Journal Watch

Prepared for IDDT by Jim Young

August 2014

Annual diabetes checks among indicators proposed for latest NICE QOF menu
A series of annual checks to monitor and improve the health of people with diabetes are among measures proposed by NICE for its latest Quality and Outcomes Framework (QOF) indicator menu:

  • BMI measurement
  • BP measurement
  • HbA1c measurement
  • Cholesterol measurement
  • Record of smoking status
  • Foot examination
  • Albumin: creatinine ratio
  • Serum creatinine measurement

The QOF is a voluntary incentive scheme for GP practices in the UK, rewarding them for how well they care for their patients, and helping them target resources for where they are most needed. It consists of groups of indicators against which practices score points according to their level of achievement.


Once-weekly exenatide as adjunct treatment of type 1 diabetes mellitus in patients receiving continuous subcutaneous insulin infusion therapy
Andrea N. Traina et al. Canadian Journal of Diabetes. Doi:10.1016/j.jcjd.2013.10.006

The use of once-weekly exenatide in type 2 diabetes mellitus is well supported, but little is known about its effectiveness in type 1 diabetes. The objective of this study was to determine the clinical efficacy of once-weekly exenatide on glycemic control in patients with type 1 diabetes when added to basal-bolus insulin therapy. The study revealed that the addition of once-weekly exenatide to insulin therapy for patients with type 1 diabetes led to significant improvements in HbA1C, body weight, body mass index and insulin doses. [Exenatide is a glucagon-like peptide-1 agonist (GLP-1 agonist), belonging to the group of incretin mimetics, approved in April 2005 for the treatment of type 2 diabetes mellitus]. [Incretins are a group of gastrointestinal hormones that cause an increase in the amount of insulin released from the beta cells of the islets of Langerhans after eating].


Effect of intensive diabetes treatment on albuminuria in type 1 diabetes
Ian H de Boer et al. The Lancet Diabetes & Endocrinology. Doi: 10.1016/S2213-8587(14)70155-X

This long-term follow-up study compared the long-term effects of intensive versus conventional treatment on incident albuminuria. 1,441 patients participated in the study and the effect on albuminuria was assessed for 18 years after the completion of the trial. It was found that intensive diabetes treatment yielded durable renal benefits that persist for at least 18 years after its application. The authors posit that such benefits should result in fewer patients requiring renal replacement therapy.


Outpatient glycemic control with a bionic pancreas in type 1 diabetes
Steven J. Russell et al. NEJM. Doi: 10.1056/NEJMoa1314474

This paper reports on the comparison between glycemic control with a wearable, bihormonal, automated, “bionic” pancreas with glycemic control using an insulin pump. It was found that compared with an insulin pump, a wearable, automated, bihormonal, bionic pancreas improved mean glycemic levels, with less frequent hypoglycemic episodes, among both adults and adolescents with type 1 diabetes mellitus. [A Bihormonal system delivers both insulin to move glucose into the body’s cells – and glucagon, for when blood glucose levels are low]


Increased risk of severe hypoglycemic events with increasing frequency of non-severe hypoglycemic events in patients with type 1 and type 2 diabetes
Seamus Sreenan et al. Diabetes Therapy. Doi: 10.1007/s13300-014-0075-x

The authors remind us that severe hypoglycaemic events (SHEs) are associated with significant morbidity, mortality and costs. However, the more common non-severe hypoglycaemic events (NSHEs) are less well explored. Their paper investigated the association between reported frequency of NSHEs and SHEs among patients with type 1 diabetes mellitus (T1DM) and type 2 diabetes mellitus (T2DM). The investigators used the PREDICTIVE study which was a global, prospective, observational study that included 7,420 with T1DM and 12,981 patients with T2DM. Using insulin detemir as the treatment the number of NSHEs and SHEs experienced during the 4 weeks prior to baseline and follow-up visits (mean 14.4 weeks) were recorded. It was found that a statistically significant association between NSHE and SHE frequency was found in both T1DM and T2DM. The authors assert that the data provided a clear rationale for the reduction of hypoglycemic events, regardless of severity, while striving for optimal glycemic control.


