Management of hyperglycaemia in type 2 diabetes: a patient-centered approach. Position statement of the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD)

A review of the efficacy and safety of oral antidiabetic drugs

INTRODUCTION

Additional oral antidiabetic agents to metformin, sulfonylureas (SU) and thiazolidinediones (TZD) are approved for the treatment of type 2 diabetes.

AREAS COVERED

The efficacy and safety of metformin, SUs, TZDs, dipeptidyl peptidase-IV (DPP-4) inhibitors, meglitinide analogs, α-glucosidase inhibitors (AGIs), bile-acid sequestrants (BAS) and bromocriptine will be reviewed.

EXPERT OPINION

Several new oral agents have been approved for type 2 diabetes management in recent years. It is important to understand the efficacy and safety of these medications in addition to the older agents to best maximize oral drug therapy for diabetes. Of the recently introduced oral hypoglycemic/antihyperglycemic agents, the DPP-4 inhibitors are moderately efficacious compared with mainstay treatment with metformin with a low side-effect profile and have good efficacy in combination with other oral agents and insulin. They are a recommended alternative when metformin use is limited by gastrointestinal (GI) side effects or when SU treatment results in significant hypoglycemia or weight gain. Meglitinide analogs are limited by their frequent dosing, expense and hypoglycemia (repaglinide > nateglinide), while AGIs are also limited by their dosing schedule and GI side-effect profile. BAS and bromocriptine have the lowest efficacy with regard to HbA(1c) reduction, also are plagued by GI adverse reactions, but have a low risk of hypoglycemia.

Protocol for ADDITION-PRO: a longitudinal cohort study of the cardiovascular experience of individuals at high risk for diabetes recruited from Danish primary care

Background

Screening programmes for type 2 diabetes inevitably find more individuals at high risk for diabetes than people with undiagnosed prevalent disease. While well established guidelines for the treatment of diabetes exist, less is known about treatment or prevention strategies for individuals found at high risk following screening. In order to make better use of the opportunities for primary prevention of diabetes and its complications among this high risk group, it is important to quantify diabetes progression rates and to examine the development of early markers of cardiovascular disease and microvascular diabetic complications. We also require a better understanding of the mechanisms that underlie and drive early changes in cardiometabolic physiology. The ADDITION-PRO study was designed to address these issues among individuals at different levels of diabetes risk recruited from Danish primary care.

Methods/Design

ADDITION-PRO is a population-based, longitudinal cohort study of individuals at high risk for diabetes. 16,136 eligible individuals were identified at high risk following participation in a stepwise screening programme in Danish general practice between 2001 and 2006. All individuals with impaired glucose regulation at screening, those who developed diabetes following screening, and a random sub-sample of those at lower levels of diabetes risk were invited to attend a follow-up health assessment in 2009–2011 (n = 4,188), of whom 2,082 (50%) attended. The health assessment included detailed measurement of anthropometry, body composition, biochemistry, physical activity and cardiovascular risk factors including aortic stiffness and central blood pressure. All ADDITION-PRO participants are being followed for incident cardiovascular disease and death.

Discussion

The ADDITION-PRO study is designed to increase understanding of cardiovascular risk and its underlying mechanisms among individuals at high risk of diabetes. Key features of this study include (i) a carefully characterised cohort at different levels of diabetes risk; (ii) detailed measurement of cardiovascular and metabolic risk factors; (iii) objective measurement of physical activity behaviour; and (iv) long-term follow-up of hard clinical outcomes including mortality and cardiovascular disease. Results will inform policy recommendations concerning cardiovascular risk reduction and treatment among individuals at high risk for diabetes. The detailed phenotyping of this cohort will also allow a number of research questions concerning early changes in cardiometabolic physiology to be addressed.

Impact of self-treated hypoglycaemia in type 2 diabetes: a multinational survey in patients and physicians

OBJECTIVES

The objectives were to estimate the prevalence of self-treated hypoglycaemia in patients using basal insulin analogues; identify demographic, treatment related and behavioural risk factors; and describe patient and physician responses to these events.

RESEARCH DESIGN AND METHODS

The GAPP2 (Global Attitude of Patients and Physicians 2) study was an online multinational cross-sectional study of patients with type 2 diabetes currently treated with basal insulin, and healthcare professionals involved in the care of such patients. The primary variable of interest was self-treated hypoglycaemia within the last 30 days.

