Patient-reported outcomes following treatment with the human GLP-1 analogue liraglutide or glimepiride in monotherapy: results from a randomized controlled trial in patients with type 2 diabetes

AIM

As weight gain and hypoglycaemia associated with glimepiride therapy can negatively impact weight perceptions, psychological well-being and overall quality of life in type 2 diabetes, we investigated whether liraglutide treatment could improve these factors.

METHODS

Seven hundred and thirty-two patients with type 2 diabetes completed a 77-item questionnaire during a randomized, 52-week, double-blind study with liraglutide 1.2 mg (n = 245) or 1.8 mg (n = 242) compared with glimepiride 8 mg (n = 245).

RESULTS

Mean (SE) decreases in glycated haemoglobin levels were greater with liraglutide 1.2 mg [-0.84 (0.08)%] and 1.8 mg [-1.14 (0.08)%] than glimepiride [-0.51 (0.08)%; p = 0.0014 and p < 0.0001, respectively]. Patients gained weight on glimepiride [mean (SE), 1.12 (0.27) kg] but lost weight on liraglutide [1.2 mg: -2.05 (0.28) kg; 1.8 mg: -2.45 (0.28) kg; both p < 0.0001]. Patient weight assessment was more favourable with liraglutide 1.8 mg [mean (SE) score: 40.0 (2.0)] than glimepiride [48.7 (2.0); p = 0.002], and liraglutide 1.8 mg patients were 52% less likely to feel overweight [odds ratio (OR) 0.48; 95% confidence interval (CI): 0.331-0.696]. Mean (SE) weight concerns were less with liraglutide [1.2 mg: 30.0 (1.2); 1.8 mg: 32.8 (1.2)] than glimepiride [38.8 (1.2); p < 0.0001 and p < 0.001, respectively], with liraglutide groups 45% less likely to report weight concern (OR 0.55, 95% CI: 0.41-0.73). Mean (SE) mental and emotional health and general perceived health improved more with liraglutide 1.8 mg [476.1 (2.8) and 444.2 (3.2), respectively] than glimepiride [466.3 (2.8) and 434.5 (3.2), respectively; p = 0.012 and p = 0.033, respectively].

CONCLUSIONS

Improved glycaemic control and decreased weight with liraglutide 1.8 mg vs. glimepiride can improve psychological and emotional well-being and health perceptions by reducing anxiety and worry associated with weight gain.

The association of body mass index and health-related quality of life in the general population: data from the 2003 Health Survey of England

OBJECTIVES

The link between obesity/overweight and life-threatening illnesses is well established. The objective of this study was to investigate the relationship between body mass index (BMI) and health-related quality of life (HRQoL), and any differences between men and women, in the general population of England.

METHODS

HRQoL data (from EQ-5D responses of 14,416 individuals aged >or=18 in the 2003 Health Survey for England) were used, and linear regression analyses were conducted to examine the relationship between BMI and HRQoL.

RESULTS

A significant association between BMI and HRQoL was found after controlling for factors such as gender, age, and obesity-related comorbidities. The maximum HRQoL was reached at a BMI of 26.0 in men and 24.5 in women, demonstrating that BMI is negatively associated with HRQoL for both underweight and obese individuals. At higher BMI values, men reported higher HRQoL than women; at lower BMI values, HRQoL was lower in men than women.

CONCLUSIONS

There is a significant association between BMI and HRQoL in men and women in the general population. Nearly all aspects of HRQoL are adversely affected by elevated BMI.

Syndrome of inappropriate antidiuresis in small-cell lung cancer. Classification and effect of tumor regression

Patients with small-cell lung cancer and hyponatremia were examined for the syndrome of inappropriate antidiuresis (SIAD). A comparison was made between the definition based on hyponatremia, serum hypoosmolality and urine hyperosmolality (classic SIAD, 12 patients) and a definition based on measurement of plasma ADH concentration by radioimmunoassay (RIA-SIAD, nine patients) and patients without SIAD (eight patients). A standard water load test was performed as a reference before initiation of cytostatic treatment. All tests were repeated if remission of the malignant disease occurred. RIA-SIAD patients were a subgroup of classic SIAD patients, with more pronounced homeostatic abnormalities. Biochemical abnormalities were reduced after tumor regression but a completely normal renal water handling was achieved in only few patients, even when complete remission of the tumor was achieved, presumably due to the persistence of subclinical disease. However, an effect of other yet unknown factors might be of influence.

