Effect of intensive glucose lowering treatment on all cause mortality, cardiovascular death, and microvascular events in type 2 diabetes: meta-analysis of randomised controlled trials

Increased risk of diabetes following perianal abscess: a population-based follow-up study

PURPOSE

It remains unclear whether perianal abscess is a prediabetes condition or the initial presentation of type 2 diabetes. Using a population-based dataset, this study aimed to explore the risk of type 2 diabetes following perianal abscess.

METHODS

We used data sourced from the Longitudinal Health Insurance Database 2000. In total, there were 1,419 adult patients with perianal abscess in the study group and 7,095 randomly selected subjects in the comparison group. Stratified Cox proportional hazards regressions were carried out to evaluate the association between being diagnosed with perianal abscess and receiving a subsequent diagnosis of diabetes within 5 years.

RESULTS

Of the total 8,514 sampled subjects, the incidence rate of diabetes per 100 person-years was 1.87 (95 % confidence interval (CI) = 1.74-2.01); the rate among patients with perianal abscess was 3.00 (95 % CI = 2.60-3.43) and was 1.65 (95 % CI = 1.52-1.79) among comparison patients. Stratified Cox proportional hazards analysis revealed that patients with perianal abscess were more likely to have received a diagnosis of diabetes than comparison patients (hazard ratio = 1.80, 95 % CI = 1.50-2.16, p < 0.001) during the 5-year follow-up period after censoring cases that died from nondiabetes causes and adjusting for patient geographic location, urbanization level, monthly income, hypertension, coronary heart disease, hyperlipidemia, obesity, and alcohol abuse/alcohol dependence syndrome at baseline.

CONCLUSIONS

Our results suggest that patients with perianal abscess have a higher chance of contracting type 2 diabetes mellitus within the first 5 years following their diagnosis.

Sixty years of diabetes management in primary care

The incidence of diabetes has increased exponentially over the last 60 years, meaning that the management of diabetes solely by specialist healthcare professionals is no longer feasible. Since the 1970s, primary and community healthcare professionals have increasingly treated patients with diabetes. Advances in diabetes equipment and new treatments have further enabled patients to be treated more conveniently in the community and this has enhanced their quality of life. There has also been an evolution in health service strategies for diabetes – notably growing acknowledgement of the benefits of intensive glycaemic treatment for patients with type 2, as well as type 1 diabetes, and the now well-recognised importance of effective shared care programmes between primary and secondary healthcare professionals. Thus, the organisation and delivery of care for patients with diabetes has improved dramatically since 1952.

This article is a modified and updated version of ‘Review: Fifty years of diabetes management in primary care’ by Mike Kirby, published in, Br J Diabetes Vasc Dis 2002;2: 457-461. DOI:10.1177/14746514020020060801. http://www.bjdvd.com/content/2/6.toc

Stepwise self-titration of oral glucose-lowering medication using a mobile telephone-based telehealth platform in type 2 diabetes: a feasibility trial in primary care

BACKGROUND

Telehealth-supported clinical interventions may improve diabetes self-management. We explored the feasibility of stepwise self-titration of oral glucose-lowering medication guided by a mobile telephone-based telehealth platform for improving glycemic control in type 2 diabetes.

METHODS

We recruited 14 type 2 diabetes patients to a one-year feasibility study with 1:1 randomization. Intervention group patients followed a stepwise treatment plan for titration of oral glucose-lowering medication with self-monitoring of glycemia using real-time graphical feedback on a mobile telephone and remote nurse monitoring using a Web-based tool. We carried out an interim analysis at 6 months.

RESULTS

We screened 3476 type 2 diabetes patients; 94% of the ineligible did not meet the eligibility criteria for hemoglobin A1c (HbA1c) or current treatment. Mean (standard deviation) patient age at baseline was 58 (11) years, HbA1c was 65 (12) mmol/mol (8.1% [1.1%]), body mass index was 32.9 (6.4) kg/m2, median [interquartile range (IQR)] diabetes duration was 2.6 (0.6 to 4.7) years, and 10 (71%) were men. The median (IQR) change in HbA1c from baseline to six months was -10 (-21 to 3) mmol/mol (-0.9% [-1.9% to 0%]) in the intervention group and -5 (-13 to 6) mmol/mol (-0.5% [-1.2% to 0.6%]) in the control group. Six out of seven intervention group patients and four out of seven control group patients changed their oral glucose-lowering medication (p = .24).

CONCLUSIONS

Self-titration of oral glucose-lowering medication in type 2 diabetes with self-monitoring and remote monitoring of glycemia is feasible, and further studies using adapted recruitment strategies are required to evaluate whether it improves clinical outcomes.

Clinical overview of linagliptin, a dipeptidyl peptidase-4 inhibitor, in patients with Type 2 diabetes mellitus

Linagliptin is a pharmacologically unique, orally active, once-daily dipeptidyl peptidase-4 inhibitor indicated for the treatment of hyperglycemia in patients with Type 2 diabetes mellitus. Compared with other dipeptidyl peptidase-4 inhibitors, linagliptin has a favorable pharmacokinetic profile with a primarily nonrenal route of elimination that avoids the need for dose adjustment in patients with renal impairment. When administered as monotherapy or in combination with other antihyperglycemic drugs, linagliptin treatment leads to clinically meaningful reductions in glycated hemoglobin, fasting plasma glucose and postprandial plasma glucose levels. In addition, pancreatic β-cell function is enhanced. Linagliptin treatment is well tolerated, with weight-neutral effects and no increased risk of hypoglycemia. Of note, linagliptin treatment was associated with a significantly reduced risk of cardiovascular events in clinical trials of ≤2 years, although this finding remains to be confirmed in larger and longer clinical outcomes studies.

New antidiabetic therapies: innovative strategies for an old problem

PURPOSE OF REVIEW

Over the last few years, a variety of new antidiabetic drugs have been approved for clinical use and novel agents are currently under development. All of these are facing new regulations created by the demand to not only lower HbA1c but also provide long-term clinical benefit and cardiovascular safety.

