151
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Garyu JW, Meffre E, Cotsapas C, Herold KC. Progress and challenges for treating Type 1 diabetes. J Autoimmun 2016; 71:1-9. [PMID: 27210268 PMCID: PMC4903889 DOI: 10.1016/j.jaut.2016.04.004] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2016] [Accepted: 04/24/2016] [Indexed: 02/09/2023]
Abstract
It has been more than 30 years since the initial trials of Cyclosporin A to treat patients with new onset Type 1 diabetes (T1D). Since that time, there have been insights into genetic predisposition to the disease, the failures of immune tolerance, and mechanisms that cause the immune mediated β cell destruction. The genetic loci associated affect lymphocyte development and tolerance mechanisms. Discoveries related to the roles of specific immune responses gene such as the major histocompatibility complex, PTPN22, CTLA-4, IL-2RA, as well as the mechanisms of antigen presentation in the thymus have suggested ways in which autoreactivity may follow changes in the functions of these genes that are associated with risk. Antigens that are recognized by the immune system in patients with T1D have been identified. With this information, insights into the novel cellular mechanisms leading to the initiation and orchestration of β cell killing have been developed such as the presentation of unique antigens within the islets. Clinical trials have been performed, some of which have shown efficacy in improving β cell function but none have been able to permanently prevent loss of insulin secretion. The reasons for the lack of long term success are not clear but may include the heterogeneity of the immune response and in individual responses to immune therapies, recurrence of autoimmunity after the initial effects of the therapies, or even intrinsic mechanisms of β cell death that proceeds independently of immune attack after initiation of the disease. In this review, we cover developments that have led to new therapeutics and characteristics of patients who may show the most benefits from therapies. We also identify areas of incomplete understanding that might be addressed to develop more effective therapeutic strategies.
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Affiliation(s)
- Justin W Garyu
- Department of Immunobiology, Yale University, New Haven, CT, USA
| | - Eric Meffre
- Department of Immunobiology, Yale University, New Haven, CT, USA
| | - Chris Cotsapas
- Department of Neurology, Yale University, New Haven, CT, USA
| | - Kevan C Herold
- Department of Immunobiology, Yale University, New Haven, CT, USA; Department of Internal Medicine, Yale University, New Haven, CT, USA
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152
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Hwang YC. Hypoglycemia: Culprit or Bystander? Diabetes Metab J 2016; 40:190-1. [PMID: 27352252 PMCID: PMC4929222 DOI: 10.4093/dmj.2016.40.3.190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Affiliation(s)
- You Cheol Hwang
- Division of Endocrinology and Metabolism, Department of Medicine, Kyung Hee University Hospital at Gangdong, Kyung Hee University School of Medicine, Seoul, Korea.
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153
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DeJoseph M, Hoppa E. Death Investigation of Diabetes Mellitus: Scene Investigation and Interrogation of Technology. Acad Forensic Pathol 2016; 6:164-173. [PMID: 31239888 DOI: 10.23907/2016.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 03/31/2016] [Accepted: 04/21/2016] [Indexed: 11/12/2022]
Abstract
Diabetes mellitus (DM) affects millions of Americans and is a common cause of death. The medical examiner/coroner (ME/C) may be called to investigate the death of a person with DM due to the possibility of a suicide, accident, or even homicide that relates to the treatment or lack of treatment of the disease. The ME/C can ellicit abundant circumstantial information from a death scene investigation and interrogation of devices such as glucometers, insulin pumps, continuous glucose monitors, and insulin injector pens used for the management of diabetes. These devices contain stored information that can very powerfully assist the ME/C in determining the cause and manner of death. This article provides a review of DM treatment and common medical devices used in the treatment and management of DM, offers the ME/C some instruction for interrogating the devices on their own, and highlights the benefits of beholding the information contained within the devices. At the conclusion of this review, the reader should have an understanding of how these devices work, how the information they contain can be accessed, and how useful that information can be in death investigation.