Assessment of the association between glycemic variability and diabetes-related complications in type 1 and type 2 diabetes
J. Smith-Palmer et al. Diabetes Research and Clinical Practice. Doi:10.1016/j.diabres.2014.06.007

This systematic literature review used PubMed, EMBASE and Cochrane Library databases to look at studies published from June 2002 to March 2014. Twenty eight articles were included in the final review. The researchers wanted to elucidate if frequent or large glucose fluctuations may contribute independently to diabetes-related complications. Eighteen studies consistently reported a positive association between increased variability and microvascular complications and coronary artery disease in type 2 diabetes, although associations between glucose variability and other macrovascular complications were inconsistent. Seven studies reported that increased glucose variability appeared to play a minimal role in the development of micro- and macrovascular complications in type 1 diabetes. The conclusions were that in type 2 diabetes glucose variability is associated with development of microvascular complications, but the role of increased glucose variability in terms of microvascular and macrovascular complications in type 1 diabetes is less clear.


New insulin glargine 300 units/ml versus glargine 100 units/ml in people with type 2 diabetes using basal and mealtime insulin
Matthew C. Riddle et al. Diabetes Care. Doi: 10.2337/dc14-0991

This 6-month, multinational, open-label, parallel-group study recruited adults with HbA1c 7.0 to 10.0% (53–86 mmol/mol). [An open-label trial is a type of clinical trial in which both the researchers and participants know which treatment is being administered]. The subjects were randomized to using Gla-300 or Gla-100 once daily with dose titration seeking fasting plasma glucose 4.4–5.6 mmol/L. The primary end point was HbA1c change from baseline; main secondary end point was percentage of participants with one or more confirmed (≤3.9 mmol/L) or severe nocturnal hypoglycemia from week 9 to month 6. The authors report that Gla-300 controlled HbA1c as well as Gla-100 for people with type 2 diabetes treated with basal and mealtime insulin, but with consistently less risk of nocturnal hypoglycemia.


Bariatric surgery induces weight loss but does not improve glycemic control in patients with type 1 diabetes
Matthias Lannoo  et al. Diabetes Care. Doi: 10.2337/dc14-0583

This study looked at data from 22 patients with confirmed type 1 diabetes and BMI ≥35 kg/m2 from three Belgian bariatric surgery centers. Six patients underwent sleeve gastrectomy and 16 had Roux-en-Y gastric bypass surgery. The authors found that although bariatric surgery led to substantial weight loss they are unable to confirm improvement of glycemic control. They did confirm an insulin-sparing effect, which they posit was most probably due to an improvement in insulin sensitivity following weight loss.


Glucagon-like peptide 1 receptor agonist is more efficacious than insulin glargine for poorly controlled type 2 diabetes
Fu-peng Liu et al. Journal of Diabetes. Doi: 10.1111/1753-0407.12200

The researchers investigated Medline, EMBASE, Cochrane Library, and for trials that met their inclusion criteria. References and cited papers of relevant articles were also examined. From the seven trials included it was found that glucagon-like peptide 1 receptor agonist showed greater efficacy compared to insulin glargine for type 2 diabetes, and it might also prove beneficial for other diabetes-associated characteristics, including obesity, hypertension, and hyperlipidaemia. [Glucagon-like peptide-1 agonists (GLP-1 agonists) are a class of drugs for the treatment of type 2 diabetes. They are known as the "incretin mimetics"]


Barriers to initiating insulin in T2D: development of a new patient education tool to address myths, misconceptions and clinical realities
Meryl Brod et al. Patient – Patient-Centered Outcomes Research. Doi: 10.1007/s40271-014-0068-x

The purpose of this study was to identify patient beliefs as well as clinical realities about insulin that may be barriers to patients with type 2 diabetes initiating insulin treatment when that was recommended by their physician. The information was then used to develop a clinically relevant, cross-culturally valid patient education tool with the goal of providing unbiased, medically informative statements addressing these barriers. Thirteen focus groups were convened in five countries (Germany, Sweden, The Netherlands, UK, and USA). It was discovered that patient misconceptions, as well as some clinical realities about insulin treatment and diabetes could influence the decision to initiate insulin treatment and ultimately that would impact on disease management. The educational tool developed through this study was designed to help patients who are deciding whether or not to initiate insulin therapy as recommended by their physician, and facilitate patient–health-care provider interactions.