Body mass index and disability pension in middle-aged men--non-linear relations

BACKGROUND

Obesity has, in a number of studies, been found to correlate to disability and mortality, primarily due to diseases of the circulatory and musculoskeletal systems. In addition, an excess mortality among underweight subjects has been observed in previous studies.

METHODS

Five complete birth-year cohorts (1926-1930) of male residents in Malmö (n = 7697) were invited to the survey at the Department of Preventive Medicine, Malmö General Hospital, and 5926 (77%) attended with complete data. Each subject was followed from inclusion, defined by the date of examination, until the end of the calendar year when he turned 58, a total study period of approximately 11 years. Data on about 300 questionnaire items and laboratory tests were determined at the health survey visit. Nationwide Swedish data registers were used for surveillance.

RESULTS

Of the participants, 4.7% were underweight, 37.7% overweight, 7.3% obese and 50.3% normal weight; 849 (14.3%) had been granted disability pension at the end of follow-up, 717 after screening. After adjustment for smoking there was a J-shaped relation between body mass index (BMI) and incidence of disability pension, the relative risk ( with the normal group as reference) among underweight men being 1.9. For the overweight subjects it was 1.3 and for the obese 2.8, all differences were significant. Disease of the musculoskeletal and circulatory systems and mental disorders accounted for 67.2% of all main diagnoses resulting in disability pensions during follow-up. A total of 377 (6.4%) men died during follow-up. Diseases of the circulatory system, neoplasms, injury/poisoning and diseases of the respiratory system accounted for 91.8% of the deaths.

CONCLUSIONS

Both underweight, overweight and obesity were related to risk of disability pension, with a J-shaped risk relationship.

Review of previous impaired glucose tolerance intervention studies

Long-term intervention studies have evaluated the effect of diet, exercise and pharmacological regimens on the conversion rate of impaired glucose tolerance (IGT) to non-insulin dependent diabetes mellitus (NIDDM). Two UK studies, the Bedford study (10 years) and the Whitehall study (5 years), found that a diet which restricts carbohydrate intake to less than 120 g/day had no effect on the development of NIDDM in subjects with IGT. In contrast, the Swedish Malmöhus study (10 years) found that the conversion rate was reduced from 29% in the control group to 13% in a group told to limit their intake of carbohydrates and lipids and to reduce weight when overweight. A further Swedish study, the Malmö study (6 years and ongoing) is investigating a combination of dietary intervention and a strenuous exercise programme. In this study the conversion rate decreased from 29% in the control group to 11% in the diet plus exercise group. The Bedford and Whitehall studies also investigated intervention with tolbutamide and phenformin, respectively. Neither drug was found to have an effect on the conversion rate in either study. In contrast, positive results for tolbutamide were obtained in the Malmöhus study. No subjects in the tolbutamide plus diet group developed NIDDM compared with 29% in the control group. This regimen was also found to have beneficial effects on blood pressure, serum lipids and on cardiovascular morbidity and mortality.

Increased risk of ischaemic heart disease mortality in elderly men using anxiolytics-hypnotics and analgesics. Results of the 10-year follow-up of the prospective population study "Men born in 1914", Malmo, Sweden

OBJECTIVES

An increased risk of all-cause and cardiovascular mortality in users of anxiolytic-hypnotic drugs (AHD) has been reported, and use of analgesics may be an additional factor. Therefore, we examined the association of AHD and analgesic use, alone and in combination, with all-cause and ischaemic heart disease (IHD) mortality.

METHODS

Multivariate 10-year survival analysis in a population based cohort of 500 men born in 1914. Relative risks (RR) were adjusted by relevant confounders (blood pressure, serum cholesterol, diabetes mellitus, smoking habit, high alcohol consumption, history of previous IHD, cancer, and other diseases).

RESULTS

The RR of both all-cause and IHD mortality were significantly increased among those using both AHD and analgesics compared to those who took neither of these drugs: RR = 1.8 for all-cause mortality, and RR = 2.7 for IHD mortality.