RESULTS

A total of 3042 patients treated with basal insulin analogues and 1222 prescribers completed the full survey. Overall, 36% of patients had experienced self-treated hypoglycaemia during the previous 30 days. In response to self-treated hypoglycaemia, patients reported missing (7%), reducing (11%) or mistiming (4%) basal insulin doses, increasing the level of glucose monitoring (40%) or utilising healthcare resources (7%). Patients reporting irregular basal insulin dosing by missing, mistiming or reducing a dose were also significantly more likely to report an episode of self-treated hypoglycaemia in the same time period: 41% versus 34% (p = 0.004), 43% versus 33% (p < 0.001), and 56% versus 32% (p < 0.001) respectively. Nocturnal events worried significantly more patients than diurnal events (42% versus 23%, p < 0.001). Patient worry about hypoglycaemia, insulin regimen and reduced basal dosing were identified as the key differentiating variables associated with increased risk of self-treated hypoglycaemic events. Most prescribers (76%) believed that insulin analogues minimised the risk of nocturnal hypoglycaemia when compared to NPH insulin; 46% also reported being contacted at least once a month by insulin analogue patients after self-treated hypoglycaemic events.

CONCLUSIONS

Self-treated hypoglycaemia is common in approximately one third of patients using insulin analogue regimens. Additionally, self-treated hypoglycaemia was found to be associated with clinically significant effects on patient well-being and functioning, patient and physician management and healthcare utilisation despite the potential limitations of an online self-complete survey such as the need to be topic focused, the potential for under-reporting and social bias.

Effect of metformin glycinate on glycated hemoglobin A1C concentration and insulin sensitivity in drug-naive adult patients with type 2 diabetes mellitus

AIM

This study evaluated the effect of metformin glycinate on glycated hemoglobin A1c (A1C) concentration and insulin sensitivity in drug-naive adult patients with type 2 diabetes mellitus (T2DM).

SUBJECTS AND METHODS

A randomized, double-blind, placebo-controlled clinical trial was carried out in 20 patients with drug-naive T2DM. Ten subjects received metformin glycinate (1,050.6 mg) once daily during the first month and force-titrated twice daily during the second month. Ten additional patients received placebo as the control group. Before and after the intervention, metabolic profile including A1C and insulin sensitivity (euglycemic-hyperinsulinemic clamp technique) was estimated.

RESULTS

A1C concentrations decreased significantly with metformin glycinate administration (8.0 ± 0.7% vs. 7.1 ± 0.9%, P = 0.008) before and after the intervention, respectively. There were significant differences in changes from baseline of A1C between groups (0.0 ± 0.7% vs. -1.0 ± 0.5% for placebo and metformin glycinate groups, respectively; P = 0.004). A reduction of ≥1% in A1C levels was reached in 60.0% of patients with metformin glycinate administration (P = 0.02). Insulin sensitivity was not modified by the intervention.

CONCLUSIONS

Administration of metformin glycinate during a 2-month period showed a greater decrease in A1C concentrations than placebo in a selected group of drug-naive adult patients with T2DM.

Physician perceptions and practices in management of diabetes in India: Results from the IMPROVE Control program

INTRODUCTION

The impact of IMPROVE Control Training program was evaluated by a non-interventional study and validated by a physician perception questionnaire. From a survey on 1086 physicians providing diabetes care in India, we report their practices and perceptions about diabetes care and insulin therapy.

MATERIALS AND METHODS

The responses were collected using a questionnaire validated by the IMPROVE Control Steering Committee.

RESULTS

Majority [558 (51.4%)] of the physicians accepted the ADA defined HbA1c target of <7% as the standard for good glycemic control in their practice. However, 541 (49.8%) of the physicians agreed that only 20-40% of their patients were able to achieve this target. For patients who do not achieve the glycemic control with oral anti-diabetic drugs (OADs) within 6 months of initiation of therapy, initiation of an optimal insulin regimen was the preferred choice for 492 (45.3%) of the participating physicians. Premixed insulin was preferred for initiating insulin therapy in patients with type 2 diabetes, by 676 (62.2%) of the participants [as compared to basal by 375 (34.5%) participants]. Once daily premixed insulin, intensified to twice daily was preferred as most optimal insulin regimen for initiation and subsequent intensification of insulin therapy [487 (44.8%) participants]. Most of the participants preferred adopting a multi-targeted approach for treating diabetes, hypertension, and dyslipidemia.

