Update on cardiovascular outcomes at 30 years of the diabetes control and complications trial/epidemiology of diabetes interventions and complications study

Glucose management for rewards: A randomized trial to improve glucose monitoring and associated self-management behaviors in adolescents with type 1 diabetes

BACKGROUND

This randomized, controlled trial evaluated a monetary-based reinforcement intervention for increasing self-monitoring of blood glucose (SMBG) among youth with poorly controlled type 1 diabetes.

METHODS

After a 2-week baseline, 60 participants were randomized to enhanced usual care (EUC) or Reinforcers. The Reinforcers group earned monetary rewards for SMBG and associated behaviors such as uploading glucose meters. Reinforcers were withdrawn at 24 weeks. A follow-up evaluation occurred at 36 weeks.

RESULTS

Participants in the reinforcers group increased the proportion of days they completed ≥4 SMBG from 14.6% at baseline to 64.4%, 47.5%, and 37.8% at 6, 12, and 24 weeks, respectively. In contrast, EUC participants declined from 22.7% at baseline to 17.5%, 10.5%, and 11.1% (Ps < .01 vs EUC at all time points). Group differences were attenuated but remained significant after withdrawal of reinforcers. Effect sizes for SMBG were very large during reinforcement and large after withdrawal of reinforcers. In the reinforcers group, mean A1c dropped from 9.5% ± 1.2% at baseline to 9.0% ± 1.3% at week 6 and 9.0% ± 1.4% at week 12. For EUC, A1c was 9.2% ± 0.2% at baseline and ranged from 9.2% ± 1.5% to 9.6% ± 1.6% throughout the study (P < .05 vs EUC). Group differences in A1c were no longer significant at weeks 24 and 36. Effect sizes for A1c were small during reinforcement and also after withdrawal of reinforcement.

CONCLUSIONS

Monetary-based reinforcement of adolescents with type 1 diabetes caused durable increases in SMBG. Modification of the reinforcement structure may be needed to sustain improved metabolic control in this challenging age group.

Diabetes attenuated age-related aortic root dilatation in end-stage renal disease patients receiving peritoneal dialysis

AIMS/INTRODUCTION

Recently, some data have supported the concept that diabetes is negatively associated with aortic aneurysm. In the present study, we aimed to investigate the relationship between diabetes and cardiac structural and functional characteristics, in particular, aortic root dimensions, in end-stage renal disease (ESRD) patients.

METHODS

ESRD patients receiving peritoneal dialysis for >3 months were consecutively enrolled. Clinical features and echocardiographic parameters were analyzed according to the presence of diabetes history. Correlation analyses were carried out for diabetes mellitus and aortic root dilatation. Multiple logistic regression analysis was carried out to identify variables correlated with aortic root dilatation.

RESULTS

A total of 218 ESRD patients receiving peritoneal dialysis were enrolled. Patients with diabetes showed lower left ventricular internal measurements in end-diastole, left ventricular internal measurements in end-systole and aortic root diameter (ARD)/body surface area (BSA). Worse cardiac diastolic function was also observed in these patients. In addition, the age-related increase of ARD/BSA and ARD/height was attenuated in patients with diabetes. With the increase of ARD/BSA, lower levels of serum creatinine, phosphorus and serum glucose, as well as higher serum high-density lipoprotein cholesterol and apolipoprotein A-1 were also observed. Increased normalized left ventricular internal measurements were shown in patients with greater ARD/BSA. Multiple regression analysis showed that diabetes (odds ratio 0.353, P = 0.015) was an independent correlate of aortic root dilatation, even after correction for age, sex and other clinical confounders in the enrolled patients.

CONCLUSIONS

The present findings shown an inverse association between diabetes and age-related aortic root dilatation in ESRD patients. Diabetes remained to be independently correlated with aortic root dilatation even after adjustment for age, sex and other clinical confounders in ESRD patients.

Adherence, Persistence, and Switching Among People Prescribed Sodium Glucose Co-transporter 2 Inhibitors: A Nationwide Retrospective Cohort Study

INTRODUCTION

Non-adherence and non-persistence to diabetes medications are associated with worse clinical outcomes. In this study, we aimed to characterise the 1-year switching, adherence, and persistence patterns among people with diabetes aged 18 years and older prescribed sodium-glucose co-transporter 2 inhibitors (SGLT2is) in Australia.

METHODS

Using data from Australia's national Pharmaceutical Benefits Scheme (PBS), we identified 11,981 adults (mean age 60.9 years; 40.5% female) newly initiated on SGLT2is (5993 dapagliflozin; 5988 empagliflozin) from September 2015 to August 2017. Adherence was assessed via the proportion of days covered (PDC), persistence was defined as the continuous use of SGLT2i without a gap of ≥ 90 days, and switching was defined as the first change from dapagliflozin to empagliflozin or vice versa. Generalised linear models (GLMs) were used to compare the adherence (PDC = continuous), logistic regression models were used to compare the likelihoods of being adherent (PDC ≥ 0.80), and Cox proportional hazard models were used to compare the likelihoods of persistence and switching between people prescribed empagliflozin and dapagliflozin.

RESULTS

Overall, 65.8% (7879/11,981) of people dispensed SGLT2is were adherent (PDC ≥ 0.80) and 72.1% (8644/11,981) were persistent at 12 months. The mean PDC was 0.79 ± 0.27. The use of empagliflozin was associated with higher adherence (PDC = continuous) [odds ratio (OR) 1.04, 95% confidence interval (CI) 1.03-1.05], being adherent (OR 1.39, 95% CI 1.29-1.51), and persisting for 12 months [hazard ratio (HR) 1.14, 95% CI 1.06-1.22] compared with dapagliflozin. Only 4.3% (509/11,981) of people switched between the SGLT2i. Compared with dapagliflozin, people initiated on empagliflozin were less likely to switch [HR 0.46, 95% CI 0.38-0.55].

CONCLUSIONS

A considerable proportion of Australians prescribed SGLT2is were non-adherent or non-persistent. However, empagliflozin was associated with better adherence and persistence rates and a lower likelihood of switching compared with dapagliflozin.

Immune Complexes and the Risk of CVD in Type 1 Diabetes

We investigated whether the composition of modified forms of LDL in circulating immune complexes (LDL-ICs) was associated with cardiovascular disease (CVD) outcomes, including any CVD, major adverse cardiac and cerebrovascular events (MACCE), myocardial infarction (MI), and coronary artery disease, in type 1 diabetes (T1D). Our results demonstrate that the baseline levels of oxidized LDL (oxLDL), MDA-modified LDL (MDA-LDL), and advanced glycosylation-modified LDL (AGE-LDL) in circulating ICs were associated with the four CVD outcomes in unadjusted models, and adjustment by age and mean HbA_1c only resulted in minimal reduction of these associations. After adjustments were made for other cardiovascular risk factors, particularly LDL cholesterol, oxLDL-IC and MDA-LDL-IC remained independently associated with the risk of CVD, and oxLDL-IC was independently associated with the risk of MACCE and MI. In the majority of cases, the baseline levels of modified LDL-IC (measured many years before the occurrence of any CVD event) were associated with the risk of CVD over a 25-year period even after adjustment for other risk factors (including LDL cholesterol). Therefore, modified LDL biomarkers may help identify patients with T1D at high risk for MACCE and CVD events very early in the evolution of the disease, before other signals of disease are apparent.

Cost-effectiveness analysis of a pharmacotherapeutic empowerment strategy for patients with type 2 diabetes mellitus

Background

The economic feasibility of pharmacotherapeutic empowerment of patients with type 2 diabetes mellitus (DM2) is still not well established.

Objectives

To evaluate the cost-effectiveness of an individual pharmacotherapeutic empowerment strategy (IPES) for patients with DM2.

Methods

This is a cost-effectiveness study nested in a non-randomized clinical trial with patients ≥18 years of age, of both genders, with low and moderate cardiovascular risks. This study was carried out from the perspective of the municipal health system of Divinópolis in Minas Gerais state, and compared patients submitted to an IPES and patients who received only traditional care, 1 year before the beginning of the intervention (baseline) and 1 year after its completion (follow-up). The costs of the services offered by the municipality were computed, and in the intervention group IPES costs were included. Glycated hemoglobin (A1c) was the effectiveness parameter adopted. Cost-effectiveness ratio analyses, incremental cost-effectiveness ratio (ICER), and sensitivity analysis were performed.

Results

In the analysis of cost-effectiveness, it is observed that a reduction of 0.359 in A1c costs US$708.47 in the intervention group and a reduction of 0.170 costs US$1927.13 in the control group. Thus, the ICER is US$387.66 per patient/year. In the sensitivity analysis, it was observed that the IPES was dominant in 19.8% of the simulated scenarios and cost-effective in 80.2%.

Conclusions

The IPES is an alternative that presents economic feasibility for the municipal public health system scenario. The absence of randomization in patient selection is a limitation of this study.

