February 2014

February 2014

Effects of switching from insulin glargine or detemir to insulin degludec in patients with type 1 diabetes mellitus
Yoshiki Kusunoki et al. Diabetes Therapy. Doi: 10.1007/s13300-013-0048-5

The aim of this study was to analyze the changes of basal insulin dose and blood glucose profile in basal–bolus therapy of type 1 diabetes mellitus (T1DM) when the long-acting basal insulins glargine or detemir were changed to the ultra-long-acting basal insulin degludec. [A basal-bolus routine involves taking a longer acting form of insulin to keep blood glucose levels stable through periods of fasting (basal) and separate injections of shorter acting insulin (bolus) to prevent rises in blood glucose levels resulting from meals]. Sixteen patients with T1DM were enrolled in the study. It was found that in the patients switched from twice-daily basal insulin, no significant difference was found between before and after switching in the blood glucose profile. In the once-daily group, blood glucose levels showed a tendency to decrease after switching to the degludec treatment. Also, total daily insulin dose (TDD) and total daily basal insulin dose (TBD) decreased significantly in the twice-daily group, and TDD and TBD showed a tendency to decrease after switching to degludec in the once-daily group. In both groups, the changes of HbA1c were not significantly different. The authors of this paper concluded that it is possible to achieve similar glycemic control with once-daily injection and lower doses of insulin degludec in patients with T1DM who have been treated with insulin glargine or detemir.


Stepping up: a nurse-led model of care for insulin initiation for people with type 2 diabetes
John S Furler et al. Family Practice. Doi: 10.1093/fampra/cmt085

In the introduction to this paper the authors remind us that most people with type 2 diabetes (T2D) have glycaemic levels outside of target, and that although insulin is effective in improving glycaemia (and most people with T2D eventually need this) transition to insulin therapy is often delayed in primary care. The authors developed a (Stepping Up) model of care for insulin initiation in five Australian general practices (seven GPs and five practice nurses) and 18 patients. At 3 and 12 months the researchers evaluated the experiences of the GPs, PNs and patients. Testing of the model’s effectiveness is still being carried out. The qualitative evaluation highlighted how the model of care supported integration of the technical work of insulin initiation within ongoing generalist GP care. The investigators stressed that ensuring peer support for patients and also issues of clinical accountability and flexibility, managing time and resources were important. The conclusion was that the Stepping Up model allowed technical care to be embedded within generalist whole-person care, and supported clinicians and practice system to overcome clinical inertia and supported patients to make the timely transition to insulin.


Use of clinical targets in diabetes patient education: qualitative analysis of the expectations and impact of a structured self-management programme in Type 1 diabetes
R. Snow et al. Diabetic Medicine. Doi: 10.1111/dme.12401

In this study interviews were conducted before and after Dose Adjustment for Normal Eating (DAFNE) education courses with participants at three UK education centres. Data were gathered from 21 participants over 32 interviews and 146 hours of observations. [DAFNE involves attending a 5-day training course plus a follow-up session around 8 weeks after the course]. The findings suggest that patient education can create positive transformations in the lives of people with diabetes. However, a review of evidence from other studies has shown that the blood glucose results recommended by the DAFNE programme are in fact unachievable, even by these most motivated and well-informed patients. The authors note that because this information was not shared with attendees in the DAFNE programme they sometimes perceived themselves as having failed in their efforts, even when they had better than average blood glucose results. The authors posit that setting goals without information about how achievable they really are could be counterproductive in terms of supporting and maintaining patient self-efficacy long-term.


Lifecourse: management of type 1 diabetes
Andrew T Hattersley et al. Lancet Diabetes & Endocrinology. Doi: 10.1016/S2213-8587(13)70179-7

This informative article includes a poster and an audio presentation that discusses how management of type 1 diabetes changes across the course of a patient’s life. From early life where patients depend on their caregivers (their parents) for provision of therapy, monitoring of their glycaemia, and control of diet and activity, through to adulthood when patients are expected to take on these responsibilities themselves. Because this transition usually happens around the teenage years, it can be a challenging time. In adulthood, changes in a person’s life circumstances can also pose challenges for management – for example during pregnancy – while in old age, managing diabetes can be difficult due to the presence of comorbidities and frailty.  The article emphasises that management strategies must be tailored to the individual with their age and life circumstances taken into account.


‘Join us on our journey’: exploring the experiences of children and young people with type 1 diabetes and their parents
Nicky Kime. Practical Diabetes. Doi: 10.1002/pdi.1823

This paper focuses on children and young people with type 1 diabetes and on their parents, and on their experiences of diabetes care provision. Nine acute hospitals in the Yorkshire and the Humber region, UK, were recruited to participate in a qualitative research study. Children and young people with type 1 diabetes, aged 6 to 25 and their parents (approximately 250 participants), took part in talking groups to find out about their experiences of diabetes care provision. The findings showed that there are key areas for improvement in the future diabetes care provision for children and young people, including communication and support, schools, structured education and transition. These have important implications for practice and service redesign.