Defects in osmoregulation of vasopressin secretion. A report of four cases

Four patients are presented, all having pathologic responses in plasma vasopressin concentration to changes in plasma osmolality. Clinically, three of them had the syndrome of inappropriate antidiuretic hormone secretion (SIADH). The fourth had diabetes insipidus associated with an increased threshold for plasma osmolality. Two of the patients with SIADH had lowered thresholds for ADH secretion and one of these also had increased sensitivity to increments in osmolality. The latter patient, like another earlier reported similar case, had a defective blood-cerebrospinal fluid barrier. The third SIADH patient had no response at all to changes in osmolality from 230 to 305 mOsm/kg and had a small cell carcinoma of the lung. These examples illustrate that both the setting and the sensitivity of osmoreceptors and AVP-secreting neurons probably are under complex control from the CNS, and that CNS diseases can affect one or several of these pathways thereby affecting the setting of the osmoreceptor-vasopressin system.

Plasma vasopressin, cortisol, and growth hormone concentrations in relation to surgery in the suprasellar region

Posterior and anterior pituitary functions were assessed in 8 patients before, during, and after surgery for tumors in the suprasellar region. Preoperatively, all patients but one responded adequately to an osmotic stimulus with a rise in plasma vasopressin (AVP) and all but one showed adequate cortisol response to adrenocorticotropic hormone (ACTH) and hypoglycemia. During surgery a transient rise was seen in plasma levels of AVP (5 out of 8 patients), cortisol (7 out of 8 patients) and growth hormone (4 out of 8 patients). This response could be predicted from the preoperative stimulation tests. Postoperatively the AVP response to osmotic stimuli was impaired in 4 out of 5 patients, although urine volume had returned to normal after a transient polyuric phase. The response of plasma cortisol to ACTH was still adequate but lower than preoperatively.

The adrenocortical response to angiotensin II infusion in anephric and non-nephrectomized patients on regular hemodialysis

In the present study 8 anephric and 4 non-nephrectomized patients were stimulated with angiotensin II (A-II). In 5 of the anephric patients, an increased plasma aldosterone concentration (PAC) in response to ACTH stimulation had previously been demonstrated. After A-II stimulation, all 8 anephric patients responded with a significant rise in PAC although the increase was less pronounced than in 4 non-nephrectomized patients. In both groups of patients the increase in PAC was correlated to the increase in diastolic and systolic BP and to the A-II dose. Furthermore, in the non-nephrectomized patients, the plasma renin activity showed a significant decline, which was inversely correlated to the increase in PAC. When all 12 patients, regardless of the difference in remaining renin-angiotensin system, were considered as one population, the variable basal levels of PAC correlated significantly to the increase in PAC during A-II and ACTH stimulation. It is concluded that the adrenals of anephric man respond to A-II with an increase in PAC and that the reason for a lower response appears to be the lack of the renin-angiotensin system.

[Influence of two different cameras on the spectrometric measurement of oxygen saturation]

OBJECTIVES

Oxygen saturation in retinal vessels can be measured by spectrometry. However, there are no studies on the influence of different camera chips on these measurements. The presented study reports the effect of two different camera chips ("1-CCD" vs. "3-CCD") on the spectrometric measurements in the same patients.

METHODS

61 eyes of 61 patients were included in this study. The study was approved by the local ethics commission. Patients were separated in 3 groups: the first group contained healthy volunteers, the second group patients with diabetes mellitus but without previous laser treatment, the third group included patients with diabetes mellitus and previous laser coagulation treatment. The oxygen saturation was calculated from the difference between wavelengths on and right next to the retinal vessel. This methodology uses the different absorption spectra of oxy- and deoxyhaemoglobin.

RESULTS

All 3 groups demonstrated valid outcomes of the retinal oxygen saturation in arterial and venous vessels. No significant differences we found in the arterial-venous oxygen difference between the two different camera chips (group 1 p = 0.063, group 2 p = 0.204, group 3 p = 0.059).

CONCLUSION

As no significant differences could be found between the two camera chips, the less expensive system should be used if the spectrometric measurement of oxygen saturation is added to an analysis system already established on the market.