RECENT FINDINGS

The present review will discuss the following novel therapeutic options: GLP-1 mimetics and DPP-4 inhibitors are new antidiabetic drugs which favourably affect glucose metabolism without a significant risk for hypoglycaemic events and preliminary clinical data suggesting potential beneficial effects with respect to cardiovascular risk reduction. In addition, new antidiabetic concepts include SGLT2 inhibition, dual peroxisome proliferator-activated receptor agonists and G-protein receptor agonists, all of which provide beneficial cardiometabolic characteristics.

SUMMARY

The development of novel antidiabetic strategies currently does not only focus on potent glucose-lowering properties but also on safety aspects and potential cardiovascular benefits.

The dipeptidyl peptidase-4 inhibitors in type 2 diabetes mellitus: cardiovascular safety

The dipeptidyl peptidase-4 (DPP-4) inhibitors are a relatively new class of oral antidiabetic agents that improve glycemic control in patients with type 2 diabetes mellitus. These agents differ in structure, but all act by inhibiting the DPP-4 enzyme. Dipeptidyl peptidase-4 inhibition increases levels of the incretin hormones glucagon-like peptide-1 and glucose-dependent insulinotropic peptide, which in turn stimulate insulin secretion in a glucose-dependent fashion. Clinical trials have shown that DPP-4 inhibitors provide significant reductions in glycated hemoglobin levels, with a low risk of hypoglycemia. Animal model experiments and proof-of-concept studies suggest that the incretins favorably affect the cardiovascular system; it is possible that these same effects may be conveyed by DPP-4 inhibitor therapy. Pooled and meta-analyses of DPP-4 inhibitor clinical trial data have shown no increase in major adverse cardiovascular events, and, in fact, suggest a potential cardiovascular benefit to such therapy. Long-term cardiovascular safety trials are currently underway to more fully define and understand the cardiovascular impact of DPP-4 therapy in patients with type 2 diabetes mellitus.

PPAR agonists for the treatment of cardiovascular disease in patients with diabetes

Diabetes is a complex disease defined by hyperglycaemia; however, strong associations with abdominal obesity, hypertension and dyslipidaemia contribute to the high risk of cardiovascular disease. Although aggressive glycaemic control reduces microvascular complications, the evidence for macrovascular complications is less certain. The theoretical benefits of the mode of action of peroxisome proliferator-activated receptor (PPAR) agonists are clear. In clinical practice, PPAR-α agonists such as fibrates improve dyslipidaemia, while PPAR-γ agonists such as thiazolidinediones improve insulin resistance and diabetes control. However, although these agents are traditionally classed according to their target, they have different and sometimes conflicting clinical benefit and adverse event profiles. It is speculated that this is because of differing properties and specificities for the PPAR receptors (each of which targets specific genes). This is most obvious in the impact on cardiovascular outcomes--in clinical trials pioglitazone appeared to reduce cardiovascular events, whereas rosiglitazone potentially increased the risk of myocardial infarction. The development of a dual PPAR-α/γ agonist may prove beneficial in effectively managing glycaemic control and improving dyslipidaemia in patients with type 2 diabetes. Yet, development of agents such as muraglitazar and tesaglitazar has been hindered by various serious adverse events. Aleglitazar, a balanced dual PPAR-α/γ agonist, is currently the most advanced in clinical development and has shown promising results in phase II clinical trials with beneficial effects on glucose and lipid variables. A phase III study, ALECARDIO, is ongoing and will establish whether improvements in laboratory test profiles translate into an improvement in cardiovascular outcomes.

Effect of exercise on blood pressure in type 2 diabetes: a randomized controlled trial

BACKGROUND

Increased blood pressure (BP) in type 2 diabetes (T2DM) markedly increases cardiovascular disease morbidity and mortality risk compared to having increased BP alone.

OBJECTIVE

To investigate whether exercise reduces suboptimal levels of untreated suboptimal BP or treated hypertension.

DESIGN

Prospective, randomized controlled trial for 6 months.

SETTING

Single center in Baltimore, MD, USA.

PATIENTS

140 participants with T2DM not requiring insulin and untreated SBP of 120-159 or DBP of 85-99 mmHg, or, if being treated for hypertension, any SBP <159 mmHg or DBP<99 mmHg; 114 completed the study.

INTERVENTION

Supervised exercise, 3 times per week for 6 months compared with general advice about physical activity.

MEASUREMENTS

Resting SBP and DBP (primary outcome); diabetes status, arterial stiffness assessed as carotid-femoral pulse-wave velocity (PWV), body composition and fitness (secondary outcomes).

RESULTS

Overall baseline BP was 126.8 ± 13.5 / 71.7 ± 9.0 mmHg, with no group differences. At 6 months, BP was unchanged from baseline in either group, BP 125.8 ± 13.2 / 70.7 ± 8.8 mmHg in controls; and 126.0 ± 14.2 / 70.3 ± 9.0 mmHg in exercisers, despite attaining a training effects as evidenced by increased aerobic and strength fitness and lean mass and reduced fat mass (all p<0.05), Overall baseline PWV was 959.9 ± 333.1 cm/s, with no group difference. At 6-months, PWV did not change and was not different between group; exercisers, 923.7 ± 319.8 cm/s, 905.5 ± 344.7, controls.

LIMITATIONS

A completion rate of 81 %.

CONCLUSIONS

Though exercisers improve fitness and body composition, there were no reductions in BP. The lack of change in arterial stiffness suggests a resistance to exercise-induced BP reduction in persons with T2DM.

Comorbid Heart Failure and Renal Impairment: Epidemiology and Management

Heart failure mortality is significantly increased in patients with baseline renal impairment and those with underlying heart failure who subsequently develop renal dysfunction. This accelerated progression occurs independent of the cause or grade of renal dysfunction and baseline risk factors. Recent large prospective databases have highlighted the depth of the current problem, while longitudinal population studies support an increasing disease burden. We have extensively reviewed the epidemiological and therapeutic data among these patients. The evidence points to a progression of heart failure early in renal impairment, even in the albuminuric stage. The data also support poor prescription of prognostic therapies. As renal function is the most important prognostic factor in heart failure, it is important to establish the current understanding of the disease burden and the therapeutic implications.