Increased apolipoprotein C3 drives cardiovascular risk in type 1 diabetes

Type 1 diabetes mellitus (T1DM) increases the risk of atherosclerotic cardiovascular disease (CVD) in humans by poorly understood mechanisms. Using mouse models of T1DM-accelerated atherosclerosis, we found that relative insulin deficiency rather than hyperglycemia elevated levels of apolipoprotein C3 (APOC3), an apolipoprotein that prevents clearance of triglyceride-rich lipoproteins (TRLs) and their remnants. We then showed that serum APOC3 levels predict incident CVD events in subjects with T1DM in the Coronary Artery Calcification in Type 1 Diabetes (CACTI) study. To explore underlying mechanisms, we investigated the impact of Apoc3 antisense oligonucleotides (ASOs) on lipoprotein metabolism and atherosclerosis in a mouse model of T1DM. Apoc3 ASO treatment abolished the increased hepatic Apoc3 expression in diabetic mice - resulting in lower levels of TRLs - without improving glycemic control. APOC3 suppression also prevented arterial accumulation of APOC3-containing lipoprotein particles, macrophage foam cell formation, and the accelerated atherosclerosis in diabetic mice. Our observations demonstrate that relative insulin deficiency increases APOC3 and that this results in elevated levels of TRLs and accelerated atherosclerosis in a mouse model of T1DM. Because serum levels of APOC3 predicted incident CVD events in the CACTI study, inhibiting APOC3 might reduce CVD risk in T1DM patients.

Mediation of the Effect of Glycemia on the Risk of CVD Outcomes in Type 1 Diabetes: The DCCT/EDIC Study

OBJECTIVE

The Diabetes Control and Complications Trial (DCCT)/Epidemiology of Diabetes Interventions and Complications (EDIC) study has demonstrated the major role of hyperglycemia as a risk factor for clinical cardiovascular outcomes in type 1 diabetes (T1D). We assessed whether and to what extent the effect of glycemia is mediated by other established cardiovascular disease (CVD) risk factors.

RESEARCH DESIGN AND METHODS

In the DCCT, 1,441 participants were randomized to receive either intensive or conventional diabetes therapy. The EDIC observational follow-up study enrolled 96% of the surviving DCCT cohort with 94% of the survivors still actively participating after more than 27 years of follow-up. Mediation of the effect of glycemia, as captured by HbA1c, on the subsequent CVD risk was quantified using the relative change in the CVD risk associated with HbA1c between models without and with the potential mediator.

RESULTS

Adjusted for age, only a few factors (e.g., pulse, triglycerides, albumin excretion rate) explained more than 10% of the effect of glycemia on CVD risk when considered individually. In multivariable models, these traditional risk factors together mediated up to ∼50% of the effect of glycemia on the risk of CVD. However, the association between HbA1c and the risk of CVD remained highly significant even after adjustment for these risk factors.

CONCLUSIONS

While HbA1c is associated with many traditional CVD risk factors, its association with these factors alone cannot explain its effects on risk of CVD. Consequently, aggressive management of traditional nonglycemic CVD risk factors, coupled with aggressive glycemic management, is indicated for individuals with type 1 diabetes.

MiR-9 promotes the phenotypic switch of vascular smooth muscle cells by targeting KLF5

Background/aim

Diabetic vascular smooth muscle cells (VSMCs) are characterized by increased proliferation and migration. Small noncoding microRNAs (miRNAs) have been considered critical modulators of the VSMC phenotypic switch after an environmental stimulus. However, microRNA in high glucose-induced proinflammation and its atherogenic effect is still ambiguous.

Materials and methods

The technique of qRT-PCR was used to examine the expression of miR-9 in VSMCs. The downstream signaling protein relative to miR-9 regulation, Krüppel-like factor 5, and some marker genes of contractile VSMCs were analyzed by western blotting and qRT-PCR. Luciferase reporter assay was used to detect the expression of KLF5, which is regulated by miR-9. To examine the function of a miR-9 inhibitor in VSMC proliferation and migration, VSMC proliferation and migration assays were performed.

Results

Reduced transcriptional levels of miR-9 and expression of specific genes of contractile VSMCs were observed in the SMC cell line C-12511 treated with high glucose and SMCs, which were isolated from db/db mice. Moreover, the activity of KLF5 3′-UTR was dramatically reduced by a miR-9 mimic and increased by a miR-9 inhibitor. The proliferation and migration of SMCs were reduced by the miR-9 mimic.

Conclusion

miR-9 inhibits the proliferation and migration of SMC by targeting KLF5 in db/db mice.

Serum apolipoproteins and apolipoprotein-defined lipoprotein subclasses: a hypothesis-generating prospective study of cardiovascular events in T1D

APOB, APOC3, and APOE and apolipoprotein-defined lipoprotein subclasses (ADLSs; based on qualitative apolipoprotein complement) have been associated with dyslipidemia and CVD. Our main objective was to define associations of serum apolipoproteins and ADLSs with "any CVD" and "major atherosclerotic cardiovascular events" (MACEs) in a prospective study of T1D. Serum apolipoproteins and ADLSs (14 biomarkers in total) were measured in sera (obtained between 1997 and 2000) from a subset (n = 465) of the Epidemiology of Diabetes Interventions and Complications cohort. Prospective associations of "any CVD" (myocardial infarction, stroke, confirmed angina, silent myocardial infarction, revascularization, or congestive heart failure) and MACEs (fatal or nonfatal myocardial infarction or stroke), over 5,943 and 6,180 patient-years follow-up, respectively, were investigated using Cox proportional hazards models that were unadjusted and adjusted for risk factors. During 15 years of follow-up, 50 "any CVD" events and 24 MACEs occurred. Nominally significant positive univariate associations with "any CVD" were APOB, APOC3 and its subfractions [heparin precipitate, heparin-soluble (HS)], and ADLS-defined Lp-B. In adjusted analyses, APOC3-HS remained nominally significant. Nominally significant positive univariate associations with MACEs were APOC3 and its subfractions and Lp-B:C; those with total APOC3 and APOC3-HS persisted in adjusted analyses. However, these associations did not reach significance after adjusting for multiple testing. There were no significant associations of APOA1, APOA2, APOE, or other ADLSs with either "any CVD" or MACEs. These hypothesis-generating data suggest that total serum APOC3 and APOC3 in HDL are potentially important predictive biomarkers for any CVD and MACEs in adults with T1D.

The phenomenon of HbA1c stability and the risk of hypoglycemia in long-standing type 1 diabetes

AIMS

Hyperglycemia is the major factor underlying vascular complications of diabetes. Unfortunately, improved glycemia control is frequently accompanied by an increased risk of hypoglycemia. The aim of the study was to assess the relationship between hemoglobin A1c (HbA1c) and 1-week Continuous Glucose Monitoring (CGM) data in long-standing type 1 diabetes (T1DM).

METHODS

We recruited 58 subjects with long-standing T1DM consecutively enrolled to the study. Each patient underwent a 1-week CGM and laboratory profile at baseline. Subjects were divided into three subgroups according to baseline HbA1c tertiles: T1 < 7.1%, T2 = 7.1-8.0%, and T3 > 8.0%.

RESULTS

T1 patients were characterized by the longest time in range (66% of a week), whereas T3 patients experienced hyperglycemia in >50% time of the week. T1 patients were noted to have 25% of nighttime with glycemia <3.9 mmol/L (8% with glycemia <2.8 mmol/L). Most recent HbA1c closely reflected 10-years mean HbA1c values (R = 0.83; P < 0.0001).

CONCLUSIONS

(1) Long-term diabetes control (10 years HbA1c mean) is a strong predictor of the current HbA1c levels. (2) Current and historical HbA1c levels are closely linked to CGM-derived glycemia. (3) Risk of clinically significant hypoglycemia negatively correlates with HbA1c. (4) HbA1c > 8.0% is associated with unsatisfactorily low (44%) time in range.

Glycated albumin as a glycaemic marker in patients with advanced chronic kidney disease and anaemia: a preliminary report

Background: The association between glycated albumin (GA) and glycaemic status has not been fully described in patients with advanced chronic kidney disease (CKD) in relation to anaemia. The aim of this study was to evaluate the relationship between GA and fasting plasma glucose (FPG) and HbA1c in patients with advanced CKD and to evaluate the influence of anaemia in such relationship. Materials and methods: Patients with CKD stage 4 or 5 were included in the study. eGFR was calculated by the CKD-EPI creatinine equation. Plasma GA was measured by an enzymatic method. Results: Eighty-one patients were included in the study, 46 (57%) were males; the mean age was 67 ± 14 years. HbA1c was correlated with Hb (r = 0.39; p = .0003), and no significant correlation was detected between plasma GA and serum albumin (p = .82). A significant association between FPG and GA (r² = 0.41; p < .0001), and between FPG and HbA1c (r² = 0.42; p < .0001) was detected in the whole study population. Patients with moderate/severe anaemia had lower HbA1c than patients with no anaemia, while both FPG and GA were comparable between the two groups. Multivariate regression analysis showed that GA was a significant predictor of FPG in patients with moderate/severe anaemia while HbA1c did not (r² = 0.55; p < .0001 for the model). Conclusions: GA, alone or in combination with other biomarkers, can be considered for the evaluation of glycaemic status in patients with advanced CKD and severe anaemia.