CONCLUSION

Although the number of cases was small, warranting interpretative caution, the current study suggests that the combined use of AHD (mainly benzodiazepines) and analgesics seems to be associated with an increase in all-cause and IHD mortality in elderly men.

Comparison of the kinetics of glyburide and its active metabolites in humans

The pharmacokinetics of glyburide (Gb) and its active metabolites, 4-trans-hydroxyglibenclamide (M1) and 3-cis-hydroxyglibenclamide (M2), were compared in eight healthy subjects. After an overnight fast, each subject received a 3.5-mg single dose of Gb, M1 or M2 intravenously in random cross-over order. For comparison, a 3.5-mg oral dose of micronized formulation of Gb was also given in a test. The subjects continued to fast until standard meals were given at 0.5 and 5.5 h after each dose. Serum samples and urine fractions were collected for 10 h. Serum concentrations of Gb, M1 and M2, and urine concentrations of M1 and M2 were determined by a selective and sensitive liquid chromatographic method. The two metabolites had very similar pharmacokinetic profiles, except for volume of distribution and renal clearance. Estimated mean volume of distribution, total and renal clearance of M1 and M2 were 20.8 +/- 8.4 litres, 11.9 +/- 1.7 litres/h, 13.5 +/- 3.7 litres/h and 15.5 +/- 5.5 litres, 10.4 +/- 1.3 litres/h, 8.6 +/- 1.6 litres/h, respectively. Estimates of the volume of distribution and total clearance were significantly higher than those of Gb, which were 7.44 +/- 1.53 litres, 4.42 +/- 0.56 litres/h intravenously and 9.32 +/- 2.79 litres, 4.09 +/- 0.45 litres/h orally. There was no significant difference in total metabolite urine recovery between intravenous or oral administration of Gb, suggesting almost complete oral bioavailability of the micronized glibenclamide formulation.

Pharmacokinetic interactions of alcohol and acetylsalicylic acid

This study assessed the influence of acetylsalicylic acid (ASA, 1.0 g), ibuprofen (0.8 g) and paracetamol (1.0 g) on the single-dose kinetics of ethanol in 12 healthy volunteers ingesting the drug and a standardised 1840-kJ breakfast 1 h before intake of ethanol. It also assessed the influence of ethanol on the single-dose kinetics of 1.0 g ASA in ten fasting healthy volunteers. Plasma concentrations of ethanol were measured by gas chromatography, and those of the drugs by liquid chromatography. There was no effect of ASA, ibuprofen or paracetamol on the single-dose kinetics of ethanol, but concurrent intake of ethanol reduced the peak concentration of ASA by 25%.

Drug prescription attitudes and behaviour of general practitioners. Effects of a problem-oriented educational programme

A producer-independent, problem-oriented, group-education programme with 2-day meetings on drug treatment in primary health care (PHC) was developed and evaluated. Initially, it was tested on a selected group of general practitioners (district physicians), using a non-exposed group as control. A comprehensive questionnaire was used to test changes in attitudes. There was a significant change in attitudes concerning both general opinions on drugs and drug use, on information about drug treatment, and on use of drugs in selected therapeutic areas. Also, the district physicians became more critical towards information from pharmaceutical companies. Prescribing patterns tended to change in accordance with the attitude changes. Subsequently, the programme was offered to all district physicians (about 550) in the southern Swedish health care region for a 10-year period, with 20-25 district physicians per 2-day meeting. The impact of the programme on the prescribing of a selected group of drugs (antibiotics) was assessed by voluntary registration of prescription by the participants, by regional prescription analyses and by analyses of drug sales data. There were significant, consistent, and sustained changes in the prescribing of antibiotics. The study supports the view that, if drug prescribing in general practice is to be improved, producer-independent, problem-oriented, face-to-face, small-group education on drug treatment is worthwhile.