CONCLUSIONS

Physicians prefer treatment goals similar to those recommended in the current guidelines of the American Diabetes Association for managing their patients with diabetes. Premixed insulin is preferred for initiation and intensification of insulin therapy.

Insulin degludec versus insulin glargine in insulin-naive patients with type 2 diabetes: a 1-year, randomized, treat-to-target trial (BEGIN Once Long)

OBJECTIVE

To compare ultra-long-acting insulin degludec with glargine for efficacy and safety in insulin-naive patients with type 2 diabetes inadequately controlled with oral antidiabetic drugs (OADs).

RESEARCH DESIGN AND METHODS

In this 1-year, parallel-group, randomized, open-label, treat-to-target trial, adults with type 2 diabetes with A1C of 7-10% taking OADs were randomized 3:1 to receive once daily degludec or glargine, both with metformin. Insulin was titrated to achieve prebreakfast plasma glucose (PG) of 3.9-4.9 mmol/L. The primary end point was confirmation of noninferiority of degludec to glargine in A1C reduction after 52 weeks in an intent-to-treat analysis.

RESULTS

In all, 1,030 participants (mean age 59 years; baseline A1C 8.2%) were randomized (degludec 773, glargine 257). Reduction in A1C with degludec was similar (noninferior) to that with glargine (1.06 vs. 1.19%), with an estimated treatment difference of degludec to glargine of 0.09% (95% CI -0.04 to 0.22). Overall rates of confirmed hypoglycemia (PG <3.1 mmol/L or severe episodes requiring assistance) were similar, with degludec and glargine at 1.52 versus 1.85 episodes/patient-year of exposure (PYE). There were few episodes of nocturnal confirmed hypoglycemia in the overall population, and these occurred at a lower rate with degludec versus glargine (0.25 vs. 0.39 episodes/PYE; P = 0.038). Similar percentages of patients in both groups achieved A1C levels <7% without hypoglycemia. End-of-trial mean daily insulin doses were 0.59 and 0.60 units/kg for degludec and glargine, respectively. Adverse event rates were similar.

CONCLUSIONS

Insulins degludec and glargine administered once daily in combination with OADs provided similar long-term glycemic control in insulin-naive patients with type 2 diabetes, with lower rates of nocturnal hypoglycemia with degludec.

Year in diabetes 2012: The diabetes tsunami

Diabetes affects more than 300 million individuals globally, contributing to significant morbidity and mortality worldwide. As the incidence and prevalence of diabetes continue to escalate with the force of an approaching tsunami, it is imperative that we better define the biological mechanisms causing both obesity and diabetes and identify optimal prevention and treatment strategies that will enable a healthier environment and calmer waters. New guidelines from the American Diabetes Association/European Association of the Study of Diabetes and The Endocrine Society encourage individualized care for each patient with diabetes, both in the outpatient and inpatient setting. Recent data suggest that restoration of normal glucose metabolism in people with prediabetes may delay progression to type 2 diabetes (T2DM). However, several large clinical trials have underscored the limitations of current treatment options once T2DM has developed, particularly in obese children with the disease. Prospects for reversing new-onset type 1 diabetes also appear limited, although recent clinical trials indicate that immunotherapy can delay the loss of β-cell function, suggesting potential benefits if treatment is initiated earlier. Research demonstrating a role for the central nervous system in the development of obesity and T2DM, the identification of a new hormone that simulates some of the benefits of exercise, and the development of new β-cell imaging techniques may provide novel therapeutic targets and biomarkers of early diabetes detection for optimization of interventions. Today's message is that a diabetes tsunami is imminent, and the only way to minimize the damage is to create an early warning system and improve interventions to protect those in its path.

