January 2014

January 2014

Diabetes UK State of the Nation report 2013
Diabetes UK

This report from Diabetes UK highlights the problem that quality of care for diabetics is uneven throughout England. It notes that diabetes care is adequately funded but that the focus of the spending should be on prevention rather than treatment. In her introduction to the report Barbara Young CEO of Diabetes UK says “Last year our State of the Nation report highlighted a major health crisis. More and more people were living with or at risk of Type 1 and Type 2 diabetes. Growing numbers of them were experiencing devastating complications, but the NHS still struggled to deliver the care and education people with diabetes need to manage their condition. This year’s report shows precious little improvement to that bleak picture – indeed, in some areas things have got worse … there is still no specific health service focus on diabetes, no national plan to improve the quality of its care, to tackle rising incidence or stem the increase in complications”. She ends by stating that “Our State of the Nation report gives clear evidence that some areas are performing better than others, and that in many CCG patches there is considerable room for improvement. Some areas can and do deliver diabetes care well. Others can too”. The detailed PDF report is in 15 sections covering 32 pages.
http://www.diabetes.org.uk/Documents/About Us/What we say/0160b-state-nation-2013-england-1213.pdf


Action for Diabetes
NHS England

Action for Diabetes has been produced in response to the Public Accounts Committee report on adult diabetes services published in 2012. It is for Clinical Commissioning Groups (CCGs) as a reference on the work that is going on across NHS England, and for the wider community interested in diabetes care to see what action NHS England is taking in this important area.  It sets out the action that NHS England is taking now to improve outcomes for people with and at risk of diabetes – in both of its roles, as a direct commissioner and a support to the commissioning system. The document describes the action they are taking and will take in their role as a direct commissioner of services to: drive the prevention of Type 2 diabetes and earlier diagnosis of all diabetes, and to support better management of diabetes in primary care. It also describes what they are doing and will do in providing leadership and support to CCGs as commissioners of secondary and community services to deliver high-quality care, as defined by NICE, to people with and at risk of diabetes. 


National Paediatric Diabetes Audit Report 2011-12
Royal College of Paediatrics and Child Health

The foreword of this report from the Royal College of Paediatrics and Child Health says that the “Findings from this year’s Audit are both heartening and troubling. On the positive side, nearly complete national coverage of paediatric diabetes units has been achieved, and the number of infants, children and young people with diabetes under the age of 25 years reported to the National Paediatric Diabetes Audit (NPDA) has increased. Measurements of HBA1c have also improved and the percentage of patients with HbA1c values in the range of 58mmol/mol (7.5%) has risen.” However “Despite these achievements fewer than one in five patients overall reach this level of control. We also note that the extent to which children and young people receive the care processes recommended by the National Institute for Health and Care Excellence remains low”. The report has 50 pages including: Demographic and population assessment – Care processes and treatment targets – Outcomes of care – Conclusions and future directions.


Diabetes Community Health Profiles
– Yorkshire and Humber Public Health Observatory

This interesting and informative resource enables access to data from Clinical Commissioning Groups (CCG) from each area in England. After selecting an area from the drop down menu individual CCG data can be downloaded. The Diabetes Community Health Profiles bring together a wide range of data on diabetes in adults into a single source for the purposes of benchmarking.  The information on offer is: Prevalence, HbA1c, stroke, myocardial infarction and heart failure rates, and spending on treatment and prescriptions. Comparisons with similar CCGs are also provided.


Proinsulin-transferrin fusion protein as a novel long-acting insulin analogue for the inhibition of hepatic glucose production
Yan Wang et al. Diabetes. Doi: 10.2337/db13-0973

In this study proinsulin-transferrin (ProINS-Tf) fusion protein was evaluated for its in vivo pharmacokinetics, efficacy and mechanism. [In Vivo is experimentation using a whole, living organism as opposed to a partial or dead organism or in a test tube or Petri dish]. [Fusion proteins are proteins created through the joining of two or more genes which originally coded for separate proteins]. In their previous studies the authors had shown that ProINS-Tf was converted to active insulin (INS)-Tf in hepatoma cells. This led them to hypothesize that this fusion protein could be administered as a prodrug, and be converted to a biologically active protein with specificity for the liver versus other INS-sensitive tissues (muscle and adipose). This might conceivably reduce negative side-effects seen with other INS analogs. The data from their study showed that ProINS-Tf exhibited a slow, but sustained hypoglycemic efficacy and long plasma half-life. They suggest that ProINS-Tf fusion protein can potentially be administered as a prodrug with sustained Tf-mediated activation and selectivity in inhibiting hepatic glucose production.