Antihyperglycaemic efficacy, response prediction and dose-response relations of treatment with metformin and sulphonylurea, alone and in primary combination

The short-term (2-12 weeks) antihyperglycaemic efficacy of metformin (M), glibenclamide (G), and their primary combination (MG) was assessed in a double-blind study including 165 unselected patients with Type 2 diabetes. Patients with diet failure were randomized to M, G or MG. The dose was titrated with a fasting blood glucose concentration (FBG) of < 6.7 mmol l-1 as the target, using at most six dose levels, the first three comprising increasing monotherapy (M or G) or low-dose primary combination (MGL), and the second three add-on therapies (M/G and G/M) and primary combination therapy escalated to high dose (MGH). Success rates were higher on MGL than on monotherapy. The difference in achieving acceptable control (FBG < or = 7.8 mmol 1(-1)) was 70% versus 51% (95% confidence interval 3-36%, p = 0.032). When the drugs were combined, a slightly greater FBG reduction (p = 0.026) was observed, at lower dosage (p = 0.013). The response could not be predicted from body weight, but depended upon initial FBG (p = 0.019) and meal-stimulated C-peptide (p = 0.007). FBG declined progressively with increasing doses of metformin, whereas glibenclamide exerted most of its effect at low dose. Primary combination therapy with metformin and sulphonylurea may be clinically useful.

Comparison of excess costs of care and production losses because of morbidity in diabetic patients

OBJECTIVE

To assess and compare excess costs of care and production losses because of morbidity in diabetic patients and the general population of a Swedish community.

RESEARCH DESIGN AND METHODS

Costs of production losses were calculated from medical and social insurance records on sickness benefit days (short-term illness) and premature retirement (permanent disability) in people with diabetes and in the entire population of the community (a municipality comprising a town and rural surroundings, with 28,000 inhabitants). Care costs included those of consultations and inpatient care, as well as costs of insulin, oral antidiabetic medications, other drugs, test material, and treatment devices, and they were obtained from patient records, the health care administration, and the statistics of community pharmacy sales.

RESULTS

Of the diabetic patients < 65 years of age, above which both diabetic and nondiabetic people get retirement pension, and sickness benefits cease, 62% of those on insulin treatment in each gender had insulin-dependent diabetes mellitus (IDDM). All insulin-treated non-insulin-dependent diabetes mellitus (NIDDM) patients were > 40 years of age. Both the insulin-treated and the non-insulin-treated diabetic patients were prematurely retired twice as often as the average population and had twice as many inpatient days. The insulin-treated subjects also had twice as many sickness benefit days. The excess costs of production losses as a result of morbidity in people with diabetes were about $7,000 per individual and year. The corresponding excess costs of inpatient care were $800. The therapeutic expenditures for control of diabetes were about $600 per individual and year. If converted to U.S. conditions, the costs of lost production as a result of excess morbidity (< 65 years of age) would be $12 billion and $9 billion for people with insulin-treated and non-insulin-treated diabetes, respectively.

CONCLUSIONS

If improved metabolic control by intensified treatment would reduce excess morbidity in both IDDM and NIDDM, the predominant costs of production losses imply that intensified antidiabetic treatment might save costs.

Therapeutic comparison of metformin and sulfonylurea, alone and in various combinations. A double-blind controlled study

OBJECTIVE

To assess and compare the therapeutic efficacy and safety of metformin (M) and sulfonylurea (glyburide, G), alone and in various combinations, in patients with non-insulin-dependent diabetes mellitus (NIDDM).

RESEARCH DESIGN AND METHODS

Of 165 patients (fasting blood glucose [FBG] > or = 6.7 mmol/l) initially treated with diet alone, 144 (FBG still > or = 6.7 mmol/l) were randomized to double-blind, double-dummy controlled treatment with M, G, or primary combination therapy (MG). The dose was titrated, with FBG < 6.7 mmol/l as target, using, at most, six dose levels. The first three dose levels comprised increasing single-drug therapy (M or G) or primary combination at increasing but low dosage (MGL), and the second three levels were composed of various high-dose combinations, i.e., add-on therapy (M/G or G/M) and primary combination escalated to high dosage (MGH). Medication was maintained for 6 months after completed dose titration.