Glycemic control: a combination of lifestyle management and the use of drugs

Some 30% of contemporary cardiology patients have coexisting known diabetes, and another 40% have either undiagnosed diabetes or prediabetes. There is still no final conclusive evidence of cardiovascular benefit by good glycemic control in type 2 diabetes, although studies like the United Kingdom Prospective Diabetes Study (UKPDS) and the Prospective Pioglitazone Clinical Trial in Macrovascular Events, and meta-analyses based on these and other randomized controlled trials of blood glucose-lowering therapies have been encouraging. On the other hand, microvascular disease is clearly reduced by good glycemic control. Structured education has remained a mandatory prerequisite of any successful treatment. Not only is appropriate weight management by diet and exercise able to revert new onset diabetes to normal, but it is also the foundation of any successful pharmacotherapy of diabetes. Aiming at normal fasting plasma glucose concentrations of 5.3 mmol/L or 95 mg/dL appears to be safe since publication of the long-term outcome results of the Outcome Reduction with an Initial Glargine INtervention trial. Individualized target glycosylated hemoglobin levels as near to normal as safely possible (i.e., <7% and avoiding hypoglycaemia) are the goal for glycemic control. Hypoglycemia seems to emerge as a real concern in cardiology patients. Based on the findings of UKPDS, including the “legacy” study, metformin is the most widely recommended first-line drug therapy in type 2 diabetes, also in terms of preventing cardiovascular complications. An alternate first-line option in some parts of the world, especially Asian countries, is the class of alpha-glucosidase inhibitors. In most patients, combination therapies with two or three classes of drugs are warranted. Early combination are the golden strategy as type 2 diabetes is a multi-causal disease; the various classes of drugs have distinct and synergistic modes of action, and the blood glucose-lowering efficacy of these drugs is more or less fully maintained in combination. The recent joint American Diabetes Association/European Association for the Study of Diabetes position statement mentions five options as step two of the treatment algorithm for combination with metformin: sulfonylureas, pioglitazone, dipeptidyl peptidase-4 inhibitors, glucagon-like peptide-1 agonists, and basal insulin.

Getting better at chronic care in remote communities: study protocol for a pragmatic cluster randomised controlled of community based management

Background

Prevalence and incidence of diabetes and other common comorbid conditions (hypertension, coronary heart disease, renal disease and chronic lung disease) are extremely high among Indigenous Australians. Recent measures to improve quality of preventive care in Indigenous community settings, while apparently successful at increasing screening and routine check-up rates, have shown only modest or little improvements in appropriate care such as the introduction of insulin and other scaled-up drug regimens in line with evidence-based guidelines, together with support for risk factor reduction. A new strategy is required to ensure high quality integrated family-centred care is available locally, with continuity and cultural safety, by community-based care coordinators with appropriate system supports.

Methods/design

The trial design is open parallel cluster randomised controlled trial. The objective of this pragmatic trial is to test the effectiveness of a model of health service delivery that facilitates integrated community-based, intensive chronic condition management, compared with usual care, in rural and remote Indigenous primary health care services in north Queensland. Participants are Indigenous adults (aged 18–65 years) with poorly controlled diabetes (HbA1c>=8.5) and at least one other chronic condition. The intervention is to employ an Indigenous Health Worker to case manage the care of a maximum caseload of 30 participants. The Indigenous Health Workers receive intensive clinical training initially, and throughout the study, to ensure they are competent to coordinate care for people with chronic conditions. The Indigenous Health Workers, supported by the local primary health care (PHC) team and an Indigenous Clinical Support Team, will manage care, including coordinating access to multidisciplinary team care based on best practice standards. Allocation by cluster to the intervention and control groups is by simple randomisation after participant enrolment. Participants in the control group will receive usual care, and will be wait-listed to receive a revised model of the intervention informed by the data analysis. The primary outcome is reduction in HbA1c measured at 18 months. Implementation fidelity will be monitored and a qualitative investigation (methods to be determined) will aim to identify elements of the model which may influence health outcomes for Indigenous people with chronic conditions.

Discussion

This pragmatic trial will test a culturally-sound family-centred model of care with supported case management by IHWs to improve outcomes for people with complex chronic care needs. This trial is now in the intervention phase.

Trial registration

Australian New Zealand Clinical Trials Registry ACTR12610000812099

The relationship between glycaemic control and heart failure in 83,021 patients with type 2 diabetes

AIMS/HYPOTHESIS

The aim of this study was to examine the relationship between glycaemic control and hospitalisation for heart failure in patients with type 2 diabetes.

METHODS

Patients included in the Swedish National Diabetes Register (NDR) during 1998-2003 were followed until hospitalisation for heart failure, death or 31 December 2009. Unadjusted and adjusted incidence rates for heart failure were estimated by Poisson regression and relative risk was estimated by Cox regression.