Modelling of 24-hour glucose and insulin profiles in patients with type 2 diabetes mellitus treated with biphasic insulin aspart
Rikke M Røge et al. Journal of Clinical Pharmacology. Doi: 10.1002/jcph.270

The authors of this paper remind us that Insulin therapy for patients with diabetes is designed to mimic the endogenous insulin response of healthy subjects and thereby generate normal blood glucose levels. In order to control the blood glucose in insulin-treated patients with diabetes it is important to be able to predict the effect of exogenous insulin on blood glucose. They postulate that a pharmacokinetic/pharmacodynamic model for glucose homoeostasis describing the effect of exogenous insulin would to be able to predict the effect of exogenous insulin on blood glucose. [Pharmacokinetics looks at the fate of drugs administered to a patient] and [Pharmacodynamics is the study of the biochemical and physiological effects of drugs on the body].In their research they extended the previously developed integrated glucose–insulin (IGI) model to predict 24-hour glucose profiles for patients with Type 2 diabetes following exogenous insulin administration. The IGI model was successfully extended to include the effect of exogenous insulin. Circadian variations in glucose homeostasis were assessed, and a significant improvement was achieved by including a circadian rhythm on the endogenous glucose production in the model. They posit that their extended model is a useful tool for clinical trial simulation and for elucidating the effect profile of new insulin products.


Glycemic control and all-cause mortality risk in type 1 diabetes patients: the EURODIAB Prospective Complications Study
Danielle A.J.M et al. Journal of Clinical Endocrinology & Metabolism. Doi: 10.1210/jc.2013-2824

The preamble to this paper says that glycemic targets and the benefit of intensive glucose control are currently under debate because intensive glycemic control has been suggested to have negative effects on mortality risk in type 2 diabetes patients. To illuminate this the investigators examined the association between glycated hemoglobin (HbA1c) and all-cause mortality in patients with type 1 diabetes mellitus. Their clinic-based study looked at 2,764 European patients with type 1 diabetes aged 15–60 years who were enrolled in the EURODIAB Prospective Complications Study. They discovered that all-cause mortality risk was increased at both low and high HbA1c levels, which suggested to them that target HbA1c below a certain threshold may not be appropriate in this population. Their caveat was that these low HbA1c levels may be related to anemia, renal insufficiency, infection, or other factors not available in our database. However, they posit that if their data are confirmed, the potential mechanisms underlying this increased mortality risk among those with low HbA1c will need further study.


Old and new basal insulin formulations: understanding pharmacodynamics is still relevant in clinical practice
Paolo Rossetti et al. Diabetes, Obesity and Metabolism. Doi: 10.1111/dom.12256

The abstract to this paper reports that the clinical evidence in favour of analogues is still controversial. Although their major benefit is a reduction in the hypoglycaemia risk, some cost/effectiveness analyses have not been favourable to analogues, largely because of their higher price. Nevertheless, these new formulations have conquered the insulin market. Human insulin represents currently no more than 20% of market share. The authors assert that despite (in fact because of) the widespread use of insulin analogues it remains critical to analyse the pharmacodynamics (PD) of basal insulin formulations appropriately to interpret the results of clinical trials correctly.  The abstract expands upon this by explaining that the data may help physicians in tailoring insulin therapy to patients’ individual needs and, additionally, when clinical evidence is not available, to optimize insulin treatment. For patients at low risk of hypoglycaemia, it might be acceptable and also cost-effective not to use long-acting insulin analogues as basal insulin replacement. Conversely, in patients with a higher degree of insulin deficiency and increased risk for hypoglycaemia, analogues are the best option due to their more physiological profile, as has been shown in PD and clinical studies.


How many people inject insulin? UK estimates from 1991 to 2010
Sarah E Holden et al. Diabetes, Obesity and Metabolism. Doi: 10.1111/dom.12260

 In this study patients receiving prescriptions for insulin were identified in the Clinical Practice Research Datalink and attributed a diagnosis of type 1 or type 2 diabetes. The annual prevalence of insulin use was calculated and applied to population data. It was found that the crude prevalence rate of insulin use increased from 2.43 per 1,000 population in 1991 to 6.71 per 1,000 in 2010. The largest change was an increase in the prevalence of insulin users with a diagnosis of type 2 diabetes from 0.67 to 4.34 per 1,000 population. The absolute number using insulin increased from 137,000 people in 1991 to 421,000 in 2010. Summarising their findings the authors calculated that the number of people using insulin trebled between 1991 and 2010, largely due to a considerable increase in the number of people with type 2 diabetes using insulin.


‘Looking for the needle in the haystack’: a qualitative study of the pathway to diagnosis of type 1 diabetes in children
Juliet A Usher-Smith et al. BMJ Open. Doi: 10.1136/bmjopen-2013-004068

In this study the parents of children aged 1 month to 16 years diagnosed with new onset T1D within the previous 3 months, children over 6 years diagnosed with new onset T1D within the previous 3 months and GPs who saw those children prior to diagnosis, were interviewed.  It was found that even with some knowledge of T1D, it took many parents several weeks of a complex cyclical and iterative decision-making process and often a physical trigger, such as weight loss, to decide to consult a healthcare professional. By that stage, many had already made or suspected the diagnosis of T1D themselves. The five GPs interviewed felt that the main challenges to diagnosing T1D in children were the rarity of the condition coupled with how well most of the children appeared, and the difficulty in obtaining urine or blood samples from children. The findings from the study highlighted the difficulties for parents and GPs in recognising the early symptoms of T1D. The authors suggest that future interventions should be targeted at parents in the appraisal interval and include the importance of timely presentation to a healthcare professional and the differences between types 1 and 2 diabetes. Primary care physicians should also take parental concerns seriously and do urine dipstick tests during the consultation for children with symptoms of T1D.