Long-Term Effects of Initiating Continuous Subcutaneous Insulin Infusion (CSII) and Continuous Glucose Monitoring (CGM) in People with Type 1 Diabetes and Unsatisfactory Diabetes Control

Background: We aimed to assess the long-term effects of the introduction of continuous subcutaneous insulin infusion (CSII) and continuous glucose monitoring (CGM) in people with type 1 diabetes (T1D). Methods: A prospective single-centre cohort study including participants with T1D and HbA1c > 7.5%. After completing a course in flexible intensified insulin treatment (FIT), participants were offered treatment change to CSII/CGM. FIT participants with HbA1c ≤ 7.5% who remained on multiple daily injections (MDI) and without CGM were monitored as a separate cohort to compare the cumulative incidence of diabetic complications. Results: The study cohort included 41 participants with T1D (21 male/20 female). The mean age (±SD) at inclusion was 24.2 ± 10.9 years, the mean follow-up was 8.9 ± 2.8 years, and the mean diabetes duration at the end of the study was 15.9 ± 10.1 years. The mean HbA1c level before the introduction of CSII was 8.8 ± 1.3% (73 ± 8 mmol/mol), and decreased significantly thereafter to 8.0 ± 1.1% (63 ± 7 mmol/mol) (p = 0.0001), and further to 7.6 ± 1.1% (59 ± 11 mmol/mol) after the initiation of CGM (p = 0.051). In the MDI group the HbA1c levels did not change significantly during a mean follow-up of 6.8 ± 3.2 years. The frequency of severe hypoglycaemia after the introduction of CSII/CGM declined significantly (from 9.7 to 2.2 per 100 patient-years, p = 0.03), and the cumulative incidence of newly diagnosed diabetic microvascular complications were comparable between the study group and the observational cohort. Conclusion: In people with T1D and unsatisfactory diabetes control the introduction of CSII and CGM results in a substantial and long-term improvement.

The early detection of atherosclerosis in type 1 diabetes: why, how and what to do about it

The major cause of morbidity and often premature mortality in people with type I diabetes (T1D) is cardiovascular disease owing to accelerated atherosclerosis. We review publications relating to the rationale behind, and clinical tests for, detecting and treating early atherosclerosis in people with T1D. Currently available tools for atherosclerosis assessment include risk equations using vascular risk factors, arterial intima-media thickness, the ankle-brachial index, coronary artery calcification and angiography, and for more advanced lesions, intravascular ultrasound and optical coherence tomography. Evolving research tools include risk equations incorporating novel clinical, biochemical and molecular tests; vascular MRI and molecular imaging. As yet there is little information available to quantify early atherosclerosis. With better means to control the vascular risk factors, such as hypertension, dyslipidaemia and glycaemic control, and emerging therapies to control novel risk factors, further epidemiologic and clinical trials are merited to facilitate the translation into clinical practice of robust means to detect, monitor and treat early atherosclerosis in those with T1D.

A co-curricular diabetes-specific elective with interprofessional students and faculty

BACKGROUND AND PURPOSE

Develop and assess the effectiveness of an interprofessional co-curricular elective in improving pharmacy students' confidence in providing diabetes self-management education and support (DSMES) to patients.

EDUCATIONAL ACTIVITY AND SETTING

As part of an interprofessional collaboration, a student organized diabetes-specific enrichment elective, was offered originally to medical students and then extended to include pharmacy students. The interprofessional elective included an overview of diabetes and its prevention, medications, insulin therapy/administration, blood glucose monitoring, insulin pumps, nutrition and fitness. This elective served as a co-curricular activity, in that it was not offered for course credits, rather provided an opportunity to learn in an interprofessional environment with small group, unstructured interactions. The impact of the elective on pharmacy student confidence was evaluated using a retrospective pre-post survey.

FINDINGS

A total of 16 pharmacy students participated (response rate of 63%). A Wilcoxon signed-rank test revealed an increase in students' confidence in most of the areas assessed. Eighty percent of respondents found the elective valuable.

SUMMARY

An interprofessional co-curricular diabetes-specific elective significantly improved pharmacy students' confidence in providing DMSES to patients in the majority of assessed areas. Pharmacy and medical students were given the opportunity to learn alongside one another and learn from an interprofessional team of instructors in a setting that modeled such communication and collaboration. Developing such enrichment electives may be beneficial to equip students with the skills needed to provide education/support to patients with chronic diseases and interact with other health professionals effectively.

B-type natriuretic peptide attenuates endoplasmic reticulum stress in H9c2 cardiomyocytes underwent hypoxia/reoxygenation injury under high glucose/high fat conditions

Exogenously administered B-type natriuretic peptide (BNP) has been shown to provide cardioprotection against various heart diseases. However, the underlying mechanisms remain elusive. This study explores whether BNP exerts its cardioprotection against hypoxia/reoxygenation (H/R) injury under high glucose/high fat (HG/HF) conditions in cardiac H9c2 cells and uncovers the underlying mechanisms. Our data revealed that BNP significantly increased the cell viability and decreased the release of lactate dehydrogenase (LDH) and creatine kinase (CK), with a maximal effect at the BNP concentration of 10^-7 mol/L. In addition, by analyzing the activation of cleaved caspase-3 and by Annexin V-FITC/PI staining, we showed that BNP attenuated H/R-induced cell apoptosis in HG/HF conditions. Western blot analysis showed enhanced phosphorylation of protein kinase RNA (PKR)-like endoplastmic reticulum (ER) kinase (PERK) and eukaryotic initiation factor 2α (eIF2α)(one of the three main signaling pathways in endoplastmic reticulum (ER) stress), and increased expression of GRP78 and CHOP proteins (ER stress-related proteins) in H9c2 cells which underwent H/R in HG/HF conditions. Treatment with BNP or 8-Br-cGMP (an analog of cGMP) reversed this activation. However, this effect was significantly weakened by KT-5823, a selective cGMP-dependent protein kinase G (PKG) inhibitor. In addition, similar to BNP, treatment with a specific inhibitor of ER stress tauroursodeoxycholic acid (TUDCA) protected the cells against H/R injury exposed to HG/HF conditions. In conclusion, these findings demonstrated that BNP effectively protected cells against H/R injury under HG/HF conditions by inhibiting the ER stress via activation of the cGMP-PKG signaling pathway.

Diuretic treatment of the patient with diabetes and heart failure. Role of SGLT2 inhibitors and similarities with carbonic anhydrase inhibitors

Sodium-glucose cotransporter-2 inhibitors have changed the concept of the effects that hypoglycemic drugs have on hearth failure (HF). For the first time, a therapeutic group has modified the evolution of HF. Its effect goes beyond glycemic control, and different theories have been postulated to justify this benefit. In the article we sent, we analyze the influence of the different pharmacological groups used in type 2 diabetes mellitus on HF, and we present the theory of the mechanism of action associated with the benefit of these drugs. In our opinion, this benefit in HF is secondary to its diuretic effect, specifically an effect very similar to carbon dioxide inhibitors. We think that our theory is novel, explains the mechanism of action and we have not found in the literature any article that explains the mechanism of action in such a precise way.

Early atherosclerosis is associated with retinal microvascular changes in adolescents with type 1 diabetes

BACKGROUND/OBJECTIVE

Adolescents with type 1 diabetes have early macrovascular changes (increased intima-media thickness [IMT]) and early retinal changes that predict clinical disease in adulthood. We hypothesized that early changes in the macrovascular and retinal microvascular beds develop in parallel before retinopathy develops. We therefore aimed to investigate the relationship between changes in atherosclerosis (carotid and aortic IMT) and retinal vascular geometry cross-sectionally and longitudinally in adolescents with type 1 diabetes.

METHODS

Ninety adolescents with type 1 diabetes (41 boys, aged 13.6 ± 3.5 years) who were enrolled in a randomized controlled trial had evaluations at baseline; 41 randomized to placebo were also investigated at 12 months for carotid and aortic IMT using ultrasound and retinal vascular geometry was measured from retinal photographs.

RESULTS

There were significant associations between thicker mean/maximum carotid IMT and wider retinal arteriolar and venular calibers; for every 0.1 mm increase in mean carotid IMT, retinal arteriolar caliber increased by 7.90 μm (95% confidence interval [CI] 4.50, 11.30, P < 0.0001) and venular caliber by 9.61 μm (95% CI 4.16, 15.06, P = 0.0008). Increased mean aortic IMT was associated with increased arteriolar tortuosity (2.61, 95% CI 0.50, 4.71, P = 0.02).

CONCLUSIONS

The early changes of atherosclerosis are associated with retinal microvascular changes in adolescents with type 1 diabetes. This supports parallel adverse changes in the macro and microvascular circulations from early adolescence in type 1 diabetes, and highlights the importance of early intervention.