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Affiliation(s)
| | - Eric Hoppa
- Connecticut Children's Medical Center - Division of Emergency Medicine
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154
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Schuetz C, Markmann JF. Islet cell transplant: Update on current clinical trials. CURRENT TRANSPLANTATION REPORTS 2016; 3:254-263. [PMID: 28451515 DOI: 10.1007/s40472-016-0103-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
In the last 15 years clinical islet transplantation has made the leap from experimental procedure to standard of care for a highly selective group of patients. Due to a risk-benefit calculation involving the required systemic immunosuppression the procedure is only considered in patients with type 1 diabetes, complicated by severe hypoglycemia or end stage renal disease. In this review we summarize current outcomes of the procedure and take a look at ongoing and future improvements and refinements of beta cell therapy.
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Affiliation(s)
- Christian Schuetz
- Islet transplantation laboratory, Division of Transplantation, Department of Surgery
| | - James F Markmann
- Islet transplantation laboratory, Division of Transplantation, Department of Surgery
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155
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Rodriguez-Gutierrez R, Lipska KJ, McCoy RG, Ospina NS, Ting HH, Montori VM. Hypoglycemia as an indicator of good diabetes care. BMJ 2016; 352:i1084. [PMID: 26951142 PMCID: PMC6886856 DOI: 10.1136/bmj.i1084] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Rene Rodriguez-Gutierrez and colleagues argue that more attention should be paid to hypoglycemia when assessing management of diabetes
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Affiliation(s)
- Rene Rodriguez-Gutierrez
- Knowledge and Evaluation Research Unit, Division of Endocrinology, Diabetes, Metabolism and Nutrition, Department of Medicine, Mayo Clinic, Rochester, MN 55905, USA Division of Endocrinology, University Hospital Dr Jose E Gonzalez, Autonomous University of Nuevo Leon, Monterrey, Mexico
| | - Kasia J Lipska
- Section of Endocrinology, Yale School of Medicine, New Haven, CT, USA
| | - Rozalina G McCoy
- Division of Primary Care Internal Medicine, Mayo Clinic, Rochester, MN, USA Division of Health Care Policy and Research, Mayo Clinic, Rochester, MN, USA
| | - Naykky Singh Ospina
- Knowledge and Evaluation Research Unit, Division of Endocrinology, Diabetes, Metabolism and Nutrition, Department of Medicine, Mayo Clinic, Rochester, MN 55905, USA
| | | | - Victor M Montori
- Knowledge and Evaluation Research Unit, Division of Endocrinology, Diabetes, Metabolism and Nutrition, Department of Medicine, Mayo Clinic, Rochester, MN 55905, USA
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156
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Cahn A, Cernea S, Raz I. Outcome studies and safety as guide for decision making in treating patients with type 2 diabetes. Rev Endocr Metab Disord 2016; 17:117-27. [PMID: 27106831 DOI: 10.1007/s11154-016-9351-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Cardiovascular disease is the leading cause of mortality in patients with diabetes. Over the past 20 years multiple CV outcome studies have been conducted assessing the cardiovascular benefits of tight glycemic control or of particular glucose lowering agents. Improved glycemic control per-se failed to significantly reduce the risk of adverse cardiovascular outcomes in the short term, and it is only after >15 years that a reduction in adverse CV outcomes with tight glycemic control was perceived. Moreover tight glycemic control and increased attendant hypoglycemia led to increased mortality observed in the ACCORD trial. These data highlighted the importance of setting individualized glycemic targets and assessing the CV safety of the individual glucose lowering agents. Three DPP-4 inhibitors have presented CV outcome data to date demonstrating overall CV safety yet the question of increased hospitalization for heart failure with saxagliptin remains unexplained. Lixisenatide was the first GLP-1 receptor agonist to publish CV outcome data which demonstrated overall safety. The SGLT-2 inhibitor empagliflozin demonstrated CV superiority and a reduction in all-cause mortality and hospitalization for heart failure vs. placebo via mechanisms which remain to be fully elucidated. The outcome studies, though large and costly, have had a considerable effect on diabetes guidelines, these now emphasizing the importance of individualization of care. The outcome studies will presumably influence the new guidelines and dictate better tailoring of the drug regimen to the individual patient, matching patient comorbidities to the accumulating data regarding the safety and efficacy of each drug and class.
