June 2014

June 2014

Association between intensification of metformin treatment with insulin vs sulfonylureas and cardiovascular events and all-cause mortality
Christianne L. Roumie et al. JAMA. Doi:10.1001/jama.2014.4312

In the introduction to this paper the authors note that clinicians begin administration of insulin to attain fast and flexible control of blood glucose levels, and a few trials have suggested that early insulin initiation is effective in preserving beta cell function. Accordingly, there has been an increase in early initiation of insulin and its use as an add-on therapy to metformin. In this study from America they looked at patients treated with metformin from 2001 through to 2008 who subsequently added either insulin or sulfonylurea. The main outcomes recorded were the risk of acute myocardial infarction, hospitalization for stroke, or all-cause death. Of the 178,341 monotherapy patients, 2,948 added insulin and 39,990 added a sulfonylurea. It was found that the addition of insulin as opposed to a sulfonylurea was associated with an increased risk of a composite of nonfatal cardiovascular outcomes and all-cause mortality. The authors say that their findings require further investigation to understand risks associated with insulin use in these patients.


Insulin therapy in people with type 2 diabetes: opportunities and challenges?
Philip Home et al. Diabetes Care. Doi: 10.2337/dc13-2743

Prompted by recent new evidence on the use of insulin in type 2 diabetes this working party of diabetes specialists examined the opportunities and challenges of insulin therapy. The group was aware of evidence that the benefits of insulin therapy are still usually offered late, and thus the aim of the discussion was how to define the optimal timing and basis for decisions regarding insulin and to apply these concepts in practice. The paper reviewed current evidence and circumstances in which insulin can be used, and considered individualized choices of alternatives and combination regimens, and offered some guidance on personalized targets and tactics for glycemic control in type 2 diabetes.


DPP-4 inhibitors can minimize the hypoglycemic burden and enhance safety in elderly people with diabetes
Angelo Avogaro et al. Diabetes, Obesity and Metabolism. Doi: 10.1111/dom.12319

 In this paper the authors remind us that the clinical management of T2DM in the elderly is challenging and requires individualization of optimal glycemic targets depending on co-morbidities, cognitive functioning, and ability to recognize and self-manage the disease. However, there is a lack of solid evidence-based medicine supporting treatment guidelines for older people with diabetes. This review set out to delineate the potential advantages of using DPP-4 inhibitors in elderly people with T2DM. Although more information is needed to reach definitive conclusions, growing evidence suggests that DPP4-I may become a valuable component in the pharmacologic management of elderly persons with T2DM, mainly because DPP-4 inhibitors have a low risk of hypoglycemia, neutral effect on body weight, and apparently greater safety in patients with kidney failure.


Retinal vessel calibers predict long-term microvascular complications in type 1 diabetes mellitus
Rebecca Broe et al. Diabetes. Doi: 10.2337/db14-0227

Although retinal vessel calibers have been associated with the presence of microvascular complications, their long-term predictive value has only been sparsely investigated. To address this the investigators examined retinal vessel calibers as 16-year predictors of diabetic nephropathy, neuropathy and proliferative retinopathy in a young population-based Danish cohort with type 1 diabetes. They used semi-automated computer software to analyze vessel diameters on baseline retinal photos. They found both wider venular diameters and smaller arteriolar diameters were predictive of the 16-year development of nephropathy, neuropathy and proliferative retinopathy. The authors suggest that retinal vessel caliber changes may be early markers of microvascular complications and a potential non-invasive predictive test on future risk of diabetic retinopathy, neuropathy and nephropathy.


Brachial-ankle pulse wave velocity predicts all-cause mortality and cardiovascular events in patients with diabetes
Yasutaka Maeda et al. Diabetes Care. Doi: 10.2337/dc13-1886

This study evaluated the benefit of brachial-ankle pulse wave velocity (baPWV) for the prediction of cardiovascular morbidity and mortality in subjects with diabetes. A total of 3,628 outpatients were followed for between two and three years. It was found that an elevation of baPWV was significantly correlated to the incidence of coronary artery events, cerebrovascular events, and all-cause mortality. The authors suggest that this large-scale cohort study provides evidence that high baPWV is a useful independent predictor of mortality and cardiovascular morbidity in subjects with diabetes.