The role of autophagy in the pathogenesis of diabetic nephropathy
Kosuke Yamahara et al. Journal of Diabetes Research. Doi: 10.1155/2013/193757

Because the multipronged drug approach targeting blood pressure and serum levels of glucose, insulin, and lipids fails to fully prevent the onset and progression of diabetic nephropathy, the authors posit that a new therapeutic target to combat diabetic nephropathy is required. Autophagy is a catabolic process that degrades damaged proteins and organelles in mammalian cells and plays a critical role in maintaining cellular homeostasis. The authors report than recent studies have suggested that autophagy activity is altered in both podocytes and proximal tubular cells under diabetic conditions. [Podocytes are cells in the Bowman’s capsule in the kidneys that wrap around the capillaries of the glomerulus]. They also posit that under diabetic conditions, an altered nutritional state due to nutrient excess may interfere with the autophagic response stimulated by intracellular stresses, leading to exacerbation of organelle dysfunction and diabetic nephropathy. This review discusses new findings showing the relationships between autophagy and diabetic nephropathy and suggests the therapeutic potential of autophagy in diabetic nephropathy. The authors expect that autophagy activation will become a potential therapy to combat diabetic nephropathy, with the caveat that further examinations are needed to conclude whether autophagy activation is a safe therapy for any kidney diseases, since some reports have suggested that autophagy activation was associated with tubular cell damages in some acute kidney injury models.


Effect of glargine insulin delivery method (pen-device vs. vial-syringe) on glycemic control and patient preferences in patients with type 1 and type 2 diabetes
Stacey A. Seggelke et al. Endocrine Practice. Doi: 10.4158/EP13404.OR
This study recruited thirty-one patients recently discharged from hospital and evaluated the effects of two glargine insulin delivery methods (pen vs. vial-syringes) on glycemic control and patient preferences. In the hospital, all patients were treated with basal/bolus regimen. Upon discharge, 21 patients received glargine by pen for 3 months and were then switched to vial-syringes for the next 3 months (Group 1). Group 2 consisted of 10 patients discharged on vial-syringes and converted to pens after 3 months. HbA1c was measured at enrolment, 3 and 6 months. A questionnaire assessing patient preference was administered at 3 and 6 months. It was found that patients switching to glargine pen achieved lower HbA1c at 6 months of follow-up. Patients in both groups overwhelmingly preferred glargine pens over vial-syringes.


Effect of once-daily insulin detemir on oral antidiabetic drug use in patients with type 2 diabetes
J. Vora et al. Journal of Clinical Pharmacy and Therapeutics. Doi: 10.1111/jcpt.12116

The introduction to this paper reminds us that while there are acknowledged benefits to continuing metformin when initiating insulin, there appears to be growing concern over the role of sulphonylureas and thiazolidinediones when used in combination with insulin. This 24-week, multinational observational study investigated the effects of continuing or discontinuing oral antidiabetic drugs (OADs) following the initiation of once-daily insulin detemir.
It found that discontinuation (or switching) of OADs at the time of insulin initiation appears to be governed principally by concerns about hypoglycaemia and weight. However, HbA1c improvements were smaller in patients discontinuing OADs at the time of insulin initiation and may be associated with insufficient insulin titration.


Quantitative estimation of insulin sensitivity in type 1 diabetic subjects wearing a sensor augmented insulin pump
Michele Schiavon et al. Diabetes Care. Doi: 10.2337/dc13-1120

In this study 12 subjects with type 1 diabetes were studied during breakfast, lunch and dinner, in a clinical research unit, wearing both subcutaneous insulin pump and continuous glucose monitoring (CGM).  A new index of insulin sensitivity was calculated using a simple algebraic formula, for each meal, using only CGM and insulin pump data and this was compared with the oral minimal model. [The glucose minimal-model method estimates insulin sensitivity from the time course of glucose and insulin after a glucose bolus]. The authors assert that they have presented a novel method for estimating insulin sensitivity in subjects with type 1 diabetes on sensor augmented insulin pump therapy, and that this new index correlates well with the reference oral minimal model estimate of insulin sensitivity.


Treatment intensification with stepwise addition of prandial insulin aspart boluses compared with full basal-bolus therapy (FullSTEP Study): a randomised, treat-to-target clinical trial
Helena W Rodbard et al. The Lancet Diabetes & Endocrinology. Doi:10.1016/S2213-8587(13)70090-1

This study compared stepwise addition of bolus insulin with a full basal-bolus regimen in patients with type 2 diabetes inadequately controlled on basal insulin plus oral antidiabetic drugs.
The FullSTEP study was a 32-week multinational trial of 401 patients carried out at 150 sites across seven countries to assess the effectiveness of a stepwise dosing approach versus a basal-bolus regimen. The primary outcome was non-inferiority of stepwise addition of bolus insulin versus complete basal-bolus therapy, as assessed by change in HbA1c from baseline to 32 weeks. [Noninferiority trials are intended to show that the effect of a new treatment is not worse than that of an active control by more than a specified margin]. It was found that stepwise prandial insulin intensification provides glycaemic control non-inferior to a full basal-bolus regimen after 32 weeks, with significantly lower hypoglycaemia risk and better patient satisfaction.