Journal Watch

Prepared for IDDT by Jim Young

May 2016

Day and night closed-loop glucose control in patients with type 1 diabetes under free-living conditions
Eric Renard et al. Diabetes Care. Doi:

This study started by testing a wearable artificial pancreas (AP) during evening and night (E/N-AP) under free-living conditions in twenty adult patients with type 1 diabetes (T1D). It then investigated AP during day and night (D/N-AP) for 1 month. The participants had recently completed a previous study comparing 2-month E/N-AP versus 2-month sensor augmented pump (SAP). The findings were that D/N-AP and E/N-AP both achieved better glucose control than SAP under free-living conditions. Although time in the different glycemic ranges was similar between D/N-AP and E/N-AP, D/N-AP further reduced glucose variability.


The impact of primary care organization on avoidable hospital admissions for diabetes in 23 countries
Tessa Van Loenen et al. Scandinavian Journal of Primary Health Care. Doi: 10.3109/02813432.2015.1132883

This study examined whether there were differences between countries in diabetes-related hospitalization rates that could be attributed to differences in the organization of primary. A total of 23 countries were included in the study. Unsurprisingly it found that continuity of care was associated with lower rates of diabetes-related hospitalization. However, counterintuitively, broader task profiles for general practitioners and more medical equipment in general practice were associated with higher rates of admissions for uncontrolled diabetes. Indeed, countries where patients perceive better access to care had higher rates of hospital admissions for long-term diabetes complications! To complicate things further, there was no association between disease management programmes and rates of diabetes-related hospitalization. Hospital bed supply was strongly associated with admission rates for uncontrolled diabetes and long-term complications. The authors concluded that countries with elements of strong primary care do not necessarily have lower rates of diabetes-related hospitalizations. Hospital bed supply appeared to be a very important factor in this relationship. The authors posit that it takes more than strong primary care to avoid hospitalizations.


Practical classification guidelines for diabetes in patients treated with insulin
Suzy V Hope et al. British Journal of General Practice. Doi: 10.3399/bjgp16X684961

This paper looked at the diagnostic accuracy of the UK guidelines against ‘gold standard’ definitions of type 1 and type 2 diabetes based on measured C-peptide levels. [Urinary C-peptide creatinine ratio measures endogenous insulin production. Gold standard type 1 diabetes was defined as continuous insulin treatment within 3 years of diagnosis and absolute insulin deficiency 5 years or more post-diagnosis; all others classed as having type 2 diabetes]. Baseline information and home urine samples were collected from 601 adults with insulin-treated diabetes, and diabetes duration greater than 5 years. It was found that UK guidelines correctly classified 86% of participants. Most misclassifications occurred in patients classed as having type 1 diabetes who had significant endogenous insulin levels (57 out of 601; 9%); most in those diagnosed over 35 years and treated with insulin from diagnosis, where 37 out of 66 (56%) were misclassified. The authors also report that time to insulin and age at diagnosis performed best in predicting long-term endogenous insulin production, and that BMI was a less strong predictor of diabetes type. The authors advised that caution is needed in older patients commencing insulin from diagnosis, where misclassification rates are increased.


Illness beliefs predict mortality in patients with diabetic foot ulcers
Kavita Vedhara et al. PLoS ONE. Doi:

This study asked if illness beliefs independently predicted survival in patients with diabetes and foot ulceration. The study recruited 169 patients between 2002 and 2007. Data on illness beliefs were collected at baseline. Data on survival were extracted on 1st November 2011, and the number of days survived reflected the number of days from date of recruitment to 1st November 2011. The authors report that illness beliefs do have a significant independent effect on survival in patients with diabetes and foot ulceration. They assert that their findings suggest that illness beliefs could improve our understanding of mortality risk in this patient group and could also be the basis for future therapeutic interventions to improve survival.


Principles and frequency of self-adjustment of insulin dose in T1D and correlation with markers of metabolic control
Guido Kramer et al. Diabetes Research and Clinical Practice. Doi:

This study looked at patients’ current principles and frequency of insulin dose self-adjustment (ISA) and checked their ability for correct adjustments. 117 people with Type 1 diabetes were interviewed and the number of ISAs was drawn from the last 28 days of the patients’ diary. All patients had participated in a structured education programme. It found that although all people were trained to use an insulin-to-carbohydrate ratio and a factor for correction for ISA, only half of the patients adjusted their insulin dosage using the complex rules from the treatment and education programme. Interestingly, patients who performed their ISA based upon feeling, did not show worse metabolic control.


intensive diabetes treatment and cardiovascular outcomes in type 1 diabetes
Rose Gubitosi-Klug. Diabetes Care. Doi:

This study assessed whether intensive therapy, compared with conventional therapy, affected the incidence of cardiovascular disease over a 30 year of follow-up during the Diabetes Control and Complications Trial (DCCT). The DCCT randomly assigned 1,441 patients with type 1 diabetes to intensive versus conventional therapy for a mean of 6.5 years, after which 93% were subsequently monitored during the observational Epidemiology of Diabetes Interventions and Complications (EDIC) study. Cardiovascular disease (nonfatal myocardial infarction and stroke, cardiovascular death, confirmed angina, congestive heart failure, and coronary artery revascularization) was adjudicated using standardized measures. The findings were that intensive diabetes therapy during the DCCT (6.5 years) has long-term beneficial effects on the incidence of cardiovascular disease in type 1 diabetes that persist for up to 30 years.


