Journal Watch

Prepared for IDDT by Jim Young

February 2016

Initiation of insulin adjustment for carbohydrate at onset of diabetes in children using a home-based education programme with a bolus calculator
H Thom et al. Practical Diabetes.

The preamble to this paper reminds us that glycaemic control in young people with diabetes remains sub-optimal, putting large numbers at risk of long-term complications. It also asserts that in the UK this has unfortunately failed to be addressed by the widespread use of intensive insulin therapy (multiple daily insulin injections [MDI] and insulin pumps) in routine everyday clinical practice. A major influence on long-term glycaemic control appears to be the optimisation of blood glucose levels in the immediate period following diagnosis. This study utilised data collected from children and adolescents diagnosed with T1DM within NHS Tayside. The new patient programme, introduced in 2012, involved two major changes to the established practice: (1) adjustment of rapid-acting insulin to carbohydrate (CHO) content, and (2) setting of standardised blood glucose targets. The authors successfully introduced insulin adjustment for CHO and preprandial glucose targets using a commercially available bolus calculator with MDI from the onset of diagnosis in a home-based new patient programme. They observed significant improvements in HbA1c in the first 12 months compared with their previous experience over the preceding decade. Based on their findings they suggest that this intensive approach should be adopted as routine practice.
http://www.practicaldiabetes.com/SpringboardWebApp/userfiles/espdi/file/January%202016/OA%20ThomQ7%20laserwords.pdf

 

GLP-1 analogue use in patients with sub-optimally controlled type 1 diabetes or obesity improves weight and HbA1c
Louise Curtis et al. Practical Diabetes

The authors of this paper say that Intensive insulin therapy in type 1 diabetes (T1DM) can be associated with weight gain for two reasons: the nonphysiological pharmacokinetic and metabolic profiles that follow subcutaneous administration of insulin, and a higher rate of hypoglycaemia which can lead to increased calorie intake. While most medical therapies in the management of diabetes increase weight, there are a limited number of drugs which have proven to have some benefit as add-on therapy to lifestyle for weight loss in type 2 diabetes (T2DM). Incretins are a group of gut derived hormones involved in glucose regulation. The peptide hormone GLP-1 mediates the incretin pathway leading to lower postprandial glucose levels via multiple mechanisms. They act by increasing insulin secretion and decreasing glucagon secretion from the pancreas following nutrient ingestion. Six GLP-1 analogues are known to hold extrapancreatic effects including slowing the rate of gastric emptying and reducing gastric acid secretion resulting in a decrease of the postprandial glucose peak. The authors state in their paper that currently GLP-1 analogues are not licensed for T1DM but have potential for improving glycaemic control through these mechanisms of action. In this study the investigators carried out a retrospective observational case note review of their patients with T1DM who were started on a GLP-1 analogue between 2011 and 2014. They found that adding a GLP-1 analogue to an established insulin regimen led to a sustained, statistically significant and clinically relevant weight loss in T1DM patients and also improved glycaemic control, with no evidence of metabolic decompensation. The authors assert that they have demonstrated that the addition of a GLP-1 analogue to existing treatment for a selected group of patients resulted in significantly improved glycaemic control and weight reduction in patients with type 1 diabetes.
http://www.practicaldiabetes.com/SpringboardWebApp/userfiles/espdi/file/January%202016/OA%20Partridge%20laserwords.pdf

 

Diabetes Transition Service Specification
Quality Strategy Team, Medical Directorate, NHS England
 
This guidance sets out a best practice model and outlines the considerations commissioners may want to make in stipulating and providing services for young people with diabetes going through the transition process. The caveat at the end of the document says “Commissioners should note that this national context is emerging, and that the nature and prevalence of diabetes in the UK is an evolving picture. The incidence of type 2 diabetes in young people is increasing with the prevalence of childhood obesity”. The specification is non-mandatory but is well worth a read as it is designed to inform the development of a clear local approach with multi-agency partnerships including: health, social care, education, local authorities and where appropriate, third sector providers. The subject headings are:
Introduction
Wider context of transition and diabetes in young adults
Mental health and diabetes
Financial cost of failing to implement appropriate transition
Needs of parents and carers
Structure of service development
Paediatric/early preparation
Planned transfer
Supported integration
Links to other documents and sources of support
https://www.england.nhs.uk/wp-content/uploads/2016/01/diabetes-transition-service-specification.pdf

