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October 2015

Impact of insulin initiation on glycaemic variability and glucose profiles in a primary healthcare Type 2 diabetes cohort
J. Manski-Nankervis et al. Diabetic Medicine. Doi: 10.1111/dme.12979

This study utilised continuous glucose monitoring to examine the effects of insulin initiation with glargine, with or without glulisine, on glycaemic variability and glycaemia in people with Type 2 diabetes receiving maximum oral hypoglycaemic agents in primary healthcare. It examined data from 89 participants at baseline and at 24 weeks after insulin commencement. It discovered that insulin initiation reduced hyperglycaemia but did not alter glycaemic variability. The most significant postprandial excursions were seen in the morning, which identifies prebreakfast as the most effective target for short-acting insulin therapy.


A comparison of prescribing and non-prescribing nurses in the management of people with diabetes
Molly Courtenay et al. Journal of Advanced Nursing. Doi: 10.1111/jan.12757

The aim of this study was to compare nurse prescribers and non-prescribers managing people with diabetes in general practice. Over 28,000 nurses in the UK can prescribe the same medicines as doctors provided that it is in their level of experience and competence. Over 30%, mostly in general practice, prescribe medicines for patients with diabetes. The study looked at nurses managing care of people with Type 2 diabetes in twelve general practices in England; six could prescribe, six could not. The patients – that were recruited by the nurses – were followed up for 6 months. It found that there were no differences in reported self-care activities or HbA1c test results between the patients of prescribers and non-prescribers. Mean HbA1c decreased significantly in both groups over 6 months. Patients of prescribers were more satisfied possibly because consultation duration was longer for prescribers. Non-prescribing nurses sought support from other healthcare professionals more frequently. Most prescribing nurses were on a higher salary band than non-prescribers which impacted on employment costs.


2 month evening and night closed-loop glucose control in patients with type 1 diabetes under free-living conditions
 Jort Kropf f et al. Lancet. DOI: http://dx.doi.org/10.1016/S2213-8587(15)00335-6

This study assessed the effect on glucose control with use of an artificial pancreas (AP) in patients with type 1 diabetes during the evening and night combined with patient-managed sensor-augmented pump therapy (SAP) during the day, versus 24 h use of patient-managed SAP only. The study was conducted in France, Italy, and the Netherlands. The AP consisted of a continuous glucose monitor (CGM) and insulin pump connected to a modified smartphone with a model predictive control algorithm. The primary endpoint was the percentage of time spent in the target glucose concentration range (3·9–10·0 mmol/L) between 2000 to 0800 hours. CGM data for 3 to 8 weeks of the interventions were analysed. The 2 month study period also allowed assessment of HbA1c as one of the secondary outcomes. The results supported the use of AP at home as a safe and beneficial option for patients with type 1 diabetes. The authors report that the HbA1c results were encouraging but preliminary. No serious adverse events occurred during the study


Fear of hypoglycemia in adults with type 1 diabetes: impact of therapeutic advances and strategies for prevention
Pamela Martyn-Nemeth et al. Journal of Diabetes and Its Complications. Doi: http://dx.doi.org/10.1016/j.jdiacomp.2015.09.003

This review summarised the current state of the science related to fear of hypoglycemia (FOH) in adults with type 1 diabetes. Particular attention was paid to FOH as a critical deterrent to diabetes self-management, psychological well-being, and quality of life. The investigators examined the influence of contemporary treatment regimens, technology, and interventions to identify gaps in knowledge and opportunities for research and practice. The study used a literature search of MEDLINE, PsycINFO, and EMBASE. It was found that fear of hypoglycemia influenced diabetes management and quality of life. Gender and age differences were noted in the experiences of the responders. Responses varied from increased vigilance to potentially immobilizing distress. Unsurprisingly fear of hypoglycemia was greater at night. It was noted that the strategies to reduce fear of hypoglycemia have had varying success. The authors concluded that fear of hypoglycemia remains a problem, despite advances in technology, insulin analogs, and evidence-based diabetes management. They posit that clinical care should consistently include assessment for its influence on diabetes self-management and psychological health.  They also suggest that further research is needed regarding the influence of newer technologies and individualized strategies to reduce fear of hypoglycemia while maintaining optimal glucose control


HbA1c below 7 % as the goal of glucose control fails to maximize the cardiovascular benefits
Pin Wang et al. Cardiovascular Diabetology. Doi: 10.1186/s12933-015-0285-1

This study asked if lowering HbA1c level below 7.0 % improved cardiovascular outcomes in patients with diabetes. The investigators looked at studies that recorded cardiovascular outcome trials of glucose-lowering drugs or strategies in patients with type 2 diabetes mellitus. It used data from 15 studies involving 88,266 diabetic patients with 4,142 events of non-fatal myocardial infarction, 6,997 of major cardiovascular events, 3,517 of heart failure, 6,849 of all-cause mortality, 2,084 of non-fatal stroke, 3,816 cases of cardiovascular death. It found that there was a 7 % reduction of major cardiovascular events but only when relatively tight glucose control resulted in a follow-up HbA1c level above 7.0 %, however, they also found that patients benefited from a reduction in the incidence of non-fatal myocardial infarction only when the follow-up HbA1c value was below 7.0 %. It also discovered that, apart from the HbA1c value above 7.0 %, the application of thiazolidinediones also increased the risk of heart failure, while the gliptins showed neutral effects with respect to heart failure. In conclusion the author’s assessment was that relatively tight glucose control has some cardiovascular benefits. However, HbA1c below 7.0 % as the goal to maximize the cardiovascular benefits remains open to question.