RESULTS

In 83,021 patients with type 2 diabetes, 10,969 (13.2%) were hospitalised with a primary or secondary diagnosis of heart failure during a mean follow-up of 7.2 years. The incidence increased by male sex (p < 0.001), older age (p < 0.001) and longer diabetes duration (p < 0.001). In Cox regression adjusting for risk factors of heart failure the HR per each percentage unit higher HbA(1c) (10 mmol/mol) for heart-failure hospitalisation was 1.12 (95% CI 1.10, 1.14). By category of HbA(1c) the HR for heart failure hospitalisation was: HbA(1c) 6.0 to <7.0% (42 to <53 mmol/mol), 0.91 (95% CI 0.84, 0.98); HbA(1c) 7.0 to <8.0% (53 to <64 mmol/mol), 0.99 (95% CI 0.91, 1.07); HbA(1c) 8.0 to <9.0% (64 to < 75 mmol/mol), 1.10 (95% CI 1.01, 1.20); HbA(1c) 9.0 to <10.0% (75 to <86 mmol/mol), 1.27 (95% CI 1.15, 1.41); HbA(1c) ≥ 10.0 % (≥ 86 mmol/mol), 1.71 (1.51, 1.93) (reference HbA(1c) <6% [42 mmol/mol]). The HR for patients with HbA(1c) 7.0 to <8.0% (53 to < 64 mmol/mol) compared with patients with HbA(1c) 6.0 to <7.0% (42 to <53 mmol/mol) was 1.09 (95% CI 1.03, 1.14).

CONCLUSIONS/INTERPRETATION

Poor glycaemic control (HbA(1c) >7% [53 mmol/mol]) is associated with an increased risk of hospitalisation for heart failure in patients with type 2 diabetes.

Outcomes and lessons from the PROactive study

Beyond improvement of glucose control, thiazolidinediones exert pleiotropic effects, which may contribute to some cardiovascular protection. PROactive ("PROspective pioglitAzone Clinical Trial In macroVascular Events") has provided valuable, although controversial, information on the impact of pioglitazone on cardiovascular outcomes in a high-risk population of patients with type 2 diabetes and established macrovascular disease. Since 2005, there has been much debate on the relative value of the statistically non-significant 10% reduction in the quite challenging primary composite endpoint (combining cardiovascular disease-driven and procedural events in all vascular beds) versus the statistically significant 16% decrease in the more robust and conventional main secondary endpoint (all-cause mortality, myocardial infarction, and stroke) observed with pioglitazone. Revisiting PROactive deserves much interest following the report of inconclusive results on cardiovascular efficacy and safety of rosiglitazone in RECORD, the withdrawal (limitation) of rosiglitazone because of cardiovascular safety concern, the recent publication of a statement positioning pioglitazone in type 2 diabetes and the near availability of cheaper generics of pioglitazone. Although subanalyses may have more limited value from a statistical viewpoint, they nonetheless can provide valuable information on the drug efficacy/safety profile and clinical insights into which patients might benefit most (in terms of cardiovascular outcomes) from pioglitazone therapy.

Addition of either pioglitazone or a sulfonylurea in type 2 diabetic patients inadequately controlled with metformin alone: impact on cardiovascular events. A randomized controlled trial

BACKGROUND AND AIMS

Metformin is the first-line therapy in type 2 diabetes. In patients inadequately controlled with metformin, the addition of a sulfonylurea or pioglitazone are equally plausible options to improve glycemic control. However, these drugs have profound differences in their mechanism of action, side effects, and impact on cardiovascular risk factors. A formal comparison of these two therapies in terms of cardiovascular morbidity and mortality is lacking. The TOSCA.IT study was designed to explore the effects of adding pioglitazone or a sulfonylurea on cardiovascular events in type 2 diabetic patients inadequately controlled with metformin.

METHODS

Multicentre, randomized, open label, parallel group trial of 48 month duration. Type 2 diabetic subjects, 50-75 years, BMI 20-45 Kg/m(2), on secondary failure to metformin monotherapy will be randomized to add-on a sulfonylurea or pioglitazone. The primary efficacy outcome is a composite endpoint of all-cause mortality, nonfatal myocardial infarction, nonfatal stroke, and unplanned coronary revascularization. Principal secondary outcome is a composite ischemic endpoint of sudden death, fatal and non-fatal myocardial infarction and stroke, endovascular or surgical intervention on the coronary, leg or carotid arteries, major amputations. Side effects, quality of life and economic costs will also be evaluated. Efficacy, safety, tolerability, and study conduct will be monitored by an independent Data Safety Monitoring Board. End points will be adjudicated by an independent external committee.