Management of severe hypoglycaemia: cultural similarities, differences and resource consumption in three European countries

BACKGROUND

To investigate the characteristics of people with insulin-treated diabetes, who have experienced severe hypoglycaemic events (SHEs), in Germany, Spain or UK.

METHODS

Patients with type 1 (n=319) or insulin-treated type 2 diabetes (n=320) who had experienced ≥ 1 SHE in the preceding year were enrolled. Their median age was 53 years (range, 16-94 years). Data were collected using a questionnaire administered by an experienced interviewer.

RESULTS

The median number of reported SHEs was 2-3 in 12 months. Most events (69%) occurred at home, usually during the day or evening (74%) and most commonly due to insufficient food consumption (45%). In patients whose hypoglycaemia awareness was tested, 68% had normal awareness. Patients requiring emergency healthcare treatment frequently had impaired hypoglycaemia awareness, and developed hypoglycaemic coma more often. Hospital treatment was usually provided in an emergency department (72-94%). The duration of stay was longest in Germany. Following a SHE, patients receiving professional treatment were more likely to: consult their physician, test their blood glucose more often, adjust insulin dose and receive self-management training.

CONCLUSIONS

This survey of diabetes patients aged 16-94 years showed that SHEs represent a substantial burden on national healthcare systems in Germany, UK and Spain. The pattern of occurrence and treatment was similar in all three countries, despite differences in cultures and healthcare systems.

Quantitative assessment of optic nerve head pallor

Ischaemia, loss of neural tissue, glial cell activation and tissue remodelling are symptoms of anterior ischaemic as well as glaucomatous optic neuropathy leading to pallor of the optic nerve head. Here, we describe a simple method for the pallor measurement using a fundus camera equipped with a colour CCD camera and a special dual bandpass filter. The reproducibility of the determined mean pallor value was 11.7% (coefficient of variation for repeated measurements in the same subject); the variation over six healthy subjects was 14.8%. A significant difference between the mean pallor of an atrophic disc and that of the contralateral eye of the same individual was found. However, even the clinically unaffected eye showed a significantly increased pallor compared to the mean of the healthy control group. Thus, optic disc pallor measurement, as described here, may be helpful in the early detection and follow-up of optic neuropathy.

Towards metabolic mapping of the human retina

Functional alterations are first signs of a starting pathological process. A device that measures parameter for the characterization of the metabolism at the human eye-ground would be a helpful tool for early diagnostics in stages when alterations are yet reversible. Measurements of blood flow and of oxygen saturation are necessary but not sufficient. The new technique of auto-fluorescence lifetime measurement (FLIM) opens in combination with selected excitation and emission ranges the possibility for metabolic mapping. FLIM not only adds an additional discrimination parameter to distinguish different fluorophores but also resolves different quenching states of the same fluorophore. Because of its high sensitivity and high temporal resolution, its capability to resolve multi-exponential decay functions, and its easy combination with laser scanner ophthalmoscopy, multi-dimensional time-correlated single photon counting was used for fundus imaging. An optimized set up for in vivo lifetime measurements at the human eye-ground will be explained. In this, the fundus fluorescence is excited at 446 or 468 nm and the time-resolved autofluorescence is detected in two spectral ranges between 510 and 560 nm as well as between 560 and 700 nm simultaneously. Exciting the fundus at 446 nm, several fluorescence maxima of lifetime t1 were detected between 100 and 220 ps in lifetime histograms of 40 degrees fundus images. In contrast, excitation at 468 nm results in a single maximum of lifetime t1 = 190 +/- 16 ps. Several fundus layers contribute to the fluorescence intensity in the short-wave emission range 510-560 nm. In contrast, the fluorescence intensity in the long-wave emission range between 560 and 700 nm is dominated by the fluorescence of lipofuscin in the retinal pigment epithelium. Comparing the lateral distribution of parameters of a tri-exponential model function in lifetime images of the fundus with the layered anatomical fundus structure, the shortest component (t1 = 190 ps) originates from the retinal pigment epithelium and the second lifetime (t2 = 1,000 ps) from the neural retina. The lifetime t3 approximately 5.5 ns might be influenced by the long decay of the fluorescence in the crystalline lens. In vitro analysis of the spectral properties of expected fluorophores under the condition of the living eye lightens the interpretation of in vivo measurements. Taking into account the transmission of the ocular media, the excitation of NADH is unlikely at the fundus.