Osteocalcin levels are inversely associated with Hba1c and BMI in adult subjects with long-standing type 1 diabetes
Ernesto Maddaloni et al. Journal of Endocrinological Investigation. Doi: 10.1007/s40618-014-0092-7

The authors of this study remind us that diabetic osteopathy is an upcoming complication of diabetes characterized by osteoporosis, increased risk for bone fractures and alterations in bone metabolism. Osteocalcin (OC) is a bone-specific protein produced by osteoblasts involved in the regulation of glucose and energy metabolism. The aim of their study was to determine whether OC serum levels were correlated with metabolic control in adult subjects with type one diabetes mellitus (T1DM).The data from the study showed that in T1DM of long duration, OC serum levels are inversely associated with HbA1c and BMI, which supported their hypothesis that a poor glycemic control can affect osteoblast function.


Increase in physical activity is associated with lower HbA1c levels in children and adolescents with type 1 diabetes
Å. Beraki et al. Diabetes Research and Clinical Practice. Doi:10.1016/j.diabres.2014.01.029

This paper evaluated the associations between physical activity and metabolic control, measured by HbA1c, in a large group of 4,655 children and adolescents with type 1 diabetes. The data was obtained from the Swedish pediatric diabetes quality registry. It was found that mean HbA1c level was higher in the least physically active groups than in the most physically active groups. The authors suggest that in clinical practice these patients should be recommended daily physical activity as a part of their treatment.


England-wide Care Home Diabetes Audit
Institute of Diabetes for Older People

The initial findings from this first-ever England-wide Care Home Diabetes Audit revealed a lack of comprehensive assessment, monitoring and specialist care. However, the authors of the 24-page report assert that an opportunity exists to introduce Care Quality Commission-backed quality standards, and that these standards will make all of the stakeholders involved “sit up and take notice”. In their strongly worded introduction Professor Alan Sinclair, Director of the Institute of Diabetes for Older People (IDOP) and lead for the National Care Home Diabetes Audit, and Dr Chris Walton, Chair of the Association of British Clinical Diabetologists (ABCD) demand that “we should no longer have vulnerable people being treated by an unskilled workforce, and that it is time to act!”


Interpretation of HbA1c: association with mean cell volume and haemoglobin concentration
Simmons and T. Hlaing.  Diabetic Medicine. Doi: 10.1111/dme.12518

Because the utility of HbA1c in diabetes diagnosis is reduced in settings that are associated with altered haemoglobin glycation, the authors of this paper studied whether HbA1c varies with mean cell volume and mean cell haemoglobin concentration. The study was conducted in Australia and 1,315 adults were included. It found that a mean HbA1c difference of 5 mmol/mol (0.5%) across the mean cell haemoglobin concentration suggested that an accompanying full blood count examination may be required for use in the diagnosis of diabetes. However, the authors say that further studies are required to confirm this.


The Association between serum uric acid and residual ß-cell function in Type 2 Diabetes
Wei Tang et al. Journal of Diabetes Research. Doi: 10.1155/2014/709691

The aim of this study was to investigate the relationship of serum uric acid (sUA) with residual β-cell function in type 2 diabetes. Oral glucose tolerance tests (OGTT) were performed on 1,021 patients with type 2 diabetes. It was found that sUA was significantly associated with insulin secretion and the results suggest an independent positive association between sUA and residual β-cell function in type 2 diabetes. Patients with higher sUA have greater insulin secretion ability than those with lower sUA at the early stage of disease, but their residual β-cell function seems to decay more rapidly. http://www.hindawi.com/journals/jdr/2014/709691/