CONCLUSIONS

TOSCA.IT is the first on-going study investigating the head-to-head comparison of adding a sulfonylurea or pioglitazone to existing metformin treatment in terms of hard cardiovascular outcomes.

REGISTRATION

Clinicaltrials.gov ID NCT00700856.

Recent advances in incretin-based therapies

The global burden of type 2 diabetes is growing. Traditional therapies are suboptimal and there is a clear unmet need for treatments that offer effective glucose control while addressing the comorbid factors associated with diabetes, such as obesity and risk of cardiovascular disease, without the fear of hypoglycaemia. Glucagon-like peptide-1 receptor agonists and dipeptidyl peptidase-4 inhibitors offer a novel way of reducing hyperglycaemia by targeting the incretin system. This review provides an overview of the development of incretin-based therapies and explains their differing modes of action compared with traditional interventions. A comparison of the clinical profiles of current glucagon-like peptide-1 receptor agonists [liraglutide and exenatide (twice-daily and once-weekly)] and dipeptidyl peptidase-4 inhibitors (sitagliptin, saxagliptin, vildagliptin and linagliptin) is performed alongside a discussion of the placement of incretin-based therapies in treatment guidelines. Further improvements in this class are expected, and we will examine some of the novel glucagon-like peptide-1 receptor agonists and dipeptidyl peptidase-4 inhibitors currently under development.

Management of type 2 diabetes mellitus in older adults

In the near future, the majority of patients with diabetes will be adults aged 65 or older. Unlike young adults with diabetes, elderly diabetic people may be affected by a variety of comorbid conditions such as depression, cognitive impairment, muscle weakness (sarcopenia), falls and fractures, and physical frailty. These geriatric syndromes should be considered in the establishment of treatment goals in older adults with diabetes. Although there are several guidelines for the management of diabetes, only a few are specifically designed for the elderly with diabetes. In this review, we present specific conditions of elderly diabetes which should be taken into account in the management of diabetes in older adults. We also present advantages and disadvantages of various glucose-lowering agents that should be considered when choosing a proper regimen for older adults with diabetes.

Effects of saxagliptin added to sub-maximal doses of metformin compared with uptitration of metformin in type 2 diabetes: the PROMPT study

OBJECTIVE

The PROMPT study compared efficacy and tolerability of two treatment intensification strategies: adding saxagliptin or uptitrating metformin monotherapy, in patients with type 2 diabetes (T2D) and inadequate glycaemic control on a sub-maximal metformin dose.

RESEARCH DESIGN AND METHODS

In this double-blind, 24-week study, metformin-tolerant patients with T2D on metformin monotherapy were randomised to receive fixed-dose metformin 1500 mg/day, plus either add-on saxagliptin 5 mg/day (SAXA-MET) or a two-step metformin uptitration (MET-UP) to a maximum dose (2500 mg/day).

CLINICAL TRIAL REGISTRATION

NCT01006590.

MAIN OUTCOME MEASURES

Primary: absolute change from baseline in glycated haemoglobin A(1c) (HbA(1c)) (Week 24). Secondary: proportion of patients achieving a therapeutic glycaemic response (Week 24); change from baseline in fasting plasma glucose (Week 24); safety and tolerability. Exploratory analyses comprised three patient-related questionnaires, including the validated 5-dimension Digestive Health Status Index (DHSI).

RESULTS

A total of 286 patients were randomised: (SAXA-MET: 147; MET-UP: 139). Baseline mean (SD) HbA(1c): 7.71 (0.85; SAXA-MET); 7.80 (0.82; MET-UP). Adjusted mean reductions from baseline in HbA(1c) (Week 24): -0.47% (SAXA-MET); -0.38% (MET-UP); mean (95% CI) difference in treatment effect, -0.10% (-0.26, 0.07); p = 0.260. The proportion of patients (95% CI) achieving a therapeutic glycaemic response (HbA(1c) < 7%): 43.8% (34.8, 49.6) (SAXA-MET) vs. 35.0% (29.0, 43.8) (MET-UP). Of the five DHSI domains, mean (95% CI) differences were observed for diarrhoea-predominant score (+0.8 [-2.5, 4.0] vs. +7.9 [4.6, 11.2]) and dysmotility score (-0.5 [-2.0, 1.0] vs. +1.9 [0.3, 3.4]), (SAXA-MET and MET-UP, respectively). The most common adverse event was diarrhoea: 6.1% (SAXA-MET) vs. 12.2% (MET-UP).