 

Day and night glycaemic control with a bionic pancreas versus conventional insulin pump therapy in preadolescent children with type 1 diabetes
Steven J Russell et al. The Lancet Diabetes & Endocrinology. Doi: http://dx.doi.org/10.1016/S2213-8587(15)00489-1

Because the safety and efficacy of continuous, multiday, automated glycaemic management has not been tested in outpatient studies of preadolescent children with type 1 diabetes, the investigators compared the safety and efficacy of a bihormonal bionic pancreas versus conventional insulin pump therapy. Their study (conducted in the USA) looked at preadolescent children (aged 6–11 years) with type 1 diabetes diagnosed for over 1 year. They found that the bionic pancreas improved mean glycaemia and reduced hypoglycaemia compared to insulin pump therapy. The authors advise that studies of a longer duration during which children use the bionic pancreas during their normal routines at home and school should be done to investigate the potential for use of the bionic pancreas in real-world settings.
http://www.thelancet.com/journals/landia/article/PIIS2213-8587(15)00489-1/abstract

 

National survey of the management of Diabetic Ketoacidosis (DKA) in the UK in 2014
K. K. Dhatariya et al. Diabetic Medicine. Doi: 10.1111/dme.12875

This study examined the outcomes of adult patients presenting with DKA in 2014, and it mapped these against accepted UK national guidance. A standardised form covering clinical and biochemical outcomes, risk and discharge planning was sent to all UK diabetes specialist teams (220). The results showed that 7.8% of cases occurred in existing inpatients, 6.1% of admissions were newly diagnosed diabetes and 33.7% of patients had had at least one episode of DKA in the preceding year. They discovered significant issues with care processes. Initial nurse-led observations were carried out well, but subsequent patient monitoring remained suboptimal. Most patients were not seen by a member of the diabetes specialist team during the first 6 hours, but 95% were seen before discharge. So the conclusion was that despite widespread adoption of national guidance, several areas of management of DKA were suboptimal, and were associated with avoidable biochemical and clinical risk.
http://onlinelibrary.wiley.com/doi/10.1111/dme.12875/abstract

 

National Diabetes Audit – 2013-2014 and 2014-2015
HSCIC

The National Diabetes Audit (NDA) provides a comprehensive view of Diabetes Care in England and Wales and measures the effectiveness of diabetes healthcare against NICE Clinical Guidelines and NICE Quality Standards. The main report contains information on the national key findings and recommendations. The main report has also been developed as a power point presentation, along with slides highlighting the national findings there is also space to allow the incorporation of locally produced slides. Supplementary data for England and Wales are contained in the Excel spreadsheets. There are also 3 interactive Excel spreadsheets which allow users to select the GP practice (England only), Local Health Board (Wales only) or Secondary Care Service (England only) of choice, information for the chosen site is then displayed in tables and charts.
http://www.hscic.gov.uk/searchcatalogue?productid=20155&q=%22National+diabetes+audit%22&sort=Most+recent&size=10&page=1#top

 

Initiation of insulin pump therapy in children at diagnosis of type 1 diabetes resulted in improved long-term glycemic control
Eunice G. Lang et al. Pediatric Diabetes. Doi: 10.1111/pedi.12357

Although insulin pump therapy (IPT) is increasingly used in children and young people with type 1 diabetes, there are limited studies evaluating the optimal time to start IPT. This study asked if early initiation of IPT in children with type 1 diabetes would lead to improved glycaemic control and quality of life (QOL). Data on HbA1c, rate of severe hypoglycemia, and diabetic ketoacidosis (DKA) was collected retrospectively over a 48-month period. It was found that initiation of IPT at diagnosis of type 1 diabetes in children resulted in consistently lower HbA1c with no apparent change in hypoglycemia, DKA, or QOL.
http://onlinelibrary.wiley.com/doi/10.1111/pedi.12357/abstract