Insulin resistance: metabolic mechanisms and consequences in the heart

Insulin resistance is a characteristic feature of obesity and type 2 diabetes mellitus and impacts the heart in various ways. Impaired insulin-mediated glucose uptake is a uniformly observed characteristic of the heart in these states, although changes in upstream kinase signaling are variable and dependent on the severity and duration of the associated obesity or diabetes mellitus. The understanding of the physiological and pathophysiological role of insulin resistance in the heart is evolving. To maintain its high energy demands, the heart is capable of using many metabolic substrates. Although insulin signaling may directly regulate cardiac metabolism, its main role is likely the regulation of substrate delivery from the periphery to the heart. In addition to promoting glucose uptake, insulin regulates long-chain fatty acid uptake, protein synthesis, and vascular function in the normal cardiovascular system. Recent advances in understanding the role of metabolic, signaling, and inflammatory pathways in obesity have provided opportunities to better understand the pathophysiology of insulin resistance in the heart. This review will summarize our current understanding of metabolic mechanisms for and consequences of insulin resistance in the heart and will discuss potential new areas for investigating novel mechanisms that contribute to insulin resistance in the heart.

Relationship between HbA1c levels and risk of cardiovascular adverse outcomes and all-cause mortality in overweight and obese cardiovascular high-risk women and men with type 2 diabetes

AIMS/HYPOTHESIS

The optimal HbA(1c) concentration for prevention of macrovascular complications and deaths in obese cardiovascular high-risk patients with type 2 diabetes remains to be established and was therefore studied in this post hoc analysis of the Sibutramine Cardiovascular OUTcomes (SCOUT) trial, which enrolled overweight and obese patients with type 2 diabetes and/or cardiovascular disease.

METHODS

HRs for meeting the primary endpoint (nonfatal myocardial infarction, nonfatal stroke, resuscitated cardiac arrest or cardiovascular death) and all-cause mortality were analysed using Cox regression models.

RESULTS

Of 8,252 patients with type 2 diabetes included in SCOUT, 7,479 had measurements of HbA(1c) available at baseline (i.e. study randomisation). Median age was 62 years (range 51-86 years), median BMI was 34.0 kg/m(2) (24.8-65.1 kg/m(2)) and 44% were women. The median HbA(1c) concentration was 7.2% (3.8-15.9%) (55 mmol/l [18-150 mmol/l]) and median diabetes duration was 7 years (0-57 years). For each 1 percentage point HbA(1c) increase, the adjusted HR for the primary endpoint was 1.17 (95% CI 1.11, 1.23); no differential sex effect was observed (p = 0.12 for interaction). In contrast, the risk of all-cause mortality was found to be greater in women than in men: HR 1.22 (1.10, 1.34) vs 1.12 (1.04, 1.20) for each 1 percentage point HbA(1c) increase (p = 0.02 for interaction). There was no evidence of increased risk associated with HbA(1c) ≤ 6.4% (≤ 46 mmol/l). Glucose-lowering treatment regimens, diabetes duration or a history of cardiovascular disease did not modify the associations.

CONCLUSIONS/INTERPRETATION

In overweight, cardiovascular high-risk patients with type 2 diabetes, increasing HbA(1c) concentrations were associated with increasing risks of cardiovascular adverse outcomes and all-cause mortality.

Aging, diabetes, and the public health system in the United States

Diabetes (diagnosed or undiagnosed) affects 10.9 million US adults aged 65 years and older. Almost 8 in 10 have some form of dysglycemia, according to tests for fasting glucose or hemoglobin A1c. Among this age group, diagnosed diabetes is projected to reach 26.7 million by 2050, or 55% of all diabetes cases. In 2007, older adults accounted for $64.8 billion (56%) of direct diabetes medical costs, $41.1 billion for institutional care alone. Complications, comorbid conditions, and geriatric syndromes affect diabetes care, and medical guidelines for treating older adults with diabetes are limited. Broad public health programs help, but effective, targeted interventions and expanded surveillance and research and better policies are needed to address the rapidly growing diabetes burden among older adults.

It's NOT FAIR! Or is it? The promise and the tyranny of evidence-based performance assessment

Evidence-based medicine (EBM), by its ability to decrease irrational variations in health care, was expected to improve healthcare quality and outcomes. The utility of EBM principles evolved from individual clinical decision-making to wider foundational clinical practice guideline applications, cost containment measures, and clinical quality performance measures. At this evolutionary juncture one can ask the following questions. Given the time-limited exigencies of daily clinical practice, is it tenable for clinicians to follow guidelines? Whose or what interests are served by applying performance assessments? Does such application improve medical care quality? What happens when the best interests of vested parties conflict? Mindful of the constellation of socially and clinically relevant variables influencing health outcomes, is it fair to apply evidence-based performance assessment tools to judge the merits of clinical decision-making? Finally, is it fair and just to incentivize clinicians in ways that might sway clinical judgment? To address these questions, we consider various clinical applications of performance assessment strategies, examining what performance measures purport to measure, how they are measured and whether such applications demonstrably improve quality. With attention to the merits and frailties associated with such applications, we devise and defend criteria that distinguish between justice-sustaining and justice-threatening performance-based clinical protocols.

Therapeutic inertia in type 2 diabetes: insights from the PANORAMA study in France

"Therapeutic inertia" is usually defined as the failure to change or uptitrate treatment strategy when a disease is uncontrolled. In patients with type 2 diabetes (T2D) this may occur with antidiabetes treatments and/or treatment for various cardiovascular risk factors. The PANORAMA study (NCT00916513) compared individual HbA(1c) targets and actual HbA(1c) levels in 5817 patients with T2D in nine European countries, and investigated the reasons why therapeutic choices made by physicians sometimes differ from expert guidelines for this disease. Thus it provides an insight into therapeutic inertia, a fashionable paradigm which can be challenged. This article reports data specifically from the French cohort of patients (n=759). We will try to demonstrate that criticising physicians for not strictly applying the expert T2D guidelines would not be beneficial as the clinical background for this apparent therapeutic inertia is complex. It appears that it may be more clinically relevant and useful to understand the reasons why the therapeutic choice made by the physician-patient partnership can sometimes differ from guidelines. This pragmatic approach would not detract from the need to develop and implement expert guidelines as it is essential to have benchmarks to assess temporal trends of quality of healthcare delivered to patients with T2D at the national level. However, these treatment targets must be put into perspective for clinical practice. Following the Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial, it appears mandatory to individualize glycaemic targets to enable physicians to identify the most appropriate antidiabetes treatment for each patient.