RESULTS

The FBG target was achieved in 9% of patients after diet alone. Single-drug therapy was insufficient in 36% and MGL in 25% (NS) of the randomized patients. There was further improvement in glucose control by the high-dose combinations. Mean FBG +/- SE was reduced (P = 0.001) from 9.1 +/- 0.4 to 7.0 +/- 0.2 mmol/l in those maintained on single-drug treatment or low-dose primary combination. Those treated with different high-dose combinations had a large mean FBG reduction, from 13.3 +/- 0.8 to 7.8 +/- 0.6 mmol/l. HbA1c levels showed corresponding reductions, and glycemic levels rose after drug discontinuation. Fasting C-peptide rose during treatment with G and MGL but not with M, while fasting insulin was not significantly changed. Meal-stimulated C-peptide and insulin levels were unchanged by M but increased by G and, to a lesser extent, by MGL. There were no significant insulin or C-peptide differences between the different high-dose combinations (M/G, G/M, and MGH). Body weight did not change following treatment with M or combination but increased by 2.8 +/- 0.7 kg following G alone. Blood pressure was unchanged. Overall effects on plasma lipids were small, with no significant differences between groups. Drug safety was satisfactory, even if the reporting of (usually modest) adverse events was high; the profile, but not the frequency, differed between groups.

CONCLUSIONS

Dose-effect titrated treatment with either metformin or glyburide promotes equal degrees of glycemic control. The former, but not the latter, is able to achieve this control without increasing body weight or hyperinsulinemia. Near-normal glycemia can be obtained by a combination of metformin and sulfonylurea, even in advanced NIDDM.

Hypoglycemic activity of glyburide (glibenclamide) metabolites in humans

OBJECTIVE

To assess the hypoglycemic effect and the insulin-releasing effect of the main glyburide (glibenclamide) metabolites 4-trans-hydroxy-glibenclamide (M1) and 3-cis-hydroxy-glibenclamide (M2) in humans.

RESEARCH DESIGN AND METHODS

Eight healthy subjects participated in a placebo-controlled, randomized, single-blind crossover study with five single-dose tests, 3 months apart: 3.5 mg glibenclamide (Gb) orally, 3.5 mg Gb intravenously, 3.5 mg M1 intravenously, 3.5 mg M2 intravenously, and placebo intravenously, each in the fasting state. Standardized meals were given 0.5 and 5.5 h after each medication. Blood glucose levels were measured by a glucose oxidase method, and serum insulin concentrations were analyzed by a specific immunoassay.

RESULTS

Blood glucose levels during the first 5 h were significantly lowered not only by Gb but also by M1 and M2. The mean +/- SE blood glucose reductions (versus placebo) expressed as percent of area under the curve (AUC) (0-5 h) were 18.2 +/- 3.3% for M1, 12.5 +/- 2.3% for M2, 19.9 +/- 2.1% for intravenous Gb, and 23.8 +/- 1.2% for Gb orally. Serum insulin levels were significantly increased by Gb as well as by M1 and M2. and M2.

CONCLUSIONS

The two main metabolites of glyburide (glibenclamide) have a hypoglycemic effect in humans, which is due to increased insulin secretion.

Age standardisation of drug utilisation: comparisons of different methods using cardiovascular drug data from Sweden and Spain

In drug utilisation studies, the units of defined daily doses (DDD) and DDD/1000 inhabitants per day standardise for differences in dosage and population size, but not for age-related differences in drug utilisation. There is no consensus as to how age standardisation of DDD data should be carried out. Using cardiovascular drug utilisation data from Sweden and Spain, the current study compared the outcome of different methods of age standardisation. Both indirect methods (based on a comparison of observed and expected drug usage) and direct methods (using different weighting for the age categories) were used. The largest impact of standardisation was seen for diuretics. The crude rate for men and women combined was 26 DDD/1000 inhabitants per day in Costa de Ponent and 98 DDD/1000 inhabitants per day in Värmland. The corresponding figures when standardising the Costa de Ponent population were 26 and 58, respectively. Using the equivalent average rate (EAR) method, the rate for Värmland was 129 DDD/1000 inhabitants per day. Lesser but still important differences were found for beta-adrenoceptor and antihypertensives. Thus, the results of standardisation differ depending on which method is used and which drugs are evaluated. EAR is recommended for direct standardisation because of its ease of use and because it does not require the choice of a standard population.

