Journal Watch

Prepared for IDDT by Jim Young

December 2013

National Diabetes Audit – 2011-12: Report 2
Health and Social Care Information Centre

The National Diabetes Audit presented key findings from over two million patients with diabetes and reported on complications in 2010-2012 and deaths in 2012 for all age groups. It showed that people with diabetes have a 74 per cent greater risk of being admitted to hospital for heart failure compared to the rest of the population. People with type 1 diabetes in England and Wales had a 130 per cent increased risk of death and with type 2 diabetes a 35 per cent increased risk of death. It was noted that the risk of premature death for people with diabetes when compared to their peers in the general population is greatest for women and younger people.

The full report can be downloaded via the link below, where the introduction states that within the group of vascular diseases heart failure has been rather neglected, although it is by far the commonest diabetes associated vascular disease and also the complication with the second highest risk for short term mortality. The authors posit that part of the reason for heart failure being overlooked may be that it often presents less dramatically than myocardial infarction or stroke and modern diagnostic tests may be unfamiliar to health care professionals. But they assert that it is common, disabling and, in people with diabetes, it is clearly very deadly. However, it is also preventable and treatable, and should become a focus for primary and secondary prevention during routine diabetes review, along with the systematic review of smoking, exercise, weight, blood pressure and cholesterol.


Assessing the cost-effectiveness of Type 1 diabetes interventions: the Sheffield Type 1 Diabetes Policy Model
P. Thokala et al. Diabetic Medicine. Doi: 10.1111/dme.12371

This paper described the implementation and validation of the Sheffield Type 1 Diabetes Policy Model. The model is an individual patient-level simulation of Type 1 diabetes including long-term microvascular (retinopathy, neuropathy and nephropathy), macrovascular (myocardial infarction, stroke, revascularization and angina), and other diabetes-related complications and acute adverse events (severe hypoglycaemia and diabetic ketoacidosis). The model estimated the impact of interventions on costs, clinical outcomes, survival and quality-adjusted life years. [Quality-adjusted life year is a measure of disease burden, including both the quality and the quantity of life lived]. Validation of the model found that, for almost all of the diabetes-related complications predicted, event rates were within 10% of the rates reported in the studies used to build the model. The authors concluded that the model was highly flexible and has the potential to evaluate the Dose Adjustment for Normal Eating research programme, or other structured diabetes education programmes and interventions for Type 1 diabetes.


GAD-treatment of children and adolescents with recent-onset Type 1 diabetes preserves residual insulin secretion after 30 months
Johnny Ludvigsson et al. Diabetes/Metabolism Research and Reviews. Doi: 10.1002/dmrr.2503

This trial followed 70 children and adolescents with Type 1 diabetes and looked at the safety and efficacy of treatment with alum formulated glutamic acid decarboxylase (GAD) administered by subcutaneous injection. It was found that there were no treatment related adverse events and GAD preserved residual insulin secretion. [GAD is targeted by autoantibodies in people who later develop type 1 diabetes]


Co-stimulation modulation with abatacept in patients with recent-onset type 1 diabetes: follow-up one year after cessation of treatment
Tihamer Orban et al. Diabetes Care. Doi: 10.2337/dc13-0604

The authors of this paper previously reported that two years of co-stimulation modulation with abatacept slowed the decline of beta-cell function in recent-onset type 1 diabetes mellitus (T1DM). In this extension of the trial subjects were followed for a further two years after abatacept was discontinued to determine whether the effect persisted. [Abatacept inhibits the co-stimulation of T cells]. It was found that co-stimulation modulation with abatacept slowed decline of beta-cell function and improved HbA1c in recent-onset T1DM, and this beneficial effect was sustained for at least one year after cessation of abatacept infusions, or three years from T1DM diagnosis.


Do treatment quality indicators predict cardiovascular outcomes in patients with diabetes?
Grigory Sidorenkov et al. PLoS ONE. Doi: 10.1371/journal.pone.0078821

The preamble to this paper reminds us that although treatment quality indicators have been developed and tested against intermediate outcomes to evaluate if optimal treatment is actually delivered in practice; no studies have tested whether these treatment quality indicators also predict hard patient outcomes. The researchers looked at data collected from more than 10,000 diabetes patients that included indicators of measured glucose-, lipid-, blood pressure- and albuminuria-lowering treatment status and treatment intensification. The hard patient outcomes recorded were cardiovascular events and all-cause death. It was found that treatment quality indicators that measured lipid- and albuminuria-lowering treatment status were valid quality measures, since they predict a lower risk of cardiovascular events and mortality in patients with diabetes. However, the quality indicators for glucose-lowering treatment should only be used for restricted populations with elevated HbA1c levels. The authors were intrigued by their finding that the indicators for blood pressure-lowering treatment did not predict patient outcomes.