CONCLUSIONS

In metformin-tolerant patients with T2D (inadequately controlled on sub-maximal metformin monotherapy), saxagliptin was well tolerated. Although HbA(1c) reduction was not significantly different between treatment groups, the lower occurrence of gastrointestinal symptoms in the SAXA-MET group suggests that saxagliptin add-on treatment may be a suitable alternative treatment strategy to metformin uptitration.

[Intensive insulin therapy in type 2 diabetes mellitus]

In the last couple of years, the intensive conservative insulin treatment (basal-bolus regime) became more and more popular even in patients with type 2 diabetes. Using this insulin treatment, continuous patient education, co-operation between the medical team (diabetologist, dietician and diabetes-nurses) and the patient as well as the availability of modern insulins, pens and glucometers are of great importance. Clearly, the basal-bolus treatment with human insulin has advantages over the conservative (conventional) treatment with twice daily premix insulins. Moreover, the basal-bolus treatment with insulin-analogues proved to be superior in some aspects as compared to human insulins. The intensive insulin treatment (basal-bolus regime with insulin-analogues) approaches the optimal insulin substitution and, with its use the adequate correction of each element of the glucose triad (fasting blood glucose, postprandial blood glucose, HbA1c) should be considered feasible even in patients with type 2 diabetes.

Antidiabetic treatment: Though lovers be lost, love shall not

The new position statement of the American Diabetes Association and the European Association for the Study of Diabetes on the management of type 2 diabetes mellitus represents a paradigm shift in our understanding of antidiabetic treatment. It emphasises the necessity to individualise management based on patient needs. Glycaemic targets should also be pursued on an individualised basis. New therapeutic combinations are discussed, and the uncertainty surrounding the ideal choice is acknowledged. Above all, it is the mindful and experienced clinician who will implement the best available evidence towards flexible and efficacious treatment. Some areas of uncertainty may ensue, but it is expected that the new position statement will improve patient healthcare and treatment satisfaction. This now remains to be seen in practice.

Current therapeutic agents and anesthetic considerations for diabetes mellitus

As the incidence of diabetes mellitus (DM) continues to increase worldwide, more diabetic patients will be presented for surgery and anesthesia. This increase of DM is a consequence of the rise in new patients of type 2 DM, and is likely attributable to rapid economic development, improved living standards, aging population, obesity, and lack of exercise. The primary goal of management in DM is to delay, or prevent the macro- and microvascular complications by achieving good glycemic control. More understanding of the pathophysiology of DM has contributed to the advance of new pharmacological approaches. In addition to the conventional therapy for DM, glucagon-like peptide-1 (GLP-1) mimetics, dipeptidyl peptidase-4 (DPP-4) inhibitors, thiazolidinediones (TZDs), and insulin analogues are currently available effective hypoglycemic agents for the management of the patients with DM in the perioperative period and also consider the adverse effects of newly introduced agents that need more clinical observations.

Renal function in a large cohort of metformin treated patients with type 2 diabetes mellitus

Objectives

To survey renal function in a defined population on metformin treatment.

Methods

All patients in the city of Malmö who collected at least three prescriptions of metformin during two years were identified from a central registry at the National Board of Health and Welfare in Sweden. Estimated glomerular filtration rate (eGFR), from the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) formula, of 5,408 patients were compared with a control population (n=2,815) from the same town. All cases of severe lactic acidosis leading to intensive care unit admission were also sought.

Results

In patients >79 years of age, 38% and 12% of patients had a best recorded eGFR registered below 60 and 45 ml/min/1.73 m2 respectively. In the age group 70–79 years the corresponding figures were 16% and 3% respectively. The eGFR was significantly higher in metformin treated patients than in control subjects in each age group. Three cases of lactic acidosis were recorded during the 2-year period studied. No patient with lactic acidosis was found in the highest age group.

Conclusions

In spite of reduced and fluctuating GFR in elderly patients, treatment with metformin is feasible. Adjusting the dose of metformin to renal function and adequately informing the patient could enable continuous treatment in moderately reduced GFR.

Low HbA1c and mortality: causation and confounding

This commentary provides an overview of the clinically important data linking low or lowered HbA(1c) to increased total and CVD mortality in the general population, and in patients with diabetes. This sets the scene for a contribution in this issue of Diabetologia by Andersson et al (DOI: 10.1007/s00125-012-2584-3 ) that suggests that BMI might modify the relationship between HbA(1c) and mortality in patients with type 2 diabetes. The commentary provides a framework for the interpretation of epidemiological data from observational studies and clinical trials, and it addresses the clinical implications of this work. Finally, it highlights new research that is likely to advance this field.