Pronounced blood glucose-lowering effect of the antilipolytic drug acipimox in noninsulin-dependent diabetes mellitus patients during a 3-day intensified treatment period

Acute administration of the antilipolytic nicotinic acid analog acipimox to patients with noninsulin-dependent diabetes mellitus (NIDDM) is associated with increased peripheral and hepatic insulin sensitivity. However, long term acipimox treatment (250 mg, 3 times/24 h) of NIDDM patients does not improve blood glucose control, possibly due to rebound lipolysis. The current study assessed the influence of intensified acipimox administration (125 mg, 12 times/24 h) on diurnal plasma profiles of glucose, insulin, nonesterified FFA (NEFA), and triglycerides during a 3-day period. Eight NIDDM patients [mean age, 58.9 yr (range, 46-68); mean body mass index, 31.4 kg/m2 (range, 24.9-39.6)] were included in a randomized, double blind, placebo-controlled, cross-over study. Blood samples were collected every second hour during the study. The acipimox and placebo treatments were separated by a 2-week washout period. Acipimox treatment was associated with reduced diurnal mean plasma concentrations of NEFA [0.26 +/- 0.03 (+/- SEM) vs. 0.63 +/- 0.06 mmol/L; P < 0.001], triglycerides (1.74 +/- 0.21 vs. 2.10 +/- 0.18 mmol/L; P < 0.03), glucose (12.7 +/- 1.0 vs. 15.8 +/- 1.2 mmol/L; P < 0.002), and insulin (157 +/- 21 vs. 207 +/- 27 pmol/L; P < 0.05). However, despite the overall reduction in mean NEFA, during acipimox treatment NEFA increased from days 1-3 (0.18 +/- 0.03 vs. 0.34 +/- 0.04 mmol/L; P < 0.001), whereas plasma glucose (13.4 +/- 1.2 vs. 12.3 +/- 0.9 mmol/L; P < 0.03) and plasma insulin (168 +/- 23 vs. 148 +/- 17 pmol/L; P < 0.04) decreased steadily from days 1-3 during active treatment. In conclusion, inhibition of lipolysis using the intensified acipimox treatment regiment was associated with a pronounced blood glucose- and plasma insulin-lowering effect. However, minor rebound effects of lipolysis occurred in some patients despite the presence of allegedly effective acipimox levels. This suggests that caution should be employed concerning long term use of acipimox as a hypoglycemic agent in NIDDM patients.

Slow elimination of glyburide in NIDDM subjects

OBJECTIVE

To determine the terminal elimination half-life of glyburide in non-insulin-dependent diabetes mellitus (NIDDM) subjects after cessation of long-term treatment.

RESEARCH DESIGN AND METHODS

Ten NIDDM patients (5 of each sex, 36-72 years old, without hepatic or renal disease) taking a median glyburide dose of 14 mg/day, who were to start insulin therapy because of sulfonylurea failure, were studied. Serum glyburide concentrations, measured by a newly developed selective and sensitive liquid chromatographic method, were followed from 10 to 48 h after the last glyburide dose.

RESULTS

Serum glyburide levels declined in three different phases, with a terminal gamma-phase between 18 and 48 h having a mean +/- SD half-life of 15.0 +/- 6.7 h. Two patients had half-lives over 20 h. The half-life values did not correlate with fasting blood glucose, age, body weight, body mass index, or creatinine levels. The latter agrees with the assumption that glyburide is completely eliminated by metabolic transformation. Although longer than previously observed, the current half-life values are in accordance with clinical experience that glyburide is a long-acting sulfonylurea.