Correlations of the glycemic variability with oxidative stress and erythrocytes membrane stability in patients with type 1 diabetes under intensive treatment

OBJECTIVES

This study aimed to evaluate the correlations of glycemic variability with erythrocyte membrane stability parameters and oxidative stress markers in patients with type 1 diabetes mellitus (T1DM) under intensive treatment.

MATERIAL AND METHODS

90 patients with T1DM and under intensive treatment of the disease were evaluated in relation to anthropometric indices, records of glycemic averages and parameters of glycemic variability, biochemical dosages (glucose, uric acid, lipidogram, glycated hemoglobin, microalbuminuria, creatinine and iron) reticulocyte count, erythrocyte membrane stability parameters and oxidative stress markers (thiobarbituric acid reactive substances, TBARS, and glutathione reductase, GR).

RESULTS

Indicators of glycemic variability in the short and long term showed correlations with parameters of membrane stability and markers of oxidative stress (GR). In addition, the comparison of these same parameters between the subgroups consisting of quartiles of GV or glycemic control also showed significant differences.

CONCLUSION

In the T1DM patients studied here, glycemic variability showed correlations with oxidative stress and erythrocyte membrane stability variables. This corroborates the hypothesis that glycemic fluctuations interfere with lipid peroxidation and cell membrane behavior, emphasizing its participation in mechanisms related to the development of chronic complications of diabetes.

Cost-effectiveness Analysis of a Flash Glucose Monitoring System for Patients with Type 1 Diabetes Receiving Intensive Insulin Treatment in Sweden

Flash glucose monitoring - an alternative to traditional self-monitoring of blood glucose (SMBG) - prevents hypoglycaemic events without impacting glycated haemoglobin (HbA1c).21 Given the potential benefits, this study assessed the cost-effectiveness of using flash monitoring versus SMBG alone in patients with type 1 diabetes (T1D) receiving intensive insulin treatment in Sweden. Methods: This study used the IQVIA CORE Diabetes Model (IQVIA CDM, v9.0) to simulate the impact of flash monitoring versus SMBG over 50 years from the Swedish societal perspective. Trial data informed cohort data, intervention effects, and resource utilisation; literature and Tåndvards-Läkemedelförmånsverket (TLV) sources informed utilities and costs. Scenario analyses explored the effect of key base case assumptions. Results: In base case analysis, direct medical costs for flash monitor use were SEK1,222,333 versus SEK989,051 for SMBG use. Flash monitoring led to 0.80 additional quality-adjusted life years (QALYs; 13.26 versus 12.46 SMBG) for an incremental cost effectiveness ratio (ICER) of SEK291,130/QALY. ICERs for all scenarios remained under SEK400,000/QALY. Conclusion: Hypoglycaemia and health utility benefits due to flash glucose monitoring may translate into economic value compared to SMBG. With robust results across scenario analyses, flash monitoring may be considered cost-effective in a Swedish population of T1D intensive insulin users.

Type 1 diabetes

Type 1 diabetes is a chronic autoimmune disease characterised by insulin deficiency and resultant hyperglycaemia. Knowledge of type 1 diabetes has rapidly increased over the past 25 years, resulting in a broad understanding about many aspects of the disease, including its genetics, epidemiology, immune and β-cell phenotypes, and disease burden. Interventions to preserve β cells have been tested, and several methods to improve clinical disease management have been assessed. However, wide gaps still exist in our understanding of type 1 diabetes and our ability to standardise clinical care and decrease disease-associated complications and burden. This Seminar gives an overview of the current understanding of the disease and potential future directions for research and care.

Oxidative Stress and Cardiovascular Risk in Type 1 Diabetes Mellitus: Insights From the DCCT/EDIC Study

Background

Hyperglycemia leading to increased oxidative stress is implicated in the increased risk for the development of macrovascular and microvascular complications in patients with type 1 diabetes mellitus.

Methods and Results

A random subcohort of 349 participants was selected from the DCCT / EDIC (Diabetes Control and Complications Trial/Epidemiology of Diabetes Interventions and Complications) cohort. This included 320 controls and 29 cardiovascular disease cases that were augmented with 98 additional known cases to yield a case cohort of 447 participants (320 controls, 127 cases). Biosamples from DCCT baseline, year 1, and closeout of DCCT , and 1 to 2 years post‐ DCCT ( EDIC years 1 and 2) were measured for markers of oxidative stress, including plasma myeloperoxidase, paraoxonase activity, urinary F 2α isoprostanes, and its metabolite, 2,3 dinor‐8 iso prostaglandin F 2α . Following adjustment for glycated hemoblobin and weighting the observations inversely proportional to the sampling selection probabilities, higher paraoxonase activity, reflective of antioxidant activity, and 2,3 dinor‐8 iso prostaglandin F 2α , an oxidative marker, were significantly associated with lower risk of cardiovascular disease (−4.5% risk for 10% higher paraoxonase, P <0.003; −5.3% risk for 10% higher 2,3 dinor‐8 iso prostaglandin F 2α , P =0.0092). In contrast, the oxidative markers myeloperoxidase and F 2α isoprostanes were not significantly associated with cardiovascular disease after adjustment for glycated hemoblobin. There were no significant differences between DCCT intensive and conventional treatment groups in the change in all biomarkers across time segments.

Conclusions

Heightened antioxidant activity (rather than diminished oxidative stress markers) is associated with lower cardiovascular disease risk in type 1 diabetes mellitus, but these biomarkers did not change over time with intensification of glycemic control.

Clinical Trial Registration

URL : https://www.clinicaltrials.gov . Unique identifiers: NCT 00360815 and NCT 00360893.

Different Methods for Modelling Severe Hypoglycaemic Events: Implications for Effectiveness, Costs and Health Utilities

BACKGROUND

Clinical trials report severe hypoglycaemic events as the number of patients with at least one event out of the total randomised or number of events for a given total exposure. Different network meta-analysis models have been used to analyse these different data types.

OBJECTIVE

This aim of this article was to establish the impact of using the different models on effectiveness, costs and health utility estimates.

METHODS

We analysed a dataset used in a recent network meta-analysis of severe hypoglycaemic events conducted to inform National Institute for Health and Care Excellence recommendations regarding basal insulin choice for patients with type 1 diabetes mellitus. We fitted a model with a binomial likelihood reporting odds ratios (using a logit link) or hazard ratios (complementary log-log link), a model with a Poisson likelihood reporting hazard ratios and a shared-parameter model combining different types of data. We compared the results in terms of relative effects and resulting cost and disutility estimates.

RESULTS

Relative treatment effects are similar regardless of which model or scale is used. Differences were seen in the probability of having an event on the baseline treatment with the logit model giving a baseline probability of 0.07, the complementary log-log 0.17 and the Poisson 0.29. These translate into differences of up to £110 in the yearly cost of a hypoglycaemic event and 0.004 in disutility.

CONCLUSION

While choice of network meta-analysis model does not have a meaningful impact on relative effects for this outcome, care should be taken to ensure that the baseline probabilities used in an economic model are accurate to avoid misrepresenting costs and effects.

Trends in cardiovascular risk factor management in type 1 diabetes by sex

AIMS

DCCT showed that intensive type 1 diabetes management reduces complication incidence but did not focus on other cardiovascular disease risk factors, whose control in type 1 diabetes has not been well-studied. We assessed trends in cardiovascular risk factors in type 1 diabetes and attainment of concurrent American Diabetes Association (ADA) guidelines/recommendations (for HbA1c, blood pressure, LDL cholesterol, triglycerides) for complication prevention.

METHODS

Individuals with childhood-onset type 1 diabetes (n = 658; 49.4% women; baseline (1986-1988) median age 27 and duration 19 years) were followed biennially for up to 25 years, with surveys and/or examinations.

RESULTS

At the latest recorded follow-up, achievement of concurrent ADA recommendations increased for HbA1c (from 9.7 to 25.6%, p < .0001); was unchanged for blood pressure (from 89.7% to 87.4%, p = .36); and decreased for LDL cholesterol (from 62.3 to 39.7%, p < .0001). Adoption of intensive insulin therapy (from 5.9 to 64.4%, p < .0001) and hypercholesterolemia (from 67.3 to 78.9%, p = .0006) also increased. Overall, the proportion meeting all four recommendations was essentially unaltered (from 6.8% to 7.6%) (p = .69). Results were similar by gender.

CONCLUSIONS

Although the adoption of intensive insulin therapy and obtaining ADA HbA1c recommendations are increasing, overall cardiovascular risk factor compliance remains low and merits further intervention.