 

The UK NSC recommendation on Diabetic Retinopathy screening in adults
UK National Screening Committee (UK NSC)

This information source has links to the following PDFs:

Recommendation statement
Last external review – Study group
Last external review – Impact of changing intervals on outcomes
Last external review – Impact of changing intervals on uptake
Last external review – Cost utility
Last external review – DES Recommendation Summary
Last evidence review summary

The take away point was that for people with diabetes at low risk of sight loss, the interval between screening tests should change from one year to two years. The current one-year interval should remain unchanged for the remaining people at high risk of sight loss.
http://legacy.screening.nhs.uk/diabeticretinopathy

 

Estimating the impact of better management of glycaemic control in adults with Type 1 and Type 2 diabetes on the number of clinical complications, and the associated financial benefit
M. Baxter et al. Diabetic Medicine. Doi: 10.1111/dme.13062

In this study the cumulative incidence of microvascular and macrovascular complications was modelled across 5-year periods to a 25-year time horizon. Complication costs were applied to the data to estimate potential accrued cost avoidance. The startling findings were that a significant cost avoidance of approximately £340m was apparent in the first 5 years, increasing to about £5.5bn after 25 years of sustained improvement in control! The authors note that the overwhelming majority of cost avoidance arose from reductions in microvascular complications. In people with Type 1 diabetes the greatest cost avoidance comes from a reduction in renal disease (74% of cost avoidance), while in people with Type 2 diabetes it is generated by a reduction in foot ulcers and amputations and neuropathy: 57% cost avoidance). They also note that greater cost reduction accrued more rapidly in people with higher starting HbA1c levels. The authors assert that their study provides clear support for the premise that prioritized and sustained investment in early and better intervention can provide concrete financial benefits in both the short and longer term.
http://onlinelibrary.wiley.com/doi/10.1111/dme.13062/abstract

 

Diabetes in pregnancy
NICE quality standard [QS109]

The introduction to this NICE quality standard offers the perspective that approximately 700,000 women give birth in England and Wales each year, and up to 5% of these women have either pre‑existing diabetes or gestational diabetes. Of women who have diabetes during pregnancy, it is estimated that approximately 87.5% have gestational diabetes (which may or may not resolve after pregnancy), 7.5% have type 1 diabetes and the remaining 5% have type 2 diabetes. NICE recommends that this quality standard, in conjunction with the guidance on which it is based, should contribute to the improvements outlined in the following 2 outcomes frameworks published by the Department of Health:

NHS Outcomes Framework 2015–16
http://www.gov.uk/government/publications/nhs-outcomes-framework-2015-to-2016  

Public Health Outcomes Framework 2013–16.
http://www.gov.uk/government/publications/healthy-lives-healthy-people-improving-outcomes-and-supporting-transparency

It then goes on to explore in sub-categories details of the following seven statements:

Statement 1. Women with diabetes planning a pregnancy are prescribed 5 mg/day folic acid from at least 3 months before conception.
Statement 2. Women with pre‑existing diabetes are seen by members of the joint diabetes and antenatal care team within 1 week of their pregnancy being confirmed.
Statement 3. Pregnant women with pre‑existing diabetes have their HbA1c levels measured at their booking appointment.
Statement 4. Pregnant women with pre‑existing diabetes are referred at their booking appointment for retinal assessment.
Statement 5. Women diagnosed with gestational diabetes are seen by members of the joint diabetes and antenatal care team within 1 week of diagnosis.
Statement 6. Pregnant women with diabetes are supported to self‑monitor their blood glucose levels.
Statement 7. Women who have had gestational diabetes have an annual HbA1c test.

http://www.nice.org.uk/guidance/qs109