Cardioprotective role of insulin: Advantage analogues

AIM

Type II diabetes mellitus (DM) increases the risk of cardiovascular disease. Treatment with insulin substantially reduces C - reactive protein (CRP) because of its anti-atherosclerotic action. This study was designed to explore and compare the cardio protective role of regular human insulin (RHI), aspart and lispro insulin in type II DM.

MATERIALS AND METHODS

A randomized, open, parallel group, comparative clinical study was conducted on 90 patients of type II DM. After baseline clinical assessment and investigations, RHI was prescribed to 30 patients, aspart insulin to 30 patients and lispro insulin to another 30 patients for 12 weeks. The efficacy variables were change in blood pressure, glycemic control, lipid profile, serum potassium, high-sensitivity CRP (hsCRP) and UKPDS 10-year CHD risk scoring over 12 weeks. At the end of the study, the patients were followed up and changes in variables from baseline were analyzed by statistical tools.

RESULTS

Systolic blood pressure decreased significantly in aspart group (P = 0.008) whereas diastolic blood pressure was decreased significantly both in aspart (P < 0.001) and lispro group (P = 0.01). Fasting, postprandial blood glucose and HbA1c were decreased in all three groups significantly but change in aspart group was superior (P = 0.01). Triglyceride was significantly better controlled by lispro (P < 0.01) whereas aspart insulin was superior to decrease total cholesterol and LDL (P < 0.05). The extent of potassium loss was significantly more with RHI (P = 0.004) than others. CRP-lowering effect (P = 0.017) and decrease in UKPDS risk scoring (P = 0.019) in aspart and lispro group was superior to RHI group.

CONCLUSION

Short acting insulin analogues, especially aspart insulin have been found to have a better cardio protective role than RHI in type II DM.

Glucose control in diabetes: which target level to aim for?

The most important goal in the treatment of patients with diabetes is to lower the risk of long-term diabetes complications. Hyperglycaemia is the most important risk factor for microvascular complications in diabetes, but, in addition to hyperglycaemia, several other risk factors, particularly dyslipidaemia, elevated blood pressure and smoking, also determine the risk of macrovascular complications. In this review, we present evidence from longitudinal population-based studies that hyperglycaemia is an important risk factor for long-term complications of diabetes and discuss the results from clinical trials of the effects of the treatment of hyperglycaemia on the prevention of long-term micro- and macrovascular complications in type 1 and type 2 diabetes. An HbA(1c) target of <7.0% for the treatment of diabetes is generally accepted on the basis of evidence from several trials, whereas a target of <6.5% may be reasonable for patients with a short duration of type 2 diabetes and without extensive atherosclerosis.

The Influence of Stroke Risk Factors and Comorbidities on Assessment of Stroke Therapies in Humans and Animals

The main driving force behind the assessment of novel pharmacological agents in animal models of stroke is to deliver new drugs to treat the human disease rather than to increase knowledge of stroke pathophysiology. There are numerous animal models of the ischaemic process and it appears that the same processes operate in humans. Yet, despite these similarities, the drugs that appear effective in animal models have not worked in clinical trials. To date, tissue plasminogen activator is the only drug that has been successfully used at the bedside in hyperacute stroke management. Several reasons have been put forth to explain this, but the failure to consider comorbidities and risk factors common in older people is an important one. In this article, we review the impact of the risk factors most studied in animal models of acute stroke and highlight the parallels with human stroke, and, where possible, their influence on evaluation of therapeutic strategies.

Insulin glargine versus sitagliptin in insulin-naive patients with type 2 diabetes mellitus uncontrolled on metformin (EASIE): a multicentre, randomised open-label trial

BACKGROUND

In people with type 2 diabetes, a dipeptidyl peptidase-4 (DPP-4) inhibitor is one choice as second-line treatment after metformin, with basal insulin recommended as an alternative. We aimed to compare the efficacy, tolerability, and safety of insulin glargine and sitagliptin, a DPP-4 inhibitor, in patients whose disease was uncontrolled with metformin.

METHODS

In this comparative, parallel, randomised, open-label trial, metformin-treated people aged 35-70 years with glycated haemoglobin A(1c) (HbA(1c)) of 7-11%, diagnosis of type 2 diabetes for at least 6 months, and body-mass index of 25-45 kg/m(2) were recruited from 17 countries. Participants were randomly assigned (1:1) to 24-week treatment with insulin glargine (titrated from an initial subcutaneous dose of 0·2 units per kg bodyweight to attain fasting plasma glucose of 4·0-5·5 mmol/L) or sitagliptin (oral dose of 100 mg daily). Randomisation (via a central interactive voice response system) was by random sequence generation and was stratified by centre. Patients and investigators were not masked to treatment assignment. The primary outcome was change in HbA(1c) from baseline to study end. Efficacy analysis included all randomly assigned participants who had received at least one dose of study drug and had at least one on-treatment assessment of any primary or secondary efficacy variable. This trial is registered at ClinicalTrials.gov, NCT00751114.

FINDINGS

732 people were screened and 515 were randomly assigned to insulin glargine (n=250) or sitagliptin (n=265). At study end, adjusted mean reduction in HbA(1c) was greater for patients on insulin glargine (n=227; -1·72%, SE 0·06) than for those on sitagliptin (n=253; -1·13%, SE 0·06) with a mean difference of -0·59% (95% CI -0·77 to -0·42, p<0·0001). The estimated rate of all symptomatic hypoglycaemic episodes was greater with insulin glargine than with sitagliptin (4·21 [SE 0·54] vs 0·50 [SE 0·09] events per patient-year; p<0·0001). Severe hypoglycaemia occurred in only three (1%) patients on insulin glargine and one (<1%) on sitagliptin. 15 (6%) of patients on insulin glargine versus eight (3%) on sitagliptin had at least one serious treatment-emergent adverse event.