Diallyl trisulfide ameliorates myocardial ischemia-reperfusion injury by reducing oxidative stress and endoplasmic reticulum stress-mediated apoptosis in type 1 diabetic rats: role of SIRT1 activation

Diallyl trisulfide (DATS) protects against apoptosis during myocardial ischemia-reperfusion (MI/R) injury in diabetic state, although the underlying mechanisms remain poorly defined. Previously, we and others demonstrated that silent information regulator 1 (SIRT1) activation inhibited oxidative stress and endoplasmic reticulum (ER) stress during MI/R injury. We hypothesize that DATS reduces diabetic MI/R injury by activating SIRT1 signaling. Streptozotocin (STZ)-induced type 1 diabetic rats were subjected to MI/R surgery with or without perioperative administration of DATS (40 mg/kg). We found that DATS treatment markedly improved left ventricular systolic pressure and the first derivative of left ventricular pressure, reduced myocardial infarct size as well as serum creatine kinase and lactate dehydrogenase activities. Furthermore, the myocardial apoptosis was also suppressed by DATS as evidenced by reduced apoptotic index and cleaved caspase-3 expression. However, these effects were abolished by EX527 (the inhibitor of SIRT1 signaling, 5 mg/kg). We further found that DATS effectively upregulated SIRT1 expression and its nuclear distribution. Additionally, PERK/eIF2α/ATF4/CHOP-mediated ER stress-induced apoptosis was suppressed by DATS treatment. Moreover, DATS significantly activated Nrf-2/HO-1 antioxidant signaling pathway, thus reducing Nox-2/4 expressions. However, the ameliorative effects of DATS on oxidative stress and ER stress-mediated myocardial apoptosis were inhibited by EX527 administration. Taken together, these data suggest that perioperative DATS treatment effectively ameliorates MI/R injury in type 1 diabetic setting by enhancing cardiac SIRT1 signaling. SIRT1 activation not only upregulated Nrf-2/HO-1-mediated antioxidant signaling pathway but also suppressed PERK/eIF2α/ATF4/CHOP-mediated ER stress level, thus reducing myocardial apoptosis and eventually preserving cardiac function.

Long term (4 years) improved insulin sensitivity following islet cell transplant in type 1 diabetes

BACKGROUND

Impaired insulin sensitivity (IS) predicts complications and mortality in type 1 diabetes (T1D). Insulin sensitivity improves shortly after islet cell transplant for T1D, yet long-term changes in IS and associated factors such as patient characteristics, transplant factors, clinical management, and IS-related biomarkers are unknown.

METHODS

Up to 9 years (mean 4) of longitudinal data were available on 22 adults (18 female) with T1D who received 1 to 3 transplants in Phase 1/2 or 3 clinical trials (2004-2014). Metabolic testing posttransplant estimated IS by the Homeostasis Model Assessment for Insulin Resistance (HOMA-IR; 111 observations) and the Simple Index of Insulin Sensitivity (SIis ; 95 observations).

RESULTS

Simple Index of Insulin Sensitivity significantly increased the first year posttransplant (P = .02), then stabilized (P = .39); HOMA-IR remained stable posttransplant (P = .92). Adjusting for age and BMI, higher SIis was associated with lower HbA1c following transplant (P = .03). Greater IS as measured by lower HOMA-IR and higher SIis was associated with lower fasting C-peptide (both P ≤ .04) and also with higher exenatide dose (both P ≤ .01). More islets transplanted were associated with higher SIis (P < .0001). Lower leptin at transplant predicted lower HOMA-IR and higher SIis after transplant, and lower bone marker receptor activator of nuclear factor kappa-B ligand predicted lower HOMA-IR (all P ≤ .01).

CONCLUSIONS

Insulin sensitivity measured by SIis was improved several years following transplant, while IS measured by HOMA-IR did not worsen. Higher exenatide dose, more islets transplanted, and diet and exercise (lowering leptin and receptor activator of nuclear factor kappa-B ligand) may improve IS, which may enhance glycaemic control and lower metabolic demand on transplanted islets. Long-term clamp studies are needed to confirm these results.

Coronary artery calcifications and diastolic dysfunction versus visceral fat area in type 1 diabetes: VISCERA study

AIMS

Type 1 diabetic patients (T1DM) experience a higher cardiovascular disease and mortality risk than controls. We investigated whether visceral adipose tissue (VAT) contributes to coronary artery calcifications (CAC) and cardiac dysfunction in T1DM.

METHODS

A cross-sectional study of 118 T1DM patients without a history of cardiovascular disease (men/women: 68/50, age 46±12years, HbA1c 7.6±0.9%, BMI 25.8±4.1kg/m²) was conducted. CAC and VAT were measured using a CT scan. CAC was scored using the Agatston method. Cardiac functional abnormalities were assessed by echocardiography.

RESULTS

CAC scored ≥10 in 42% of patients. Systolic function was normal in all, but diastolic dysfunction was present in 75%. Forty-six percent had VAT≥100cm². CAC score≥10 occurred more often in subjects with VAT≥100cm² (54% vs 31%; p=0.01). Age (OR=1.10; p<0.0001), diabetes duration (OR=1.10; p=0.008), gender (OR=4.28; p=0.016), LDL-cholesterol (OR=1.03; p=0.009) and metabolic syndrome (OR=5.79; p=0.005) were independently associated with a CACS≥10. Subjects with CACS≥10 were more prone to have diastolic dysfunction (84 vs 54%; p=0.03). Factors independently associated with diastolic dysfunction were age (OR=1.11; p=0.002), waist circumference (OR=1.10; p=0.016) and VAT (OR=0.99; p=0.035).

CONCLUSIONS

Excess VAT in T1DM, present in 46%, is associated with diastolic dysfunction and CAC, present in respectively 75% and 42% of patients. Timely detection might improve future cardiovascular risk.

Diabetes Mellitus in Peru

BACKGROUND

Peru is an upper medium-income developing country with an increasing prevalence of chronic diseases, including diabetes.

OBJECTIVE

To review and describe the epidemiology, drivers, and diabetes care plan in Peru.

METHODS

The medical literature was reviewed based on systematic searching of PubMed, Scielo, and various gray literature from the International Diabetes Federation, World Health Organization, and local Peruvian agencies.

FINDINGS

In Peru, diabetes affects 7% of the population. Type 2 diabetes accounts for 96.8% of outpatients visits with this condition. Type 1 diabetes has an incidence of 0.4/100,000 per year, and gestational diabetes affects 16% of pregnancies. The prevalence of glucose intolerance is 8.11% and that of impaired fasting glucose 22.4%. The prevalence of overweight, obesity, and metabolic syndrome in adults is 34.7%, 17.5%, and 25%, respectively. Metabolic syndrome prevalence is greater in women and the elderly and at urban and low-altitude locations. Diabetes is the eighth cause of death, the sixth cause of blindness, and the leading cause of end-stage kidney disease and nontraumatic lower limb amputation. In Peru, diabetes accounts for 31.5% of acute myocardial infarctions and 25% of strokes. Infections, diabetic emergencies, and cardiovascular disorders are the main causes for admissions, with a mortality rate < 10%, mainly as a result of infections, chronic kidney disease, and stroke. Sixty-two percent of the population has health insurance coverage, with inequities in the distribution of health care personnel across the country. Less than 30% of treated patients have a hemoglobin A1c < 7%.

CONCLUSIONS

Diabetes is a major health care issue in Peru that exposes difficult challenges and shortcomings. The national strategy for tackling diabetes includes promotion of healthy lifestyles; training primary care physicians and providing them with evidence-based clinical practice guidelines, safe and effective medications, and tools for monitoring treatment; and, finally, construction of a comprehensive health care network for early referral in order to prevent, detect, and treat diabetic complications.

Patient Perspectives on Nurse-led Consultations Within a Pilot Structured Transition Program for Young Adults Moving From an Academic Tertiary Setting to Community-based Type 1 Diabetes Care

PURPOSE

We aimed to evaluate patient self-management activities, patient perceptions of the therapeutic relationship and satisfaction with nurse-led consultations as part of a structured, pilot program transitioning young adults with type 1 diabetes (T1DM) to adult-oriented community-based practices.

DESIGN AND METHODS

A descriptive, cross-sectional study of patients receiving nurse-led consultations. Patients provided sociodemographic/health information, glycated hemoglobin (HbA1c) measures and completed questionnaires assessing self-management (Revised Self-Care Inventory) and the therapeutic relationship (Caring Nurse-Patient Interaction - short scale). HbA1c values were compared to guideline recommendations.

RESULTS

Twenty patients participated. HbA1c was ≤7.5% in 3/14 (21%) and 5/14 (36%) exhibited poor glycemic control (≥9.5%). The greatest concordance for self-care was in relation to insulin therapy (4.5±0.5) while patients reported the lowest adherence to diet recommendations (2.9±0.8). Overall satisfaction with nurse-led consultations was high (4±0.5 out of 5). Patients considered diabetes knowledge and technical competence as very important and were most pleased with the humanistic aspects of nursing care. Respect for privacy was deemed the most important (and most frequently observed) nursing attitude/behavior during consultations.

CONCLUSIONS

Young adults found the nurse-led consultations with therapeutic education to develop T1DM self-care skills are an important complement to medical management during transition.

PRACTICE IMPLICATIONS

Patient autonomy and privacy should be respected during this developmental period. Nurses taking a humanistic approach towards accompanying and supporting the patient can enhance the therapeutic relationship during transition and promote continuity of care. Transition nurses can use technical competence and therapeutic education to empower patients for self-management.