CONCLUSIONS

The elimination of glyburide in NIDDM subjects is slower than previously reported. The long half-life adds support to the use of a once-daily dosage of glyburide. It also justifies increased caution when using this sulfonylurea.

Antidepressants in suicide: differences in fatality and drug utilisation

All forensic autopsy cases in southern Sweden in 1986-89 in which antidepressant drugs were found in the blood were assessed and the findings related to the sales of antidepressants as expressed as defined daily doses per 1,000 inhabitants per day. There was a total of 272 antidepressant-positive cases, which were divided in three groups: 1. suicide or possible suicide caused by antidepressant drugs, 2. suicide or possible suicide caused by other means (including other drugs and other toxic agents), and 3. other deaths. Amitriptyline was the agent most commonly involved in suicide or possible suicide caused by antidepressants, and it was also the most commonly sold antidepressant. When corrected for sales, trimipramine was most frequently involved as the causal agent. Conversely, despite frequent sales, lofepramine appeared only rarely to be involved. This may be related to lower toxicity of lofepramine, reduced lofepramine absorption at overdose and/or to differences in the administration of various antidepressant drugs to patients with differing degrees of risk of suicide.

Long-term randomized placebo-controlled double-blind therapeutic comparison of glipizide and glyburide. Glycemic control and insulin secretion during 15 months

OBJECTIVE

To examine the long-term (15 months) effects on glycemic control and insulin secretion of glipizide and glyburide treatment in patients with non-insulin-dependent diabetes mellitus (NIDDM).

RESEARCH DESIGN AND METHODS

Prospective, randomized, double-blind, placebo-controlled study on 46 NIDDM patients comparing fasting levels and test-meal responses of glucose and insulin during 15 months of follow-up.

RESULTS

A comparable reduction in HbA1c levels by both agents versus placebo was observed throughout the study period, but after a marked initial reduction in both sulfonylurea groups, all three groups showed gradually increasing HbA1c levels. However, both glipizide and glyburide achieved and maintained lowered postprandial glucose levels and increased fasting and postprandial insulin levels compared with placebo.

CONCLUSIONS

Both glipizide and glyburide may achieve and maintain glycemic reduction and stimulation of insulin secretion during long-term treatment. However, these agents do not prevent the gradual increase in overall glycemia that develops over time in NIDDM patients.

Low-dose aspirin to pregnant women: single dose pharmacokinetics and influence of short term treatment on bleeding time

Single dose pharmacokinetics of 75 mg aspirin was investigated in two groups of ten women with clinically normal pregnancies. Eleven non-pregnant subjects in the same age were controls. In group A, gestational age was 27-30 completed weeks, and in group B, 36-39 weeks. Venous blood samples were taken before and up to 240 minutes after the intake of the aspirin. Liquid chromatographic assays for acetylsalicylic acid (ASA) and its metabolite, salicylic acid (SA), was performed. The pharmacokinetics of ASA and SA were similar in group A and B but pregnant subjects had a slower uptake and a lower peak level than controls. The late elimination phase for their compound did not differ between the groups. Nine pregnant women with normal pregnancies had their bleeding time measured by a modified Ivy technique using a Simplate II device before, at the end of, and two weeks after daily administration of 75 mg ASA for two weeks. All had a normal bleeding time before and two weeks after the end of the medication. Eight of the nine subjects had an increased bleeding time by Ivy tests, (p < 0.01) whereas the bleeding time assessed by Duke's method was within normal limits. These studies suggest that during pregnancy changes of the uptake rate and distribution volume modulate the pharmacokinetics of ASA and that this drug given in low dosage to gravidae marginally alters their platelet function.