Treatment intensification for patients with type 2 diabetes and poor glycemic control
Alex Z. Fu and John Sheehan. Diabetes, Obesity and Metabolism. Doi: 10.1111/dom.12683

This investigation used a large U.S. insurance claims database to conduct a study of adult patients with T2D and an HbA1c greater than 8% after more than 3 months of therapy including metformin. The authors defined treatment intensification as prescription for injectable or additional oral antidiabetes drugs (OADs).  Of the 11,525 patients meeting inclusion criteria, mean age at index date was 57 years, 40% were female, and mean index HbA1c was 9.1%. Overall, 37% of patients intensified within 6 months, 11% intensified between 6 and 12 months, and 52% did not intensify within the 12 months. Higher index HbA1c was associated with early intensification. In summary, fewer than half of patients with T2D and treatment failure received intensification within 12 months in a real-world U.S. population. The authors posit that the factors associated with treatment inertia can be used to target clinical care for these patients.


Gut microbiota of Type 1 diabetes patients with good glycaemic control and high physical fitness is similar to people without diabetes
C. J. Stewart et al. Diabetic Medicine. Doi: 10.1111/dme.13140

The authors say that although existing bacterial profiling studies focus on people who are most at risk at the time of diagnosis, there are limited data on the gut microbiota of people with long-standing Type 1 diabetes. Their study compared the gut microbiota of ten patients with Type 1 diabetes and good glycaemic control and high levels of physical-fitness with that of ten matched controls without diabetes. Analysis showed that the gut microbiota and resulting functional bacterial profiles from patients with long-standing Type 1 diabetes in good glycaemic control and high physical fitness levels were comparable with those of matched people without diabetes.


Real-world therapeutic benefits of patients on insulin glargine versus NPH insulin
Albrecht Fiesselmann et al. Acta Diabetologica. Doi: 10.1007/s00592-016-0862-0

The addition of a single injection of insulin to oral drugs [basal supported oral therapy (BOT)] has been shown to greatly reduce blood glucose levels. The intermediate-acting NPH insulin (NPH) and the long-acting insulin glargine (Lantus®) have been compared for use in BOT in numerous clinical trials; however, their efficacy and safety in a real-life setting have not been described. TIP (therapeutic benefits of patients on insulin glargine vs. NPH insulin being poorly controlled on prior short-time basal-insulin supported therapy with NPH insulin or insulin glargine) is a non-interventional, multicentre, observational study over 24 weeks. A total of 2629 patients were enrolled and 1931 were fully evaluable (1614 insulin glargine, 303 NPH insulin). The findings were that a slightly greater reduction in FBG and HbA1c levels was seen in the insulin glargine group compared to the NPH group. Additionally, hypoglycaemia, including nocturnal and severe events, was more prevalent in the patients receiving BOT with NPH. The occurrence of new micro- or macro-vascular complications and adverse events was low for both groups. A large proportion of patients changed from NPH therapy to insulin glargine therapy during the study, which was mainly attributable to insufficient glucose modulation. Improvements in quality of life and treatment satisfaction were found for both types of insulin. The authors conclude that their observational study provided evidence from a real-life setting that BOT with insulin glargine provides slightly greater reductions in weight, FBG and HbA1c levels, with a lower risk of hypoglycaemia than patients receiving NPH. This conclusion indicates that insulin glargine may be preferable to NPH insulin for BOT.


Phase 3 trial of transplantation of human islets in type 1 diabetes complicated by severe hypoglycemia
Bernhard J. Hering et al. Diabetes Care. Doi:

This study evaluated the effectiveness and safety of a standardized human pancreatic islet product in subjects in whom impaired awareness of hypoglycemia (IAH) and severe hypoglycemic events (SHEs) persisted despite medical treatment. The multicenter study was conducted at eight centers in North America. Forty-eight adults with T1D for over 5 years were enrolled. The primary end point was the achievement of HbA1c of less than 7.0% (53 mmol/mol) at day 365 and freedom from SHEs from day 28 to day 365 after the first transplant. It found that transplanted purified human pancreatic islets (PHPI) provided glycemic control, restoration of hypoglycemia awareness, and protection from SHEs in subjects with intractable IAH and SHEs. Safety events occurred related to the infusion procedure and immunosuppression, including bleeding and decreased renal function. The authors suggest that islet transplantation should be considered for patients with T1D and IAH in whom other, less invasive current treatments would have been ineffective in preventing SHEs.