The Comprehensive Glucose Pentagon: A Glucose-Centric Composite Metric for Assessing Glycemic Control in Persons With Diabetes

BACKGROUND

Composite metrics have the potential to provide more complete and clinically useful information about glycemic control than traditional individual metrics such as hemoglobin A1C, %/time/area under curve of hypoglycemia and hyperglycemia.

METHODS

Using five key metrics that are derived from continuous glucose monitoring, we developed a new, multicomponent composite metric, the Comprehensive Glucose Pentagon (CGP) that demonstrates glycemic control both numerically and visually. Two of its axes are composite metrics-the intensity of hypoglycemia and intensity of hyperglycemia. This approach eliminates the use of the surrogate marker, hemoglobin A1C (A1C), and replaces it with glucose-centric metrics.

RESULTS

We reanalyzed the data from two randomized control trials, the STAR 3 and ASPIRE In-Home studies using the CGP. It provided new insights into the effect of sensor-augmented pumping (SAP) in the STAR 3 trial and sensor-integrated pumping with low-glucose threshold suspend (SIP+TS) in the ASPIRE In-Home trial.

CONCLUSIONS

The CGP has the potential to enable health care providers, investigators and patients to better understand the components of glycemic control and the effect of various interventions on the individual elements of that control. This can be done on a daily, weekly, or monthly basis. It also allows direct comparison of the effects on different interventions among clinical trials which is not possible using A1C alone. This new composite metric approach requires validation to determine if it provides a better predictor of long-term outcomes than A1C and/or better predictor of severe hypoglycemia than the low blood glucose index (LBGI).

Basal Insulin Regimens for Adults with Type 1 Diabetes Mellitus: A Cost-Utility Analysis

OBJECTIVES

To assess the cost-effectiveness of basal insulin regimens for adults with type 1 diabetes mellitus in England.

METHODS

A cost-utility analysis was conducted in accordance with the National Institute for Health and Care Excellence reference case. The UK National Health Service and personal and social services perspective was used and a 3.5% discount rate was applied for both costs and outcomes. Relative effectiveness estimates were based on a systematic review of published trials and a Bayesian network meta-analysis. The IMS CORE Diabetes Model was used, in which net monetary benefit (NMB) was calculated using a threshold of £20,000 per quality-adjusted life-year (QALY) gained. A wide range of sensitivity analyses were conducted.

RESULTS

Insulin detemir (twice daily) [iDet (bid)] had the highest mean QALY gain (11.09 QALYs) and NMB (£181,456) per patient over the model time horizon. Compared with the lowest cost strategy (insulin neutral protamine Hagedorn once daily), it had an incremental cost-effectiveness ratio of £7844/QALY gained. Insulin glargine (od) [iGlarg (od)] and iDet (od) were ranked as second and third, with NMBs of £180,893 and £180,423, respectively. iDet (bid) remained the most cost-effective treatment in all the sensitivity analyses performed except when high doses were assumed (>30% increment compared with other regimens), where iGlarg (od) ranked first.

CONCLUSIONS

iDet (bid) is the most cost-effective regimen, providing the highest QALY gain and NMB. iGlarg (od) and iDet (od) are possible options for those for whom the iDet (bid) regimen is not acceptable or does not achieve required glycemic control.

Treatment with insulin analogs and prevalence of cardiovascular complications in patients with type 1 diabetes

BACKGROUND

A lower incidence of cardiovascular events has been reported in type 2 diabetes patients treated with insulin analogs (IAs). Corresponding data on people affected by type 1 diabetes are not available yet.

METHODOLOGY

We investigated demographic and clinical data from 509 type 1 diabetics, who were treated in an outpatient clinic from 2006 to 2012. Multiple logistic regression was used to investigate the relationship between the type of insulin treatment and the prevalence of cardiovascular (CV) complications, that is, presence of coronary heart, cerebrovascular and peripheral arterial diseases, adjusting for potential confounders.

RESULTS

Results from multiple logistic regression revealed that patients with impaired renal function [estimated glomerular filtration rate (eGFR) < 90 ml/min] show lower CV complication rates when treated with IAs (25%) compared with patients treated with human insulin (HI; 28%) and HI/IA (38%, p = 0.06). CV complication rates in the complete patient collective amounted to 17% (IA), 21% (HI) and 21% (HI/IA, p = 0.08). Examination of CV complications according to the type of IA revealed the lowest complication rates in type 1 diabetics treated with insulin lispro (5.9%) and glargine (16%). However, complication rate differences among insulin treatments did not reach statistical significance.

CONCLUSION

The present cross-sectional study shows a borderline significantly lower CV morbidity in people with type 1 diabetes and impaired renal function when treated with IA compared with HI treatment after adjustment for multiple potential confounders [odds ratio (OR) = 0.78, which translates into a 22% lower complication rate]. Validation of these preliminary findings in confirmatory, prospective studies may have important clinical implications.

The role and function of HDL in patients with diabetes mellitus and the related cardiovascular risk

BACKGROUND

Diabetes mellitus (DM) is a major public health problem which prevalence is constantly raising, particularly in low- and middle-income countries. Both diabetes mellitus types (DMT1 and DMT2) are associated with high risk of developing chronic complications, such as retinopathy, nephropathy, neuropathy, endothelial dysfunction, and atherosclerosis.

METHODS

This is a review of available articles concerning HDL subfractions profile in diabetes mellitus and the related cardiovascular risk. In this review, HDL dysfunction in diabetes, the impact of HDL alterations on the risk diabetes development as well as the association between disturbed HDL particle in DM and cardiovascular risk is discussed.

RESULTS

Changes in the amount of circulation lipids, including triglycerides and LDL cholesterol as well as the HDL are frequent also in the course of DMT1 and DMT2. In normal state HDL exerts various antiatherogenic properties, including reverse cholesterol transport, antioxidative and anti-inflammatory capacities. However, it has been suggested that in pathological state HDL becomes "dysfunctional" which means that relative composition of lipids and proteins in HDL, as well as enzymatic activities associated to HDL, such as paraoxonase 1 (PON1) and lipoprotein-associated phospholipase 11 (Lp-PLA2) are altered. HDL properties are compromised in patients with diabetes mellitus (DM), due to oxidative modification and glycation of the HDL protein as well as the transformation of the HDL proteome into a proinflammatory protein. Numerous studies confirm that the ability of HDL to suppress inflammatory signals is significantly reduced in this group of patients. However, the exact underlying mechanisms remains to be unravelled in vivo.

CONCLUSIONS

The understanding of pathological mechanisms underlying HDL dysfunction may enable the development of therapies targeted at specific subpopulations and focusing at the diminishing of cardiovascular risk.

The relationship of blood glucose with cardiovascular disease is mediated over time by traditional risk factors in type 1 diabetes: the DCCT/EDIC study

AIMS/HYPOTHESIS

Chronic hyperglycaemia, as measured by HbA1c levels, is a major risk factor for atherosclerosis and cardiovascular disease (CVD) in type 1 diabetes. Our aim was to describe the degree to which the effect of HbA1c on the risk of CVD is mediated by its effect on traditional risk factors over time, and how these mediation pathways change over time.

METHODS

The DCCT and its observational follow-up study, the Epidemiology of Diabetes Interventions and Complications (EDIC), followed 1441 participants for a mean of 27 years, with periodic measurement of HbA1c and risk factors over time. We assessed the proportion of the HbA1c effect on risk of CVD that was mediated through its effects on systolic BP (SBP), pulse rate, triacylglycerols and LDL-cholesterol (LDLc) levels, and how the proportion mediated changed over time.

RESULTS

The association of HbA1c with CVD outcomes was stable over time, while that of traditional risk factors (SBP, pulse rate, triacylglycerols and LDLc) increased. At 10 years of follow-up, the effect of HbA1c on 10 year CVD risk was minimally mediated by SBP (2.7%), increasing to 26% at 20 years. Likewise, from 10 year follow-up to 20 year follow-up, the proportion of HbA1c effect mediated through pulse rate increased from 6.3% to 29.3%, through triacylglycerols from 2.2% to 22.4%, and through LDLc from 9.2% to 30.7%.

CONCLUSIONS/INTERPRETATION

As participants age, the predictive association of mean HbA1c on subsequent CVD events is increasingly mediated by its effect on standard risk factors. Thus, management of traditional non-glycaemic CVD risk factors may have increasing benefits in an ageing type 1 diabetes population with longstanding hyperglycaemia.

TRIAL REGISTRATION

ClinicalTrials.gov NCT00360893 and NCT00360815.