Metabolic consequences of sustained suppression of free fatty acids by acipimox in patients with NIDDM

To examine whether overnight suppression of free fatty acid levels reduces hepatic glucose production, 20 NIDDM patients were given a slow-release formulation of the antilipolytic agent acipimox, in a double-blind crossover manner at bedtime for 4 wk. During acipimox treatment, serum free fatty acid concentrations were suppressed between 2400 and 0600 by 64% (P < 0.001), but no reduction in hepatic glucose production was observed (2.16 +/- 0.16 vs. 2.23 +/- 0.16 mg.kg-1 x min-1, acipimox vs. placebo). In contrast, from 0800 to 2000 a sustained 50% rise occurred in serum free fatty acids (P < 0.001). As a consequence, the 24-h area under the free fatty acid curve was similar during both treatment periods. In the morning, the rise in free fatty acid concentration occurred despite identical serum acipimox concentrations as those measured at midnight, when free fatty acid levels were suppressed. Although energy expenditure was higher (P < 0.05) during periods of elevated free fatty acid levels, the sums of energy expenditure measured in the morning and in the evening were similar during the acipimox and placebo periods. To exclude that the free fatty acid rise was caused by administration of acipimox only once at bedtime, additional experiments were performed administering acipimox every 2 h for 4 days. Despite similar acipimox concentration on day 1 and day 4 of this frequent dosing regimen, the free fatty acid concentrations were significantly higher on day 4 compared with day 1 (P < 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)

The acute effect of preprandial exogenous and endogenous sulphonylurea-stimulated insulin secretion on postprandial glucose excursions in patients with type 2 diabetes

Sulphonylureas improve glucose tolerance by stimulating insulin secretion. Whether improved glucose tolerance results from enhanced early insulin release or greater total insulin secretion is not clear. Insulin response to a test meal in Type 2 diabetic subjects with and without a single dose (2.5 mg) of oral and intravenous glipizide were, therefore, measured. Intravenous glipizide enhanced early insulin release more than oral glipizide (134% and 80% vs control; p < 0.01), whereas total insulin release was equally improved (78% and 54% vs control; p < 0.01). Despite slight differences in insulin release, there was no difference in glucose tolerance (median area under concentration curve (AUC); 66.6 vs 61.9 mmol x min l-1; NS). The test meal was repeated after a bolus of intravenous insulin at the beginning of the meal. This allowed comparison of the effect of exogenous and endogenous insulin supply on postprandial glucose excursions. In spite of an early and fivefold larger rise in serum insulin after intravenous administration of the hormone than after intravenous glipizide (725% vs 134%; p < 0.01), postprandial glucose was no better than after glipizide (median AUC; 87.8 vs 66.6 mmol x min l-1; NS). In contrast, glucose tolerance was better after oral glipizide compared to intravenous insulin (median AUC; 61.9 vs 87.8 mmol x min l-1; p < 0.05). In conclusion, the total amount of insulin secreted seems more important than the timing of the insulin release for the postprandial glucose tolerance in Type 2 diabetic subjects. Neither endogenous nor peripheral premeal supply of insulin could normalize postprandial glucose excursions in patients with Type 2 diabetes.

The relationship between early insulin release and glucose tolerance in healthy subjects

Sulphonylureas improve glucose tolerance by stimulating insulin secretion. Whether improved glucose tolerance results from enhanced early insulin release or greater total insulin secretion is not clear. Therefore insulin and C-peptide responses to oral glucose were measured in healthy subjects with and without a single dose of oral and intravenous glipizide. The intravenous glipizide administration caused a marked early insulin response, whereas oral glipizide administration resulted in greater total and peak insulin concentration. Oral glipizide did not reduce plasma glucose until 45 min of the glucose load. In contrast, enhancement of the early insulin response with intravenous glipizide almost completely prevented postprandial glucose rise. In conclusion, early insulin release is a major factor determining oral glucose tolerance in healthy subjects.

What is the benefit of increasing the sulfonylurea dose?

OBJECTIVE

To study the clinical benefit of increasing the dose of the sulfonylurea, glipizide, from 10 to 40 mg per day.

DESIGN

A placebo-controlled, double-blind, cross-over study.