Glimepiride: evidence-based facts, trends, and observations (GIFTS). [corrected]

Type 2 diabetes mellitus is characterized by insulin resistance and progressive β cell failure; therefore, β cell secretagogues are useful for achieving sufficient glycemic control. Glimepiride is a second-generation sulfonylurea that stimulates pancreatic β cells to release insulin. Additionally, is has been shown to work via several extra pancreatic mechanisms. It is administered as monotherapy in patients with type 2 diabetes mellitus in whom glycemic control is not achieved by dietary and lifestyle modifications. It can also be combined with other antihyperglycemic agents, including metformin and insulin, in patients who are not adequately controlled by sulfonylureas alone. The effective dosage range is 1 to 8 mg/day; however, there is no significant difference between 4 and 8 mg/day, but it should be used with caution in the elderly and in patients with renal or hepatic disease. In clinical studies, glimepiride was generally associated with lower risk of hypoglycemia and less weight gain compared to other sulfonylureas. Glimepiride use may be safer in patients with cardiovascular disease because of its lack of detrimental effects on ischemic preconditioning. It is effective in reducing fasting plasma glucose, post-prandial glucose, and glycosylated hemoglobin levels and is a useful, cost-effective treatment option for managing type 2 diabetes mellitus.

Optimizing treatment strategies with insulin glargine in Type 2 diabetes

Advances in insulin therapy have made a positive contribution to improving disease management in both Type 1 and Type 2 diabetes. The development of insulin analogs with time-action characteristics has made it easier to mimic physiological insulin secretion. The parallel improvement in delivery devices has also made insulin therapy more convenient, flexible and acceptable. The inevitable progression of Type 2 diabetes means that the majority of those people will also require insulin therapy at some point in their disease course. Current treatment options are many; when to initiate insulin and which regimen to choose are among the major questions confronting physicians in today's rapidly evolving environment. This article summarizes the current strategies for initiating and optimizing the use of the basal insulin analog, insulin glargine, in Type 2 diabetes, leading to the intermediate stage of insulin therapy with the introduction of meal-related, rapid-acting insulin analogs in a stepwise manner prior to a full replacement basal-bolus regimen.

Effect of bile acid sequestrants on glycaemic control: protocol for a systematic review with meta-analysis of randomised controlled trials

INTRODUCTION

In addition to the lipid-lowering effect of bile acid sequestrants (BASs), they also lower blood glucose and, therefore, could be beneficial in the treatment of patients with type 2 diabetes mellitus (T2DM). Three oral BASs are approved by the US Food and Drug Administration (FDA) for the treatment of hypercholesterolaemia: colestipol, cholestyramine and colesevelam. The BAS colestimide/colestilan is used in Japan. Colesevelam was recently approved by the FDA for the treatment of T2DM. We plan to provide a systematic review with meta-analysis of the glucose-lowering effect of BASs with the aim to evaluate their potential as glucose-lowering agents in patients with T2DM.

METHODS AND ANALYSIS

In accordance with the preferred reporting items for systematic reviews and meta-analyses statement, a systematic review with meta-analysis of randomised clinical trials of BASs (vs placebo, oral antidiabetes drugs or insulin), reporting measures of glycaemic control in adult patients with T2DM, will be performed. Change in glycated haemoglobin constitutes the primary endpoint, and secondary endpoints include changes in fasting plasma glucose, low-density lipoprotein cholesterol, high-density lipoprotein cholesterol, total cholesterol, triglycerides, body weight and body mass index and adverse events. Electronic searches will be performed in The Cochrane Library, MEDLINE and EMBASE, along with manual searches in the reference lists of relevant papers. The analyses will be performed based on individual patient data and summarised data. The primary meta-analysis will be performed using random effects models owing to expected intertrial heterogeneity. Dichotomous data will be analysed using risk difference and continuous data using weighted mean differences, both with 95% CIs.

ETHICS AND DISSEMINATION

The study will evaluate the potential of BASs as glucose-lowering agents and possibly contribute to the clinical management of patients with T2DM.

RESULTS

The study will be disseminated by peer-review publication and conference presentation.

PROTOCOL REGISTRATION

PROSPERO CRD42012002552.