INTERPRETATION

Our results support the option of addition of basal insulin in patients with type 2 diabetes inadequately controlled by metformin. Long-term benefits might be expected from the achievement of optimum glycaemic control early in the course of the disease.

FUNDING

Sanofi.

Drug-induced hypoglycaemia in type 2 diabetes

INTRODUCTION

Hypoglycaemia is a side effect caused by some therapies for type 2 diabetes, which can cause physical, social and psychological harm. Hypoglycaemia also prevents attainment of treatment goals and satisfactory glycaemic control.

AREAS COVERED

The risk of hypoglycaemia associated with commonly prescribed therapies, including metformin, sulphonylureas, dipeptidyl peptidase-4 enzyme (DPP-4) inhibitors, glucagon-like peptide-1 (GLP-1) agonists and thiazolidinediones, is reviewed in this paper (insulin-induced hypoglycaemia is not included). Other medications that are frequently co-prescribed in type 2 diabetes are also discussed, including anti-hypertensive drugs, antibiotics and fibrates, along with various important patient-related risk factors.

EXPERT OPINION

Hypoglycaemia is a common and potentially dangerous side effect of some medications used for type 2 diabetes. The risk of hypoglycaemia should always be considered when selecting and implementing a therapy, with a focus on the individual. Future research into new therapies should measure the frequency of hypoglycaemia prospectively and accurately. Hypoglycaemia has been shown to be a potentially life-threatening metabolic stress; therefore therapies that effectively manage diabetes without the risk of hypoglycaemia are likely to be favoured in the future.

Gene silencing of the mitochondrial adaptor p66(Shc) suppresses vascular hyperglycemic memory in diabetes

RATIONALE

Hyperglycemic memory may explain why intensive glucose control has failed to improve cardiovascular outcomes in patients with diabetes. Indeed, hyperglycemia promotes vascular dysfunction even after glucose normalization. However, the molecular mechanisms of this phenomenon remain to be elucidated.

OBJECTIVE

The present study investigated the role of mitochondrial adaptor p66(Shc) in this setting.

METHODS AND RESULTS

In human aortic endothelial cells (HAECs) exposed to high glucose and aortas of diabetic mice, activation of p66(Shc) by protein kinase C βII (PKCβII) persisted after returning to normoglycemia. Persistent p66(Shc) upregulation and mitochondrial translocation were associated with continued reactive oxygen species (ROS) production, reduced nitric oxide bioavailability, and apoptosis. We show that p66(Shc) gene overexpression was epigenetically regulated by promoter CpG hypomethylation and general control nonderepressible 5-induced histone 3 acetylation. Furthermore, p66(Shc)-derived ROS production maintained PKCβII upregulation and PKCβII-dependent inhibitory phosphorylation of endothelial nitric oxide synthase at Thr-495, leading to a detrimental vicious cycle despite restoration of normoglycemia. Moreover, p66(Shc) activation accounted for the persistent elevation of the advanced glycated end product precursor methylglyoxal. In vitro and in vivo gene silencing of p66(Shc), performed at the time of glucose normalization, blunted ROS production, restored endothelium-dependent vasorelaxation, and attenuated apoptosis by limiting cytochrome c release, caspase 3 activity, and cleavage of poly (ADP-ribose) polymerase.

CONCLUSIONS

p66(Shc) is the key effector driving vascular hyperglycemic memory in diabetes. Our study provides molecular insights for the progression of diabetic vascular complications despite glycemic control and may help to define novel therapeutic targets.

Review of the safety and efficacy of exenatide once weekly for the treatment of type 2 diabetes mellitus

OBJECTIVE

To summarize and evaluate the available literature assessing the efficacy and safety of exenatide once weekly for the treatment of type 2 diabetes mellitus.

DATA SOURCES

PubMed (1966-January 2012) and International Pharmaceutical Abstracts (1969-January 2012) were searched using the term exenatide once weekly. Abstracts presented at the European Association for the Study of Diabetes Annual Meeting in 2011 and reference citations from publications were reviewed for inclusion. Eli Lilly and Company and Amylin Pharmaceuticals were contacted for additional unpublished information.

STUDY SELECTION AND DATA EXTRACTION

All English-language articles and abstracts were evaluated for inclusion. All randomized controlled trials were included in the review.

DATA SYNTHESIS

The efficacy and safety of exenatide once weekly has been evaluated as initial monotherapy and as add-on therapy to metformin, sulfonylureas, and thiazolidinediones in patients with uncontrolled type 2 diabetes for up to 3 years. Results from 6 randomized, comparator-controlled studies in over 3000 patients indicate that treatment with exenatide once weekly results in significant glycemic improvements and weight loss. Gastrointestinal adverse effects and injection site reactions are common, but rarely lead to drug discontinuation.

CONCLUSIONS

Exenatide once weekly holds promise as a convenient, efficacious, and well-tolerated antihyperglycemic agent for the treatment of type 2 diabetes. Studies evaluating outcomes such as cardiovascular events or all-cause mortality with exenatide once weekly are lacking.

Glycemic control and cardiovascular disease: what's a doctor to do?

Cardiovascular disease (CVD) remains the leading cause of morbidity and mortality in individuals with diabetes mellitus. Moreover, rates of CVD mortality are two to four times higher in diabetes than in those without diabetes. It was conventional thinking that achieving near-normoglycemia would help reduce CVD risk and overall mortality in type 2 diabetes mellitus. Several recent large trials attempted to answer this question using a randomized control trial design with a conventional therapy and an intensive control arm. Surprisingly, these trials did not demonstrate neither mortality nor a CVD advantage with intensive glycemic control. Moreover, some studies (e.g., the ACCORD [Action to Control Cardiovascular Risk in Diabetes] study) showed increased mortality in the intensive control arm. In this review, our goal is to summarize the findings of the major trials in this field and to explore the potential reasons for why these trials had largely negative results. We conclude with some lessons that may be applied to the clinical management of patients with diabetes.

