Journal Watch

Prepared for IDDT by Jim Young

February 2017

Self-reported regular alcohol consumption in adolescents and emerging adults with type 1 diabetes
Julia M. Hermann et al. Pediatric Diabetes. DOI: 10.1111/pedi.12496

We know that the risk of hypoglycemia increases after alcohol consumption in patients with type 1 diabetes. This study aimed to investigate the association between metabolic control and self-reported alcohol consumption in young patients with type 1 diabetes. 29,630 patients from the German/Austrian DPV registry were analysed. Patients were categorised into abstainers, low-risk drinkers, and at-risk drinkers. BMI, HbA1c, and rates of severe hypoglycemia (SH) and diabetic ketoacidosis (DKA) were compared between alcohol consumption groups. Overall, 10.8% of the patients reported regular alcohol consumption. HbA1c, SH rate, and DKA rate were significantly lower in abstainers than in patients drinking alcohol. The authors suggest that self-reported alcohol consumption is likely to be underreported when collected in face-to-face settings such as doctors’ visits. Nevertheless, their data revealed a significant association between higher alcohol consumption and worse glycemic control, in particular higher DKA rates. Therefore, information about alcohol-induced complications is of great importance in diabetes education in young people with type 1 diabetes.

Hypercholesterolaemia screening in Type 1 Diabetes: a difference of opinion
T. Candler et al. Diabetic Medicine. DOI: 10.1111/dme.13322

National Institute of Health and Care Excellence guidelines on childhood Type 1 diabetes do not recommend cholesterol screening, yet the National Paediatric Diabetes Audit has an annual cholesterol measure (over 12 years) as a key outcome indicator. To clarify this, an online survey was sent to 280 members of the Association of Children’s Diabetes Clinicians to assess cholesterol screening practice in children. A total of 87 diabetes professionals (31%) responded. The results showed that 94% of respondents measured cholesterol, 33% did this annually on all children, and 7% measured fasting cholesterol. A total of 63% used no guidelines to decide treatment or further investigation. The definition of ‘high’ cholesterol varied from greater than 4.5 to greater than 8 mmol/l, with 40% giving no response or specific level. Only 14% of clinicians had started statin therapy in their diabetes clinic in the previous 5 years. The authors conclude that whilst the majority of diabetes professionals measured cholesterol in children with Type 1 diabetes, there was marked variability in sampling, in children screened and in action taken if levels were considered abnormal. It remains debatable whether cholesterol measures should be undertaken, certainly more than once, and whether cholesterol level should feature as a key outcome in the national audit in future.

Clinical, behavioural and social indicators for poor glycaemic control around the time of transfer to adult care
P. Castensøe-Seidenfaden et al. Diabetic Medicine. DOI: 10.1111/dme.13318

This retrospective cohort study describes and compares changes in glycaemic control in young people with Type 1 diabetes over time between the last 2 years in paediatric care and the first 2 years in adult care and identifies risk factors for poor glycaemic control. It found that among the 126 participants, the mean HbA1c level was 80 mmol/mol (9.4%) pre-transfer but decreased by an average of 3 mmol/mol (0.3%) each year post-transfer. The mean HbA1c of those with divorced parents was 14 mmol/mol (1.2%) higher. It also reports that almost one-third of participants were admitted to the hospital for acute diabetes care, and that low visit attendance rate, high baseline HbA1c level, learning disability and/or mental health conditions and divorced parents predicted acute hospital admissions. The authors conclude that although glycaemic control improved significantly after transfer to adult care, the mean HbA1c level remained high. They suggest that future interventions should focus on young people with divorced parents, those with a learning disability and/or mental health condition and those who do not attend clinical visits to improve HbA1c levels which would reduce hospitalisation rates.

National Diabetes Audit, 2015-2016
NHS Digital. Report 1: Care. Processes and Treatment Targets

The 39-page National Diabetes Audit makes for interesting reading, and it offers Key Findings and Recommendations, including the finding that participation has increased to 82.4% from 57.3% in 2014/15. The progressive rise in patients offered structured education also continues to increase. 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 less than 65 performing worst. The audit recommends that all services seek new approaches to diabetes service delivery for those aged under 65 to narrow the gap between them and older people. A drop in BMI and urinary albumin/ creatinine ratio measurements from earlier audits is noted, and these have not recovered. It offers details of participation and of care processes, along with education and future treatment targets.