SETTING

An outpatient clinic at the Helsinki University Hospital, Finland.

PATIENTS

Twenty-three patients with noninsulin-dependent diabetes mellitus.

METHODS

Patients were given glipizide in three different dose schedules for 3 months each: 10 mg in the morning or 10 mg or 20 mg in the morning and the evening. Glycemic control was followed by HbA1c measurements and blood glucose monitoring at home. Beta cell function was assessed by measuring insulin responses to a test meal.

RESULTS

Mean home-monitored blood glucose was 12.4 mmol/L during placebo treatment, and it was 9.6, 9.2, and 8.9 mmol/L after treatment with glipizide, 10, 20, or 40 mg, respectively. The levels of blood glucose and HbA1c differed after all treatment groups from placebo (P < 0.001) but not among themselves. The insulin response to a test meal was greatest after 10 mg of glipizide and weakest after 40 mg/d (P = 0.02 compared with the 10-mg dose). All treatments stimulated insulin secretion more than placebo (P < 0.001).

CONCLUSIONS

Increasing the glipizide dose to more than 10 mg once daily produces little or no benefit and may reduce beta-cell function.

Benzodiazepine prescribing patterns in a high-prescribing Scandinavian community

Sales statistics indicate large variations in benzodiazepine consumption between the Scandinavian countries: the current difference between Denmark (highest) and Sweden (lowest) is almost two-fold. There are also large within-country variations: e.g. benzodiazepine sales in the Swedish city of Helsingborg, which is close to Denmark, were at the average Danish level and were the highest in Sweden. Repeated prescription analyses were carried out in Helsingborg, and register data were used to compare the extent of psychiatric morbidity and psychosocial problems in this city with those in neighbouring cities. Benzodiazepine consumption was higher than the national average in all age groups. However, neither the choice of the predominant benzodiazepine agents nor the dose size or number of doses per prescription showed any major deviation. Hence, Helsingborg may have a larger proportion of benzodiazepine users or longer exposure periods among users. The latter is supported by the fact that about 40% of all benzodiazepine prescriptions were repeated. Psychiatric morbidity, suicide rate, alcohol-related diseases, unemployment and the proportion of socially isolated subjects were higher than the county average. On the other hand, within the county, there were cities that despite lower benzodiazepine sales had an equal or higher rate of suicide, unemployment and alcohol-related diseases. Of all benzodiazepine prescriptions processed in Helsingborg, > 30% were issued by < 5% of the prescribers (> or = 15 prescriptions per prescriber and per week). Thus, the higher usage of benzodiazepines in Helsingborg may partly be related to higher psychiatric morbidity and more psychosocial problems, but deviant prescribing habits among a minority of physicians are also important.

Large intercommunity difference in cardiovascular drug consumption: relation to mortality, risk factors and socioeconomic differences

A comparison of cardiovascular drug sales and cardiovascular mortality was made between two Swedish counties (Värmland and Malmöhus) and between two rural municipalities in those counties (Torsby in Värmland and Hörby in Malmöhus). Cardiovascular drug sales (defined daily doses (DDD) per 1,000 inhabitants per day) during 1986-87 were 25% higher in Värmland than in Malmöhus county, and the age-standardized mortality of coronary heart disease (CHD) was 36% (men) and 54% (women) higher. In Torsby, age-standardized CHD mortality (1986-87) was 71% (both sexes) higher than in Hörby, and the sales of cardiovascular drugs (1978-87) were 58% higher. Statistically, every third inhabitant of Torsby took one DDD of a cardiovascular drug every day, as compared to every fifth inhabitant in Hörby. In Torsby there was a 6% higher serum cholesterol, 71% lower tap water hardness, 33% lower income, a lower educational level, a three-fold higher unemployment rate, and a different ethnic background (20% eastern Finnish ancestry), all factors assumed to promote a high CHD rate. All of these factors may contribute to the higher CHD mortality, which was in turn reflected in higher sales of cardiovascular drugs.