Diabetes, hyperglycaemia, and acute ischaemic stroke

Diabetes and ischaemic stroke often arise together. People with diabetes have more than double the risk of ischaemic stroke after correction for other risk factors, relative to individuals without diabetes. Multifactorial treatment of risk factors for stroke-in particular, lifestyle factors, hypertension, and dyslipidaemia-will prevent a substantial number of these disabling strokes. Hyperglycaemia occurs in 30-40% of patients with acute ischaemic stroke, also in individuals without a known history of diabetes. Admission hyperglycaemia is associated with poor functional outcome, possibly through aggravation of ischaemic damage by disturbing recanalisation and increasing reperfusion injury. Uncertainty surrounds the question of whether glucose-lowering treatment for early stroke can improve clinical outcome. Achievement of normoglycaemia in the early stage of stroke can be difficult, and the possibility of hypoglycaemia remains a concern. Phase 3 studies of glucose-lowering therapy in acute ischaemic stroke are underway.

Glycaemic control is improved by 7 days of aerobic exercise training in patients with type 2 diabetes

AIMS/HYPOTHESIS

Cardiovascular events and death are better predicted by postprandial glucose (PPG) than by fasting blood glucose or HbA(1c). While chronic exercise reduces HbA(1c) in patients with type 2 diabetes, short-term exercise improves measures of insulin sensitivity but does not consistently alter responses to the OGTT. The purpose of this study was to determine whether short-term exercise training improves PPG and glycaemic control in free-living patients with type 2 diabetes, independently of the changes in fitness, adiposity and energy balance often associated with chronic exercise training.

METHODS

Using continuous glucose monitors, PPG was quantified in previously sedentary patients with type 2 diabetes not using exogenous insulin (n = 13, age 53 ± 2 years, HbA(1c) 6.6 ± 0.2% (49.1 ± 1.9 mmol/mol)) during 3 days of habitual activity and during the final 3 days of a 7 day aerobic exercise training programme (7D-EX) which does not elicit measurable changes in cardiorespiratory fitness or body composition. Diet was standardised across monitoring periods, with modifications during 7D-EX to offset increases in energy expenditure. OGTTs were performed on the morning following each monitoring period.

RESULTS

7D-EX attenuated PPG (p < 0.05) as well as the frequency, magnitude and duration of glycaemic excursions (p < 0.05). Conversely, average 24 h blood glucose did not change, nor did glucose, insulin or C-peptide responses to the OGTT.

CONCLUSIONS/INTERPRETATION

7D-EX attenuated glycaemic variability and PPG in free-living patients with type 2 diabetes but did not significantly alter responses to the laboratory-based OGTT. These effects appeared to be independent of changes in fitness, body composition or energy balance. ClinicalTrials.gov numbers: NCT00954109 and NCT00972452.

FUNDING

This project was funded by the University of Missouri Institute for Clinical and Translational Sciences (CRM), NIH grant T32 AR-048523 (CRM), Diabetes Action Research and Education Foundation (JPT). Medtronic supplied CGMS sensors at a discounted rate.

Influence of the glucose-lowering rate on left ventricular function in patients with type 2 diabetes and coronary heart disease

BACKGROUND

The optimal methods for glucose control and reduction in the risk of cardiovascular disease are controversial. Findings from recent clinical trials have shown different viewpoints on the advantages and disadvantages of intensive lowering of glucose. We used echocardiography to explore the influence of the glucose-lowering rate on left ventricular function in patients with type 2 diabetes mellitus (T2DM). We also attempted to discover an effective glucose-lowering rate for patients with type 2 diabetes mellitus and coronary heart disease (T2DM-CHD).

METHODS

A total of 132 cases of T2DM and 135 cases of T2DM-CHD received intensive glucose therapy. After measuring left ventricular ejection fraction (LVEF) and the E/A ratio, variations and correlation factors were evaluated.

RESULTS

LVEF was significantly higher than before intensive therapy in the T2DM group with a glucose-lowering rate of ≤6mmol·L(-1)·d(-1) (P<.05). LVEF was significantly lower than before intensive therapy in the T2DM-CHD group with a glucose-lowering rate >4mmol·L(-1)·d(-1) (P<.05), whereas at the end of follow-up (3months), LVEF increased and no significant difference was observed between subgroups (P>.05). The E/A ratio increased among all subgroups after intensive therapy (P<.05). The waist-hip ratio, duration of T2DM, and age had a linear regression relationship with variations in LVEF before and after intensive therapy.

CONCLUSIONS

For patients with T2DM and CHD, an excessively fast glucose-lowering rate could impair left ventricular systolic function. Long-term, good control of blood glucose could restore the impaired left ventricular systolic function caused by an excessively fast glucose-lowering rate. After intensive therapy, left ventricular diastolic function improved among all subgroups regardless of the glucose-lowering rate and CHD.

Intervenção nutricional padronizada em pacientes hipoglicêmicos hospitalizados

A ingestão de carboidratos de rápida absorção (CRA) pode ser útil para o aumento sérico de glicose. Neste contexto, os principais objetivos foram avaliar a eficácia e a aplicabilidade da intervenção nutricional em situações hipoglicêmicas apresentadas por pacientes conscientes, com dieta via oral e internados em hospital geral. Setenta e seis pacientes foram elegíveis e a hipoglicemia foi definida como nível de glicemia capilar ³ 50 até £ 70mg/dL. A intervenção nutricional constituiu na oferta de 15 a 24 gramas de CRA. Houve a conferência da glicemia capilar após 15-20 minutos da intervenção. A taxa de efetividade da intervenção nutricional foi de 97,6%, durante o período de estudo. Conclui-se que a administração de CRA, um método não invasivo, foi aplicável em unidades de um hospital geral e foi potencialmente eficaz na restauração da glicemia capilar em pacientes hipoglicêmicos com dieta via oral e conscientes.