The changing relationship between HbA1c and FPG according to different FPG ranges
X. Guan et al. Journal of Clinical Investigation. Doi: 10.1007/s40618-015-0389-1

The authors of this paper say that since the American Diabetes Association included hemoglobin HbA1c in the diagnostic criteria for diabetes in 2010, the clinical use of HbA1c has remained controversial. To examine this they explored the use of HbA1c for diagnosing diabetes and intermediate hyperglycemia in comparison with fasting plasma glucose (FPG). They found that the relationship between HbA1c and FPG changed according to the different FPG ranges. When FPG was higher, the relationship was stronger, and HbA1c and FPG were highly consistent in diagnosing diabetes, but they were not in predicting intermediate hyperglycemia.


A study of a virtual clinic integrating primary and specialist care for patients with Type 2 diabetes mellitus
N. Basudev et al. Diabetic Medicine. Doi: 10.1111/dme.12985
This study, with randomized allocation to virtual clinic or usual care, looked at 208 patients with Type 2 diabetes who were recruited from six general practices in South London. The primary outcome for the study was glycaemic control, secondary outcomes included: lipids, blood pressure, weight and renal function (eGFR). Data was collected from participants’ records at baseline and at 12 months. The 12–month data showed equivalence between the virtual clinic and control groups for glycaemic control with both achieving clinically significant reductions in HbA1c. The virtual clinic group showed superiority over the intervention group for blood pressure control. There were no significant differences between the groups in terms of cholesterol, weight and renal function. The conclusion was that the virtual clinic model explored in this study showed a clinically important improvement in glycaemic control, although this improvement was not superior to that observed in the control participants. The authors suggest that this might be attributable to the systemic impact of the virtual clinic on the practice as a whole.


Prevalence of depression in Type 1 diabetes and the problem of over-diagnosis
L. Fisher et al. Diabetic Medicine. Doi: 10.1111/dme.12973

In this sample of 368 individuals with Type 1 diabetes it was found that there was an unexpectedly low rate of current depression and major depressive disorder. It was also found that there was a very high rate of false-positive results using a patient health questionnaire. The authors suggest that when one considers the high prevalence of diabetes distress, much of what has been considered depression in adults with Type 1 diabetes may be attributed to the emotional distress associated with managing a demanding chronic disease and is not necessarily due to underlying psychopathology.


Patients with coronary artery disease and diabetes need improved management
Viveca Gyberg et al. Cardiovascular Diabetology. Doi: 10.1186/s12933-015-0296-y

This survey investigated screening for glucose perturbations in people with coronary artery disease and compared patients with known and newly detected type 2 diabetes with those without diabetes in terms of their life-style and pharmacological risk factor management in relation to contemporary European guidelines. A total of 6,187 patients (aged 18 to 80 years) with coronary artery disease and known glycaemic status based on a self reported history of diabetes (previously known diabetes) or the results of an oral glucose tolerance test and HbA1c (no diabetes or newly diagnosed diabetes) were investigated in 24 European countries between 2012 and 2013. The comprehensive results listed in the abstract showed that despite advances in patient management there is further potential to improve both the detection and management of patients with diabetes and coronary artery disease.


Impact of postprandial glucose control on diabetes-related complications: how is the evidence evolving?
S. Madsbad. Journal of Diabetes and Its Complications. Doi: http://dx.doi.org/10.1016/j.jdiacomp.2015.09.019

In this abstract the authors report that conflicting findings in the literature and lack of long-term definitive outcome studies have led to difficulty in drawing conclusions about the role of postprandial hyperglycemia in diabetes and its complications. Although recent scientific publications support the role of postprandial glucose as a key contributor to overall glucose control and a predictor of microvascular and macrovascular events, the need remains for definitive evidence to support the precise relationship between postprandial glucose excursions and the development and progression of cardiovascular complications of diabetes. Drawing firm conclusions on the relationship between postprandial glucose and microvascular and macrovascular complications is challenged by the absence of antidiabetic agents that can specifically exert their action on postprandial glucose alone, without a basal glucose-lowering effect. The conclusion being that the precise role of postprandial hyperglycemia in relation to development of diabetic complications is unclarified and is one of the remaining unanswered questions in diabetes. Nevertheless, current evidence supports postprandial glucose control as an important strategy to consider in the comprehensive management plan of individuals with diabetes.

InDependent Diabetes Trust