[Change of retinal oxygen saturation in healthy subjects and in early stages of diabetic retinopathy during breathing of 100% oxygen]

BACKGROUND

Disturbances in the microcirculation are a source of retinal diabetic alterations. Comprehensive studies of blood flow parameters have been performed, but it is not known how ageing, duration of diabetes, blood sugar, glycolysed haemoglobin and elevated systemic blood pressure act in the early stages of diabetic retinopathy.

MATERIAL AND METHODS

The arterial and venous oxygen saturation (aOS, vOS) were measured with a Jena Ophthalmo Spectrometer in 28 healthy subjects (NP) (30.3 +/- 13.1 years), 31 Type I diabetics (T I) (42.2 +/- 12.9 years), and in 25 Type II diabetics (T II) (58.9 +/- 6.9 years), suffering form mild or moderate non-proliferative diabetic retinopathy, before, during breathing of 100 % oxygen for 6 minutes, and after respiration of air during 10 minutes.

RESULTS

Before oxygen breathing, the venous oxygen saturation in diabetics increased with age. During breathing of 100 % oxygen, the vOS increased considerably by 20 % in all groups. The arterio-venous difference of oxygen saturation was decreased with age in diabetics, but there was no dependence on age in normals. In Type II diabetics, the vOS before oxygen breathing was increased with HbA1c. There was also a positive correlation between vOS and blood pressure before oxygen breathing.

CONCLUSION

Healthy subjects and diabetics in the early stages of diabetic retinopathy exhibit comparable changes of oxygen saturation during breathing of 100 % oxygen. Measurements of venous OS are most evident. First differences were detectable between diabetics and normals in the normalisation after oxygen respiration.

[A coping with Stress Training (SBT) for persons with mental illness--pilot study on a group training programme in support of occupational rehabilitation]

OBJECTIVE

This pilot study investigates the effects of a coping with stress training (SBT) programme which had been offered in the Workshop for Disabled People of the Stuttgart Occupational Rehabilitation Center Rudolf-Sophien-Stift to persons with mental illness. The group training is aimed at supporting the participants in coping effectively with stress, avoiding over- or under-stimulation and strengthening positive experiences.

METHOD

In a control-group study design, data was collected from 19 participants of the training group and 11 participants of a (waiting) control group. Data collection was carried out before and after the training.

RESULTS

In the pre-post comparison the training group shows a reduction of symptoms in general and especially in somatization, obsessive-compulsiveness, anxiety, and paranoid ideation. The participants showed improvements in quality of life in the areas of capability, ability to enjoy and relax, positive and negative mood. In respect of attitudes of competence and control they showed improvements in internal control attitudes. Also, as regards illness coping and prevalent coping styles, active and problem-oriented coping styles were found to have increased to some extent. In the problem solving training, 84.2% of the participants stated in their self-ratings that they had been able to achieve positive changes in a specific problem area.

CONCLUSIONS

From a methodological angle it has to be pointed out that the study had examined a very small group. Although a number of open questions remain the results obtained are encouraging and in accordance with the objectives of the training. Further studies need to be carried out with larger samples from different facilities in the fields of medical, vocational and social rehabilitation.

A tool to evaluate the fertiliser value and the environmental impact of substrates from wastewater treatment

Fertilisers may contain pollutants that are applied to the field together with the nutrients. Comparing fertilisers is difficult because of their different concentrations of nutrients and pollutants. In this study an already existing model was taken. It was further developed to compare nutrient fluxes (N, P, K, Ca, Mg, S, humus) and pollutants (heavy metals and pharmaceuticals) of pig and cattle slurry as well as human urine. The data used is taken from literature and, in the case of pharmaceuticals in urine, daily excretion rates were calculated. An amount of 19 m3 ha(-1) a(-1) undiluted urine can be applied, limiting factor is sulphur. Without taking over-fertilisation into account, an addition of mineral fertiliser is required to any organic fertiliser application. In general, heavy metal, antibiotic, and hormone fluxes are higher by using animal manure then urine as fertiliser. However, additional loads of other pharmaceuticals consumed by humans have to be considered. Overall, the model is a suitable tool worthwhile to be extended in aspects of hygiene, environmental impacts as for example, degradation processes as well as ecotoxicology.