Baseline characteristics in the Aliskiren Trial in Type 2 Diabetes Using Cardio-Renal Endpoints (ALTITUDE)

INTRODUCTION

Patients with type 2 diabetes are at enhanced risk for macro- and microvascular complications. Albuminuria and/or reduced kidney function further enhances the vascular risk. We initiated the Aliskiren Trial in Type 2 Diabetes Using Cardio-Renal Endpoints (ALTITUDE). Aliskiren, a novel direct renin inhibitor, which lowers plasma renin activity, may thereby provide greater cardio-renal protection compared with angiotensin converting enzyme inhibitor (ACEi) or angiotensin receptor blocker (ARB) alone.

MATERIALS AND METHODS

ALTITUDE is a randomized, double-blind, placebo-controlled study in high risk type 2 diabetic patients receiving aliskiren 300 mg once daily or placebo added to recommended cardio-renal protective treatment including ACEi or ARB, but not both. The number of patients randomized was 8606.

RESULTS

Baseline characteristics (median, IQR) are: age 65 (58, 72) years, male 68%, BMI 29.1 (25.7, 32.2) kg/m(2), cardiovascular disease 47.9%, blood pressure 134.7 (126, 150)/74.3 (67, 81) mmHg, HbA(1c) 7.5 (6.6, 8.6)%, LDL-cholesterol 2.4 (1.9, 3.0) mmol/L, haemoglobin 130 (119, 143) g/L, serum creatinine 115 (91, 137) µmol/L, eGFR 51.7 (42, 65) ml/min per 1.73 m(2), geometric mean UACR 198.9 (52, 2886) mg/g and frequency of micro/macroalbuminuria 25.7% and 58.2%. ALTITUDE is an event-driven trial to continue until 1628 patients experience a primary cardiovascular-renal event.

CONCLUSIONS

ALTITUDE will determine the potential cardio-renal benefit and safety of aliskiren in combination with ACEi or ARB in high risk patients with type 2 diabetes.

A study of patients' perceptions of diabetes care delivery and diabetes: propositional analysis in people with type 1 and 2 diabetes managed by group or usual care

OBJECTIVE

We investigated the perceptions of diabetes care and diabetes in patients followed long-term by group or usual care.

RESEARCH DESIGN AND METHODS

Three open questions were administered to 120 patients (43 with T1DM and 77 with T2DM) who had been randomized at least 2 years before to be followed by group care and 121 (41 T1DM and 80 T2DM) who had always been on usual care. The responses were analyzed by propositional analysis, by identifying the focal nuclei, i.e., the terms around which all sentences are organized, and then other predicates, according to their hierarchical relationship to the nuclear proposition. Specific communicative units were arbitrarily classified into three categories: attitudes, empowerment, and locus of control.

RESULTS

Patients on group care showed more positive attitudes, higher sense of empowerment, and more internal locus of control than those on usual care. In addition, they expressed a wider and more articulated range of concepts associated with the care received and made less use of medical terminology (P < 0.001, all). Higher HbA(1c) was associated with negative attitudes (P = 0.025) and negative empowerment (P = 0.055).

CONCLUSIONS

Group treatment reinforces communication and peer identification and may achieve its clinical results by promoting awareness, self-efficacy, positive attitudes toward diabetes and the setting of care, an internal locus of control, and, ultimately, empowerment in the patients.

Hypoglycemia in type 2 diabetes: current controversies and changing practices

Hypoglycemia is well-recognized to limit the degree of glycemic control possible for many individuals for diabetes. Although the likelihood of hypoglycemia increases as A1c levels decrease in type 1 diabetes, insulin-treated type 2 diabetic persons with higher A1c appear paradoxically to have more hypoglycemia which may explain, in part, the adverse outcome reported in the ACCORD study. Approaches to glucose-lowering that cause lesser degrees of risk for hypoglycemia, technologies to better ascertain hypoglycemic events, and better understanding of patient characteristics associated with greater likelihood of hypoglycemia will all be required to reduce this limiting factor in optimizing glycemic treatment.

Glucose control and cardiovascular outcomes: reorienting approach

Cardiovascular disease accounts for nearly 70% of morbidity and mortality in patients with diabetes mellitus. Strides made in diabetes care have indeed helped prevent or reduce the burden of microvascular complications in both type 1 and type 2 diabetes. However, the same cannot be said about macrovascular disease in diabetes. Several prospective trials so far have failed to provide conclusive evidence of the superiority of glycemic control in reducing macrovascular complications or death rates in people with advanced disease or those with long duration of diabetes. There are trends that suggest that benefits are restricted to those with lesser burden and shorter duration of disease. Furthermore, it is also suggested that benefits might accrue but it would take a longer time to manifest. Clinicians are faced with the challenge to decide how to triage patients for intensified care vs less intense care. This review focuses on evidence and attempts to provide a balanced view of the literature that has radically affected how physicians treat patients with macrovascular disease. It also takes cognizance of the fact that the natural course of the disease may be changing as well, possibly related to better overall awareness and possibly improved access to information about better individual healthcare. The review further takes note of some hard held notions about the pathobiology of the disease that must be interpreted with caution in light of new and emerging data. In light of recent developments ADA and EASD have taken step to provide some guidance to clinicians through a joint position statement. A lot more research would be required to figure out how best to manage macrovascular disease in diabetes mellitus. Glucocentric stance would need to be reconsidered, and attention paid to concurrent multifactorial interventions that seem to be effective in reducing vascular outcomes.

Epidemiology of micro- and macrovascular complications of type 2 diabetes in Korea

The prevalence of diabetes in Korea has increased six- to sevenfold over the past 40 years with its complications becoming major causes of morbidity and mortality. The rate of death among patients with diabetes is about twice as high as that among persons without diabetes and the most common cause of death is cardiovascular disease (30.6%). Despite the seriousness of diabetic complications, 30 to 70% of patients receive inadequate care, and only 40% of treated diabetic patients achieve the optimal control with HbA1c level <7% in Korea. In 2006, over 30 to 40% of patients with diabetes have microvascular complications and around 10% of them have macrovascular complications from our national data. Despite there are some debates about intensive glycemic control resulting in the deterioration of macrovascular complication, multifactorial treatment approaches including proper glycemic control are important to prevent diabetic complications. There have been needs for finding proper biomarkers for predicting diabetic complications properly but we still need more longitudinal studies to find this correlation with causal relationship. In this article, we wanted to review the recent status of micro- and macrovascular complications of type 2 diabetes in Korea from integration of many epidemiologic studies.