Residual beta-cell function in diabetes children followed and diagnosed in the TEDDY study
Andrea K. Steck et al. Pediatric Diabetes. DOI: 10.1111/pedi.12485

This study explored whether children diagnosed with type 1 diabetes during islet autoantibody surveillance through The Environmental Determinants of Diabetes in the Young (TEDDY) study retain greater islet function than children diagnosed through the community. TEDDY children identified at birth with high-risk human leukocyte antigen and followed every 3 months until diabetes diagnosis were compared to age-matched children diagnosed with diabetes in the community. Both participated in long-term follow up after diagnosis. HbA1c and mixed meal tolerance test were performed within 1 month of diabetes onset, then at 3, 6, and 12 months, and biannually thereafter. The results showed that TEDDY children often had no symptoms (58%) at diagnosis and none had diabetic ketoacidosis (DKA) compared with 98% with diabetes symptoms and 14% DKA in the controls. At diagnosis, mean HbA1c was lower in TEDDY (6.8%, 51 mmol/mol) than control (10.5%, 91 mmol/mol) children. Total insulin dose and insulin dose-adjusted HbA1c were lower throughout the first year postdiagnosis for TEDDY compared with control children. The authors conclude that higher C-peptide levels in TEDDY vs community-diagnosed children persist for at least 12 months following diabetes onset and appear to represent a shift in the disease process of about 6 months. Symptom-free diagnosis, reduction of DKA, and the potential for immune intervention with increased baseline C-peptide may portend additional long-term benefits of early diagnosis.

Effect of continuous glucose monitoring on glycemic control in adults with type 1 diabetes using insulin injections – the DIAMOND randomized clinical trial
Roy W. Beck et al. JAMA. DOI: 10.1001/jama.2016.19975

Previous clinical trials showing the benefit of continuous glucose monitoring (CGM) in the management of type 1 diabetes have predominantly included adults using insulin pumps, even though the majority of adults with type 1 diabetes administer insulin by injection. This study set out to determine the effectiveness of CGM in adults with type 1 diabetes treated with insulin injections. The primary outcome measured was the difference in change in HbA1c level from baseline to 24 weeks. In the CGM group mean HbA1c reduction from baseline was 1.1% at 12 weeks and 1.0% at 24 weeks in the CGM group, and 0.5% and 0.4%, respectively, in the control group. The study demonstrated that among adults with type 1 diabetes who used multiple daily insulin injections, the use of CGM compared with usual care resulted in a greater decrease in HbA1c level during 24 weeks. The authors suggest that further research is needed to assess longer-term effectiveness, as well as clinical outcomes and adverse effects.

Comparing effects of insulin analogues and human insulin on nocturnal glycaemia in hypoglycaemia-prone people with Type 1 diabetes
P. L. Kristensen et al. Diabetic Medicine. DOI: 10.1111/dme.13317

A total of 72 people participated in this 2-year randomized, crossover trial of basal-bolus therapy with insulin detemir/insulin aspart or human NPH insulin/human regular insulin. They were studied for 2 nights during each treatment. Venous blood was drawn hourly during sleep. Primary endpoints were nocturnal glucose profiles and occurrence of hypoglycaemia (blood glucose of less than 3.9 mmol/l).
It found that during insulin analogue treatment, the mean nocturnal plasma glucose level was significantly higher than during treatment with human insulin (10.6 vs 8.1 mmol/l). The fasting plasma glucose level was similar between the treatments. Nocturnal hypoglycaemia was registered during 19/117 nights (16%) in the insulin analogue arm, and 41/101 nights (41%) in the human insulin arm. The conclusion was that treatment with insulin analogue reduces the occurrence of nocturnal hypoglycaemia assessed by nocturnal glucose profiles in people with Type 1 diabetes prone to severe hypoglycaemia. The authors assert that nocturnal glucose profiles provide a more comprehensive assessment of clinical benefit of insulin regimens as compared to conventional recording of hypoglycaemia.

Diabetes as a risk factor for acute coronary syndrome in women compared with men
Xue Dong et al. Diabetes/Metabolism Research and Reviews. DOI: 10.1002/dmrr.2887

Diabetes mellitus is a strong risk factor for acute coronary syndrome (ACS). Whether diabetes confers the same excess risk of ACS in both sexes is unknown. This meta-analysis (PubMed, Embase, and Cochrane Library) estimated the relative risk for ACS associated with diabetes in men and women. It found that the excess risk of ACS associated with diabetes is significantly higher in women than men. The authors posit that this finding may be explained by more adverse cardiovascular risk profiles and suggests that further work is needed to clarify the relevant biological, behavioural, or social mechanisms.

National Chronic Kidney Disease Audit

Chronic Kidney Disease (CKD) is a long-term irreversible deterioration in the function of the kidneys often found in patients who also have diabetes and high blood pressure. It affects approximately 5.5% of adults and is more common in older people. CKD is an important condition because it can contribute to cardiovascular disease (CVD) and predispose to sudden worsening of kidney function (known as acute kidney injury) at times when patients are unwell for other reasons. Although only a small number of cases progress to end stage renal disease requiring dialysis (or a kidney transplant if possible), this is very difficult for individual patients and their families, and very costly for the health economy. This report details the findings of the audit programme which compared GP practice performance against NICE quality standards. The full report and executive summary are available to download.

Safer insulin prescribing
NICE. Key therapeutic topic [KTT20]

This therapeutic topic from NICE is divided into:

Options for local implementation
Evidence context
Prescribing data

The Evidence Context section focuses on safety issues with insulin, rather than treatment recommendations, and is split into:

‘Sick-day’ rules
Continuous subcutaneous insulin infusion (insulin pump) therapy
Insulin prescribing and administration: reducing errors

The caveat given at the end is “This document summarises the evidence base on this key therapeutic topic which has been identified to support medicines optimisation. It is not formal NICE guidance