Determinants and consequences of insulin initiation for type 2 diabetes in France
Reach G et al. Patient Preference and Adherence. Doi: 10.2147/PPA.S51299

This study analysed data from the 2008, 2010, and 2011 French National Health and Wellness Survey. The survey was a self-administered, Internet-based questionnaire of 1,933 respondents with type 2 diabetes. It was found that early initiation of insulin therapy was 9.9 times more likely to be prescribed by an endocrinologist or diabetologist than by a primary care physician, and that younger age at diagnosis was a significant predictor of early insulin initiation. It was also observed that being treated with insulin was not associated with deterioration in quality of life. The authors posit that the data suggest that doctors’ concerns about patient adherence and detrimental effects on quality of life should not be a barrier to their decision regarding early initiation of insulin therapy.


The relationship between maternal fear of hypoglycaemia and adherence in children with type-1 diabetes
Evril Freckleton et al. International Journal of Behavioral Medicine. Doi: 10.1007/s12529-013-9360-8

This study looked at seventy-one mothers with children under 13, and maternal self-reported hypoglycaemic fear and illness perceptions were measured. Self-reported daily blood sugar levels were recorded over 1 week, and HbA1c levels were collected at baseline and 3 months later. It was found that high maternal fears of hypoglycaemia were predictive of suboptimal daily glycaemic control (elevated blood glucose levels), irrespective of illness duration or age at diagnosis.


Does a patient-managed insulin intensification strategy with insulin glargine and insulin glulisine provide similar glycemic control as a physician-managed strategy?
Stewart B. Harris et al.  Diabetes Care. Doi: 10.2337/dc13-1636

Because diabetes self-management is universally regarded as a foundation of diabetes care, the investigators set out to determined whether comparable glycemic control could be achieved by self-titration versus physician titration of a once-daily bolus insulin dose in patients with type 2 diabetes who were unable to achieve optimal glycemia control with a basal insulin. It was found that in patients with type 2 diabetes on stable doses of basal insulin glargine who require bolus insulin, a simple bolus insulin patient-driven titration algorithm was as effective as a physician-driven algorithm. [A medical algorithm is a calculation useful in healthcare]


Start of insulin therapy in patients with type 2 diabetes mellitus promotes the influx of macrophages into subcutaneous adipose tissue
H. J. Jansen et al. Diabetologia. Doi: 10.1007/s00125-013-3018-6

The authors of this paper hypothesised that insulin-associated increase in fat mass would also result in changes in the morphology of subcutaneous adipose tissue and in increased inflammation, especially when weight gain was excessive. [Morphology describes the outward appearance (shape, structure, colour, and pattern) as well as the internal form and structure of tissue]. To investigate this they looked at the levels of key inflammatory markers within the adipose tissue in patients with type 2 diabetes mellitus before and 6 months after starting insulin therapy. They found that insulin therapy significantly increased body weight, and at the level of the subcutaneous adipose tissue, insulin treatment led to an influx of macrophages. So although insulin therapy in patients with type 2 diabetes mellitus improved glycaemic control it also induced body weight gain and an influx of macrophages into the subcutaneous adipose tissue. In patients characterised by a pronounced insulin-associated weight gain, the influx of macrophages into the adipose tissue was accompanied by a more pronounced inflammatory status. [Macrophages function in both non-specific and specific defence mechanisms].


Admissions avoidance and diabetes
Joint British Diabetes Societies for Inpatient Care

The foreword to this guide states that the National Diabetes Inpatient Audit shows that about 1 in 6 hospital beds in England are occupied by someone with diabetes and that health economic analysis suggests diabetes admissions in England alone accounted for 607,581 excess bed days (compared to the equivalent population without diabetes) at a total estimated excess tariff expenditure of £573 million in one year. Although this document is not a clinical guideline, but a summary document for health care planners and commissioners, it does complement the recent Best Practice for Commissioning Diabetes Services. The sections include:

  • Overall diabetes admissions, bed occupancy, and cost
  • Diabetes specific admissions
  • Readmission rates and diabetes
  • Variability in diabetes admission rates
  • A whole systems approach to reducing diabetes admissions
  • Improving day case surgery listing for people with diabetes
  • Reducing diabetes specific admissions and readmissions
  • Diabetic ketoacidosis
  • Hypoglycaemia and Ambulance Trusts
  • Diabetic foot disease
  • Commissioning care to reduce hospital bed occupancy
  • National out of hours support line for people with diabetes