Intensive glycaemic control for patients with type 2 diabetes: systematic review with meta-analysis and trial sequential analysis of randomised clinical trials

OBJECTIVE

To assess the effect of targeting intensive glycaemic control versus conventional glycaemic control on all cause mortality and cardiovascular mortality, non-fatal myocardial infarction, microvascular complications, and severe hypoglycaemia in patients with type 2 diabetes.

DESIGN

Systematic review with meta-analyses and trial sequential analyses of randomised trials.

DATA SOURCES

Cochrane Library, Medline, Embase, Science Citation Index Expanded, LILACS, and CINAHL to December 2010; hand search of reference lists and conference proceedings; contacts with authors, relevant pharmaceutical companies, and the US Food and Drug Administration.

STUDY SELECTION

Randomised clinical trials comparing targeted intensive glycaemic control with conventional glycaemic control in patients with type 2 diabetes. Published and unpublished trials in all languages were included, irrespective of predefined outcomes.

DATA EXTRACTION

Two reviewers independently assessed studies for inclusion and extracted data related to study methods, interventions, outcomes, risk of bias, and adverse events. Risk ratios with 95% confidence intervals were estimated with fixed and random effects models.

RESULTS

Fourteen clinical trials that randomised 28,614 participants with type 2 diabetes (15,269 to intensive control and 13,345 to conventional control) were included. Intensive glycaemic control did not significantly affect the relative risks of all cause (1.02, 95% confidence interval 0.91 to 1.13; 28,359 participants, 12 trials) or cardiovascular mortality (1.11, 0.92 to 1.35; 28,359 participants, 12 trials). Trial sequential analyses rejected a relative risk reduction above 10% for all cause mortality and showed insufficient data on cardiovascular mortality. The risk of non-fatal myocardial infarction may be reduced (relative risk 0.85, 0.76 to 0.95; P=0.004; 28,111 participants, 8 trials), but this finding was not confirmed in trial sequential analysis. Intensive glycaemic control showed a reduction of the relative risks for the composite microvascular outcome (0.88, 0.79 to 0.97; P=0.01; 25,600 participants, 3 trials) and retinopathy (0.80, 0.67 to 0.94; P=0.009; 10,793 participants, 7 trials), but trial sequential analyses showed that sufficient evidence had not yet been reached. The estimate of an effect on the risk of nephropathy (relative risk 0.83, 0.64 to 1.06; 27,769 participants, 8 trials) was not statistically significant. The risk of severe hypoglycaemia was significantly increased when intensive glycaemic control was targeted (relative risk 2.39, 1.71 to 3.34; 27,844 participants, 9 trials); trial sequential analysis supported a 30% increased relative risk of severe hypoglycaemia.

CONCLUSION

Intensive glycaemic control does not seem to reduce all cause mortality in patients with type 2 diabetes. Data available from randomised clinical trials remain insufficient to prove or refute a relative risk reduction for cardiovascular mortality, non-fatal myocardial infarction, composite microvascular complications, or retinopathy at a magnitude of 10%. Intensive glycaemic control increases the relative risk of severe hypoglycaemia by 30%.

Was gibt es Neues beim Schlaganfall?

Anhand von selektierten Publikationen aus den vergangenen 12 Monaten werden aktuelle Entwicklungen und Neuheiten in der Prävention und Behandlung des Schlaganfalls dargestellt. Der orale direkte Thrombininhibitor Dabigatran zeigt weniger intrakranielle Blutungskomplikationen bei überlegener Wirksamkeit gegenüber Warfarin und ist seit August 2011 für die Behandlung von Patienten mit Vorhofflimmern zugelassen. Andere Antikoagulantien der neuen Generation wie Rivaroxaban und Apixaban sind gegenüber Warfarin ebenfalls überlegen, jedoch in Europa bislang noch nicht zur Behandlung von Patienten mit Vorhofflimmern zugelassen. Bei Patienten mit Vorhofflimmern wird das Risiko kardio- oder zerebrovaskulärer Ereignisse durch Angiotensin-Rezeptorblocker nicht reduziert. Eine aggressive Therapie des Diabetes mellitus senkt das Risiko für mikrovaskuläre, nicht jedoch für zerebro- und kardiovaskuläre Ereignisse oder die Sterblichkeit. Das Absetzen von Thrombozytenfunktionshemmern erhöht das Schlaganfall-Rezidivrisiko um 40%. Die Ausweitung des Zeitfensters für eine systemische Thrombolyse von 3 auf 4,5 Stunden hat weder die Blutungsrate oder Mortalität noch die mediane Latenzzeit von Aufnahme bis Lysebeginn erhöht. Ein Alter über 80 Jahre allein sollte kein Grund sein Patienten von der Lysetherapie auszuschließen. Angiotensin-Rezeptorblocker führen weder zur Verbesserung des Behandlungsergebnisses noch zur Reduktion kognitiver Störungen nach Schlaganfall. Zur Behandlung symptomatischer Carotisstenosen ist die Thrombendarteriektomie dem Stenting vorzuziehen. Das Stenting intrakranieller Stenosen und asymptomatischer extrakranieller Stenosen wird eher nicht empfohlen. Die zeitnahe Gabe von niedermolekularen Heparinen zur Thromboseprophylaxe und die Wiederaufnahme der oralen Antikoagulation 10–30 Wochen nach intrazerebraler Blutung sind wahrscheinlich sicher. Durch moderne CT-Diagnostik können Subarachnoidalblutungen und intrakranielle Aneurysmen ausreichend zuverlässig diagnostiziert werden. Endothelin-Rezeptor-Antagonisten sind zur Behandlung von Vasospasmen nach Subarachnoidalblutung unwirksam.