Journal Watch

Prepared for IDDT by Jim Young

August 2013


Insulin as an early treatment for Type 2 Diabetes – ORIGIN or end of an old question?
Stefano Del Prato et al. Diabetes Care. Doi: 10.2337/dcS13-2019

This paper reminds us that cardiovascular (CV) disease accounts for more than 60% of the years of life lost because of diabetes. Although this increase in CV risk is largely attributable to the coexistence of multiple metabolic and circulatory disorders, the elevation of plasma glucose levels remains strongly associated with increased CV morbidity and mortality. Based on this, the authors set out to answer two questions:
1) Could diabetic patients with shorter diabetes duration or even with prediabetes benefit more from near-normal plasma glucose level normalization? 
2) Could this be achieved with early use of insulin? 
Based on the Outcome Reduction with Initial Glargine Intervention trial (ORIGIN), the conclusion was that CV benefits did not the result from early insulin treatment in high-risk patients with recent-onset diabetes. The authors also observed that it increased severe and nonsevere hypoglycemia.


Early insulinization to prevent diabetes progression
Itamar Raz et al. Diabetes Care. Doi: 10.2337/dcS13-2014

This article reviewed data collected from clinical studies that considered the place of early insulin treatment in preservation of β-cell function in type 2 diabetic patients. [Beta cells are a type of cell in the pancreas located in the islets of Langerhans. They produce, store and release insulin]. Following a series of reviews of recent research studies the paper concluded that with regard to the initiation of insulin therapy for Type 2 diabetes, with the intention of preserving ß-cell function, the level of evidence supporting this decision is relatively high. The recommendation being that short-term insulin treatment is safe, with low incidence of hypoglycemia and less concern for weight gain. However the place of long-term early insulin treatment in well-controlled type 2 diabetic patients is still debatable.


Combining Incretin-based therapies with insulin – realizing the potential in Type 2 diabetes
Jiten Vora. Diabetes Care. Doi: 10.2337/dcS13-2036

Based on the observation that basal insulin primarily improves fasting plasma glucose (FPG) control, and that the glucose-dependent effect of incretins would additionally benefit postprandial plasma glucose (PPG) control, this paper looked at the evidence and practicalities. [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]. The conclusion was that improvements in glycemic control may reduce the incidence of diabetes-related complications, and taken together with the reduced risk of hypoglycemia, an incretin plus basal insulin regimen could provide significant health-economic advantages.


Type 1 diabetes and living without a partner
Lene E. Joensen et al. Diabetes Research and Clinical Practice. Doi:10.1016/j.diabres.2013.07.001
This Danish study of 2,419 adult outpatients with type 1 diabetes looked at the association between cohabitation status and the psychological aspects of living with diabetes. It asked whether these associations are improved by social support. It found that there was significant association between living without a partner and low quality of life, low diabetes empowerment and HbA1c for both men and women. [HbA1c – Glycated hemoglobin is a form of hemoglobin that is measured primarily to identify the average plasma glucose concentration over prolonged periods of time]. However social network and social support was related to improved diabetes outcomes. The authors suggest that an assessment of cohabitation status may be useful in diabetes care and support.


Use of an insulin bolus advisor improves glycemic control in multiple daily insulin injection (MDI) therapy patients with suboptimal glycemic control
Ralph Ziegler et al. Diabetes Care. Doi: 10.2337/dc13-0251

The use of automated bolus advisors [an automated calculator built into a blood glucose meter] is associated with improved glycemic control in patients treated with insulin pump therapy. This study of 218 patients with poorly controlled diabetes (202 with type 1 diabetes, 16 with type 2 diabetes) who were using multiple daily insulin injection (MDI) assessed the impact of using an insulin bolus calculator. The conclusion was that the use of an automated bolus advisor resulted in improved glycemic control and treatment satisfaction without increasing severe hypoglycemia.


Evaluation of insulin initiation on resource utilization and direct costs of treatment over 12 months in patients with type 2 diabetes in Europe: results from INSTIGATE and TREAT observational studies
Kerstin Brismar et al. Journal of Medical Economics. Doi:10.3111/13696998.2013.812040

This report describes the changes in resource utilization in seven European countries (Germany, Greece, Portugal, Romania, Sweden, Spain, and Turkey) and the direct costs in four European countries (Germany, Spain, Sweden, and Greece) over the first 12 months of insulin treatment in patients with type 2 diabetes mellitus (T2DM). It looked at the INSTIGATE and TREAT studies of 1,450 patients with T2DM who were initiating insulin treatment for the first time between 2005 and 2010. It was found that in each country, mean direct total costs of T2DM care increased during the first 6 months after insulin initiation and decreased thereafter.


Efficacy, usability and sequence of operations of a workflow-integrated algorithm for basal-bolus insulin therapy in hospitalized type 2 diabetes patients
Julia K. Mader et al. Diabetes, Obesity and Metabolism. Doi: 10.1111/dom.12186

In this ward-controlled study 74 patients with type 2 diabetes were assigned either to an algorithm-based treatment with a basal-bolus insulin therapy or to a standard glycemic management. [A medical algorithm is a calculation useful in healthcare]. Algorithm performance was assessed by continuous glucose monitoring and the staff’s adherence to the algorithm-calculated insulin dose. The authors report that in the workplace the algorithm for basal-bolus therapy was effective in establishing glycemic control and was well accepted by medical staff. They suggest that the use of algorithm should be part of an electronic decision support system.


Interspecies transplant works in first step for new diabetes therapy
Northwestern Medicine.

This interesting article from Northwestern University in the USA describes the first step toward animal-to-human transplants of insulin-producing cells for people with type 1 diabetes. It explains how scientists have successfully transplanted islets, the cells that produce insulin, from one species to another, with the islets surviving without immunosuppressive drugs.


Inpatient diabetes education is associated with less frequent hospital readmission among patients with poor glycemic control
Sara J. Healy et al. Diabetes Care. Doi: 10.2337/dc13-0108
This paper explored the relationship between inpatient diabetes education (IDE) and hospital readmissions in patients with poorly controlled diabetes.  2,265 patients were included in the 30-day analysis and 2,069 patients were included in the 180-day analysis. It was found that patients who received IDE had a lower frequency of readmission within 30 days than did those who did not. IDE was also associated with reduced readmissions within 180 days, although the relationship was less obvious.


Excess mortality during hospital stays among patients with recorded diabetes compared with those without diabetes
N Holman et al. Diabetic Medicine. Doi: 10.1111/dme.12282

This paper used inpatient admissions to all English hospitals between April 2010 and March 2012 to look at additional mortality among patients with recorded diabetes and it identified the extent of variation in English provider trusts. Of the 10,169,003 hospital admissions analysed 11.2% had recorded diabetes but 21.5% of inpatient deaths occurred in this group. Patients with recorded diabetes had a 6.4% greater risk of dying. The additional risk of death was significantly greater in smaller trusts. These results led the authors to conclude that a diagnosis of diabetes had an adverse impact on hospital mortality that cannot be explained by usual case-mix adjustments, and that the additional risk of dying is greatest among hospital admissions that would normally have a low risk of death.