Association between fasting glucose and all-cause mortality according to sex and age: a prospective cohort study

The association of fasting glucose with the risk of death according to sex and age remains unclear, and insufficient information is available on sex- and age-specific glucose concentrations within ethnic groups. This study analyzed a sample of 12,455,361 Korean adults who participated in health examinations during 2001-2004, and were followed up until 2013. Men had 3.0 mg/dL (0.167 mmol/L) higher mean glucose concentrations than women (94.7 vs. 91.7 mg/dL), although women over 73 years had higher levels. For glucose levels of 100-199 mg/dL, each 18 mg/dL (1 mmol/L) increase in fasting glucose increased mortality by 13% (HR = 1.13, [95% CI 1.12 to 1.13], p < 0.001). In individuals with fasting glucose levels of 100-125 mg/dL, each 18 mg/dL increase in fasting glucose was associated with a 30% increase in the risk for mortality (1.30, [1.18 to 1.43]) in those aged 18-34 years, a 32% increase (1.32, [1.26 to 1.39]) in those aged 35-44 years, and a 10% increase (1.10, [1.02 to 1.19]) in those aged 75-99 years. The fasting glucose levels associated with the lowest mortality were 80-94 mg/dL regardless of sex and age. Prediabetes (100-125 mg/dL) was associated with higher mortality. The associations of hyperglycemia with mortality were stronger at younger ages.

Risk of Severe Hypoglycemia in Type 1 Diabetes Over 30 Years of Follow-up in the DCCT/EDIC Study

OBJECTIVE

During the Diabetes Control and Complications Trial (DCCT), intensive diabetes therapy achieving a mean HbA_1c of ∼7% was associated with a threefold increase in the rate of severe hypoglycemia (defined as requiring assistance) compared with conventional diabetes therapy with a mean HbA_1c of 9% (61.2 vs. 18.7 per 100 patient-years). After ∼30 years of follow-up, we investigated the rates of severe hypoglycemia in the DCCT/Epidemiology of Diabetes Inverventions and Complications (EDIC) cohort.

RESEARCH DESIGN AND METHODS

Rates of severe hypoglycemia were reported quarterly during DCCT and annually during EDIC (i.e., patient recall of episodes in the preceding 3 months). Risk factors influencing the rate of severe hypoglycemia over time were investigated.

RESULTS

One-half of the DCCT/EDIC cohort reported episodes of severe hypoglycemia. During EDIC, rates of severe hypoglycemia fell in the former DCCT intensive treatment group but rose in the former conventional treatment group, resulting in similar rates (36.6 vs. 40.8 episodes per 100 patient-years, respectively) with a relative risk of 1.12 (95% CI 0.91-1.37). A preceding episode of severe hypoglycemia was the most powerful predictor of subsequent episodes. Entry into the DCCT study as an adolescent was associated with an increased risk of severe hypoglycemia, whereas insulin pump use was associated with a lower risk. Severe hypoglycemia rates increased with lower HbA_1c similarly among participants in both treatment groups.

CONCLUSIONS

Rates of severe hypoglycemia have equilibrated over time between the two DCCT/EDIC treatment groups in association with advancing duration of diabetes and similar HbA_1c levels. Severe hypoglycemia persists and remains a challenge for patients with type 1 diabetes across their life span.

Glycaemic control and excess risk of major coronary events in persons with type 1 diabetes

OBJECTIVE

The excess risk of major coronary events (acute myocardial infarction (AMI) or death from coronary heart disease (CHD)) in individuals with type 1 diabetes (T1D) in relation to glycaemic control and renal complications is not known.

METHODS

Individuals with T1D in the Swedish National Diabetes Registry after 1 January 1998, without a previous MI (n=33 170) and 1 64 698 controls matched on age, sex and county were followed with respect to non-fatal AMI or death from CHD. Data were censored at death due to any cause until 31 December 2011.

RESULTS

During median follow-up of 8.3 and 8.9 years for individuals with T1D and controls, respectively, 1500 (4.5%) and 1925 (1.2%), experienced non-fatal AMI or died from CHD, adjusted HR 4.07 (95% CI 3.79 to 4.36). This excess risk increased with younger age, female sex, worse glycaemic control and severity of renal complications.The adjusted HR in men with T1D with updated mean haemoglobin A1c (HbA1c) <6.9% (52 mmol/mol) and normoalbuminuria was 1.30 (95% CI 0.90 to 1.88) and in women 3.16 (95% CI 2.14 to 4.65). HRs increased to 10.7 (95% CI 8.0 to 14.3) and 31.8 (95% CI 23.6 to 42.8) in men and women, respectively, with HbA1c >9.7% and renal complications.

CONCLUSIONS

The excess risk of AMI in T1D is substantially lower with good glycaemic control, absence of renal complications and men compared with women. In women, the excess risk of AMI or CHD death persists even among patients with good glycaemic control and no renal complications.

Impact of Diabetes Care by Pharmacists as Part of Health Care Team in Ambulatory Settings: A Systematic Review and Meta-analysis

OBJECTIVE

To conduct a comprehensive systematic review and meta-analyses examining the impact of pharmacist interventions as part of health care teams on diabetes therapeutic outcomes in ambulatory care settings.

DATA SOURCES

PubMed/MEDLINE, EMBASE, Cochrane Library, International Pharmaceutical Abstracts, Web of Science, Scopus, WHO's Global Health Library, ClinicalTrials.gov , and Google Scholar were searched (1995 to February 2017). Search terms included pharmacist, team, and diabetes.

STUDY SELECTION

Full-text articles published in English with comparative designs, including randomized controlled trials, nonrandomized controlled trials, and pretest-posttest studies evaluating hemoglobin A_1C (A1C), were assessed.

DATA EXTRACTION AND SYNTHESIS

Two reviewers independently screened for study inclusion and extracted data. Quality of the studies was assessed using tools developed based on the framework of the Cochrane Collaboration's recommendations.

DATA SYNTHESIS

A total of 1908 studies were identified from the literature and reference searches; 42 studies were included in the systematic review (n = 10 860) and 35 in the meta-analyses (n = 7417). Mean age ranged from 42 to 73 years, and 8% to 100% were male. The overall standardized mean difference (SMD) for A1C for pharmacist care versus comparison was 0.57 ( P < 0.01), a moderate effect representing a mean difference of 1.1% (95% CI = 0.88-1.27). The effects for systolic blood pressure and low-density lipoprotein cholesterol were between small and moderate (SMD = 0.31 and 0.32; P < 0.01). The heterogeneity was high for all outcomes (>83%), indicating functional differences among the studies. No publication bias was detected.

CONCLUSION

Pharmacists' interventions as part of the patient's health care team improved diabetes therapeutic outcomes, substantiating the important role of pharmacists in team-based diabetes management.

Banting Memorial Lecture 2016 Reducing lifetime risk of complications in adolescents with Type 1 diabetes

Adolescence is a challenging period of life for any young person, and for those with Type 1 diabetes, physiological and psychological factors can result in a deterioration in glycaemic control. In young people with Type 1 diabetes, puberty may be an additional risk factor impacting on the lifetime risk for renal and cardiovascular complications. Our longitudinal studies have identified that increases in urinary albumin excretion through childhood are associated with the development of microalbuminuria and a generalized endotheliopathy linked to cardiovascular risk. Screening of participants recruited to the Adolescent type 1 Diabetes cardio-renal Intervention Trial (AdDIT) confirms that these early changes in albumin excretion are related to both diabetic nephropathy and cardiovascular risk; in part, independent of glycaemic control. Thus, as well as current attempts to improve glycaemic control through enhanced targeted insulin delivery, pumps, sensors and closed loop, we have explored the role of angiotensin-converting enzyme inhibitors and statins in providing cardio-renal protection during adolescence.

Predictors of subclinical atherosclerosis evaluated by carotid intima-media thickness in asymptomatic young women with type 1 diabetes mellitus

OBJECTIVE

This study aimed to evaluate the occurrence and clinical predictors of subclinical atherosclerosis in asymptomatic, young adult women with type 1 DM.

SUBJECTS AND METHODS

The study included 45 women with type 1 diabetes mellitus (DM) (aged 36 ± 9 years) who underwent carotid Doppler ultrasound evaluation to determine the carotid artery intima-media thickness (CIMT) and to assess the occurrence of carotid artery plaques. Insulin sensitivity was assessed by estimated glucose disposal rate (eGDR), and metabolic syndrome (MS) was defined by the World Health Organization criteria.

RESULTS

The cohort had a mean age of 36 ± 9 years, diabetes duration of 18.1 ± 9.5 years, and body mass index (BMI) of 24.6 ± 2.4 kg/m2. MS was present in 44.4% of the participants. The CIMT was 0.25 ± 0.28 mm, and the prevalence of carotid artery plaques was 13%. CIMT correlated positively with hypertension (p = 0.04) and waist-to-hip ratio (r = 0.37, p = 0.012). The presence of carotid artery plaques correlated positively with age (p = 0.018) and hypertension (p = 0.017). eGDR correlated negatively with CIMT (r = -0.39, p = 0.009) and carotid plaques (p = 0.04). Albuminuria showed a correlation trend with CIMT (p = 0.06). Patients with carotid artery plaques were older, had a higher prevalence of hypertension, and lower eGDR. No correlation was found between CIMT and carotid plaques with diabetes duration, MS, BMI, cholesterol profile, glycated hemoglobin, high-sensitivity C-reactive protein, or fibrinogen.

CONCLUSION

Insulin resistance, central obesity, hypertension, and older age were predictors of subclinical atherosclerosis in asymptomatic, young adult women with type 1 DM.

