor) and that the glycaemic impact of bariatric surgery is related to alterations in gut microbes. This study reports on another way in which the microbiome may be involved in T2DM. NM505 is a proprietary combination of a microbiome modulator and metformin, the most widely prescribed first-line therapy worldwide for T2DM. Unfortunately metformin is often poorly tolerated, due to gastro-intestinal side-effects. This proof-of-concept study showed that NM505 improved the tolerability of metformin while further reducing blood glucose levels, introducing the possibility of revisiting metformin use in previously intolerant patients.
Diabetes complications at presentation and one year by glycated haemoglobin at diagnosis in a multiethnic and diverse socioeconomic population: results from the South London Diabetes StudyAzam M, Marwood L. Journal of Diabetes Research. Doi: http://dx.doi.org/10.1155/2015/587673
The use of a cut off HbA1c of ≥48mmol/mol has been introduced following several publications linking HbA1c and diabetes related complications, specifically retinopathy. Its use has also been adopted as the measurement of plasma glucose (fasting or during a glucose tolerance test) has been considered inconvenient. However, given that its levels can be affected by non glycaemic issues, there may be concerns as to whether it enables diagnosis of all patients with diabetes. This multiethnic South London study compared patients previously diagnosed with diabetes using glucose status with HbA1c < and > 48mmol/mol. In this cohort, 22% of people previously diagnosed with T2DM would not be deemed diabetic, where HbA1c was the sole diagnostic criterion. These people were older at diagnosis and more likely to be of white ethnicity. They were also more likely to have been asymptomatic at diagnosis. Delayed diagnosis may be clinically relevant due to the development or progression of complications. Whilst HbA1c >48 is diagnostic, a result <48mmol/mol cannot be taken as conclusive evidence to exclude T2DM. It is also worth pointing out that WHO state that a diagnosis based on glucose measurements trumps an HbA1c<48mmol/mol.
High strength, fixed combination and biosimilar insulin products: minimising the risk of medication error
Medicines and Healthcare Products Regulatory Agency. 29 April 2015
Until recently, the vast majority of insulin preparations were in the concentration of U100 (100 units/ml). However, several new high strengths insulins are now on the market including U200 insulin Degludec, U200 Humalog and U300 Lantus. These insulins have been developed for patients with large daily insulin requirements to reduce the number and volume of injections. As a result, a new term ‘the dose step’ has been developed to enable patients to appropriately dial up their required insulin dose. For original U100 Lantus, U300 Lantus, U100 Degludec and both strengths of Humalog (U100 and U200), one dose step is equivalent to one unit of insulin whilst for Degludec, one dose step on the U200 is equivalent to two units of insulin. Advice is given in this update from the European Medicines Agency to health care professionals as to how to help patients starting or transferring onto these new insulins including education, dose adjustment and blood glucose monitoring.