New directions for diabetes prevention and management in behavioral medicine

Accelerating diabetes rates have resulted in a global public health epidemic. Lifestyle change is a cornerstone of care, yet regimen demands may result in adherence difficulties. Distress, depression, and other psychosocial concerns are higher in those with diabetes. While interventions, such as the Diabetes Prevention Program appear to be effective, further research is needed to support the translation of interventions to prevent diabetes. Studies assessing optimal approaches to promoting effective decision making, coping and adherence are needed. More information is needed to evaluate the influence and potential of emerging technologies on intervention delivery and quality of life in children and adults with diabetes. Theoretically informed, interdisciplinary studies that consider ecological models are needed to develop a roadmap for policies and diabetes management recommendations. Reduction of diabetes-related health disparities is a critical area for future studies. Behavioral medicine scientists and practitioners are poised to address these and other proposed future research directions to advance diabetes prevention and management.

My Sweetheart Is Broken: Role of Glucose in Diabetic Cardiomyopathy

Despite overall reductions in heart disease prevalence, the risk of developing heart failure has remained 2-fold greater among people with diabetes. Growing evidence has supported that fluctuations in glucose level and uptake contribute to cardiovascular disease (CVD) by modifying proteins, DNA, and gene expression. In the case of glucose, clinical studies have shown that increased dietary sugars for healthy individuals or poor glycemic control in diabetic patients further increased CVD risk. Furthermore, even after decades of maintaining tight glycemic control, susceptibility to disease progression can persist following a period of poor glycemic control through a process termed "glycemic memory." In response to chronically elevated glucose levels, a number of studies have identified molecular targets of the glucose-mediated protein posttranslational modification by the addition of an O-linked N-acetylglucosamine to impair contractility, calcium sensitivity, and mitochondrial protein function. Additionally, elevated glucose contributes to dysfunction in coupling glycolysis to glucose oxidation, pentose phosphate pathway, and polyol pathway. Therefore, in the "sweetened" environment associated with hyperglycemia, there are a number of pathways contributing to increased susceptibly to "breaking" the heart of diabetics. In this review we will discuss the unique contribution of glucose to heart disease and recent advances in defining mechanisms of action.

Diabetic nephropathy in type 1 diabetes: a review of early natural history, pathogenesis, and diagnosis

Diabetic nephropathy constitutes a devastating complication in patients with type 1 diabetes mellitus, and its diagnosis is traditionally based on microalbuminuria. The aim of this review is to update through the medical literature the suggested early natural course of diabetic nephropathy, the theories behind the pathways of its pathogenesis, and its diagnosis. Poor glycemic control, dyslipidemia, smoking, advanced glycation end products, and environmental and genetic clues play an important role in the development of diabetic nephropathy. Microalbuminuria has been traditionally considered as a primary early marker of microvascular complication unraveling the risk for progress to the advanced stages of chronic kidney disease, but because of our inability to make an early diagnosis of diabetic nephropathy in young patients as well as nonalbuminuric diabetic nephropathy, recently, other additional markers of renal injury like serum and urinary neutrophil gelatinase-associated lipocalin, chitinase-3-like protein 1, cystatin C, and plasma growth differentiation factor 15 have been proposed to unmask early renal dysfunction, even before microalbuminuria supervenes. Copyright © 2016 John Wiley & Sons, Ltd.

Strategies for Diabetes Management: Using Newer Oral Combination Therapies Early in the Disease

INTRODUCTION

The duration of uncontrolled type 2 diabetes mellitus (T2DM) can adversely impact small and large vessels, eventually leading to microvascular and macrovascular complications. Failure of therapeutic lifestyle changes, monotherapy, and clinical inertia contribute to persistent hyperglycemia and disease progression. The aim was to review the complex pathophysiology of type 2 diabetes and how different oral agents can be used effectively as first-line therapy in combination with metformin, as well as in patients not achieving glycemic goals with metformin therapy.

METHODS

For this review, a non-systematic literature search of PubMed, NCBI, and Google Scholar was conducted.

RESULTS

New oral agents have made it possible to improve glycemic control to near-normal levels with a low risk of hypoglycemia and without weight gain, and sometimes with weight loss. Early combination therapy is effective and has been shown to have a favorable legacy effect. A number of agents are available in a single-pill combination (SPC) that provides fewer pills and better adherence. Compared with adding a sulfonylurea, still the most common oral combination used, empagliflozin has been shown to decrease cardiovascular (CV) events in a dedicated CV outcome study, and pioglitazone has been effective in reducing the risk of secondary CV endpoints, whereas sulfonylureas have been associated with an increased risk of CV disease. In those failing metformin, triple oral therapy by adding a non-metformin SPC such as empagliflozin/linagliptin or pioglitazone/alogliptin is a good option for reducing glycated hemoglobin (HbA1c) without significant hypoglycemia.

CONCLUSION

Clinicians have a comprehensive armamentarium of medications to treat patients with T2DM. Clinical evidence has shown that dual or triple oral combination therapy is effective for glycemic control, and early treatment is effective in getting patients to goal more quickly. Use of SPCs is an option for double or triple oral combination therapy and may result in better adherence.

Years of life gained by multifactorial intervention in patients with type 2 diabetes mellitus and microalbuminuria: 21 years follow-up on the Steno-2 randomised trial

AIMS/HYPOTHESIS

The aim of this work was to study the potential long-term impact of a 7.8 years intensified, multifactorial intervention in patients with type 2 diabetes mellitus and microalbuminuria in terms of gained years of life and years free from incident cardiovascular disease.

METHODS

The original intervention (mean treatment duration 7.8 years) involved 160 patients with type 2 diabetes and microalbuminuria who were randomly assigned (using sealed envelopes) to receive either conventional therapy or intensified, multifactorial treatment including both behavioural and pharmacological approaches. After 7.8 years the study continued as an observational follow-up with all patients receiving treatment as for the original intensive-therapy group. The primary endpoint of this follow-up 21.2 years after intervention start was difference in median survival time between the original treatment groups with and without incident cardiovascular disease. Non-fatal endpoints and causes of death were adjudicated by an external endpoint committee blinded for treatment allocation.

RESULTS

Thirty-eight intensive-therapy patients vs 55 conventional-therapy patients died during follow-up (HR 0.55 [95% CI 0.36, 0.83], p = 0.005). The patients in the intensive-therapy group survived for a median of 7.9 years longer than the conventional-therapy group patients. Median time before first cardiovascular event after randomisation was 8.1 years longer in the intensive-therapy group (p = 0.001). The hazard for all microvascular complications was decreased in the intensive-therapy group in the range 0.52 to 0.67, except for peripheral neuropathy (HR 1.12).

CONCLUSIONS/INTERPRETATION

At 21.2 years of follow-up of 7.8 years of intensified, multifactorial, target-driven treatment of type 2 diabetes with microalbuminuria, we demonstrate a median of 7.9 years of gain of life. The increase in lifespan is matched by time free from incident cardiovascular disease.

TRIAL REGISTRATION

ClinicalTrials.gov registration no. NCT00320008.

FUNDING

The study was funded by an unrestricted grant from Novo Nordisk A/S.

Young people with Type 1 diabetes of non-white ethnicity and lower socio-economic status have poorer glycaemic control in England and Wales

BACKGROUND

The impact of ethnicity and socio-economic status (SES) on glycaemic control during childhood Type 1 diabetes is poorly understood in England and Wales.

METHODS

We studied 18 478 children with Type 1 diabetes (< 19 years) attending diabetes clinics and included in the 2012-2013 National Paediatric Diabetes Audit. Self-identified ethnicity was categorized as white, Asian, black, mixed, other and 'not-stated' (did not to divulge ethnicity). A small area measure of SES was estimated from the Index of Multiple Deprivation. Multiple linear regression was used to assess associations between ethnicity, SES and glycaemic control (mean HbA_1c levels) accounting for age, gender and diabetes duration. The impact of insulin pump use on the ethnicity/SES-HbA_1c associations was tested in 13 962 children.

RESULTS

All children from minority ethnic groups had higher mean HbA_1c compared with white children, with largest differences observed in black and mixed ethnicities [8 mmol/mol (2.9%), 95% CI 5-11 and 7 mmol/mol (2.8%), 95% CI 5-9, respectively]. Lower SES was associated with higher mean HbA_1c with a dose effect. The lowest SES group had a mean HbA_1c that was 7 mmol/mol (2.8%) (95% CI 6-8) higher compared with the highest SES group, adjusted for ethnicity. Estimates for ethnicity were attenuated, but significant on adjustment for SES. Fewer non-white (white 20.3 vs. black 5.5%) and deprived (least deprived 21.1 vs. most deprived 13.2%) children were on insulin pump therapy. Ethnicity and SES remained significant predictors of HbA_1c after accounting for insulin pump use.

CONCLUSION

The association between ethnicity and glycaemic control persists after adjustment for deprivation and pump use. An alternative approach to intensive insulin therapy might benefit these vulnerable children.