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Affiliation(s)
- Avivit Cahn
- Diabetes Unit, Department of Internal Medicine, Hadassah Hebrew University Hospital, PO Box 12000, 91120, Jerusalem, Israel
- Endocrinology and Metabolism Unit, Department of Internal Medicine, Hadassah Hebrew University Hospital, Jerusalem, Israel
| | - Simona Cernea
- Department M3/Internal Medicine IV, University of Medicine and Pharmacy, Târgu Mureş, Romania
- Diabetes, Nutrition and Metabolic Diseases Outpatient Unit, Emergency County Clinical Hospital, Târgu Mureş, Romania
| | - Itamar Raz
- Diabetes Unit, Department of Internal Medicine, Hadassah Hebrew University Hospital, PO Box 12000, 91120, Jerusalem, Israel.
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157
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Monnier L, Colette C, Dejager S, Owens DR. Near normal HbA1c with stable glucose homeostasis: the ultimate target/aim of diabetes therapy. Rev Endocr Metab Disord 2016; 17:91-101. [PMID: 26803295 DOI: 10.1007/s11154-016-9325-8] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Achieving near normal glucose homeostasis implies that all components of dysglycemia that are present in diabetes states be eliminated. Reducing ambient/overall hyperglycemia is a pre-requisite to eliminate the risk of development and progression of diabetes complications. More controversially however, are the relative and related contributions of postprandial glucose excursions, glucose variability, hypoglycemia and the dawn phenomenon across the spectrum of dysglycemia. For instance, it is likely that the dawn phenomenon contributes to ambient hyperglycemia and that postprandial glucose excursions are at the cross road of ambient hyperglycemia and glucose variability with glucose fluctuations as causative risk factors for hypoglycemia. Proof-of-concept trials such as the ongoing FLAT-SUGAR study are necessary for gaining further insight into the possible harmful effects of some of these features such as excessive glycemic variability and glucose excursions, still considered to be of minor relevance by several diabetologists. Whether their role will be more thoroughly proven through further intervention trials with "hard" endpoints, remains to be seen. In the meantime more consideration should be given to medications aimed at concomitantly reducing ambient/overall hyperglycemia and those additional abnormal glycemic features of dysglycemia.
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Affiliation(s)
- L Monnier
- Institute of Clinical Research, University of Montpellier, 641 Avenue Doyen Giraud, 34093 Cedex 5, Montpellier, France.
| | - C Colette
- Institute of Clinical Research, University of Montpellier, 641 Avenue Doyen Giraud, 34093 Cedex 5, Montpellier, France
| | - S Dejager
- Department of Endocrinology, Hospital Pitié Salpétrière, Paris, France
| | - D R Owens
- Diabetes Research Group, Swansea University, Swansea, UK
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158
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Kedia R, Kulkarni S, Ross M, Shivaswamy V. Spotlight on empagliflozin/metformin fixed-dose combination for the treatment of type 2 diabetes: a systematic review. Patient Prefer Adherence 2016; 10:1999-2006. [PMID: 27757020 PMCID: PMC5053375 DOI: 10.2147/ppa.s85748] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
The dramatic rise in the prevalence of obesity and diabetes is associated with increased morbidity, mortality, and public health care costs worldwide. The need for new, effective, and long-lasting drugs is urgent. Recent research has focused on the role of the inhibitors of sodium- glucose co-transporter 2 (SGLT-2). Clinical trials have shown that SGLT-2 inhibitors have glycemic efficacy and weight-lowering potential. Dual drug therapy is a recommended therapy for patients with new-onset type 2 diabetes who need significant glycemic control. Fixed-dose combination therapy represents a particularly attractive option as it may reduce pill burden and improve adherence. The combination of metformin and empagliflozin was approved by the US Food and Drug Administration in 2014 and represents a safe and effective means to combat glycemic control and weight gain. The purpose of this systematic review is to summarize the background of the SGLT-2 inhibitors, particularly empagliflozin, and focus on the safety and efficacy of the fixed-dose combination of empagliflozin and metformin.
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Affiliation(s)
- Rohit Kedia
- Division of Diabetes, Endocrinology, and Metabolism, Department of Internal Medicine, University of Nebraska Medical Center
| | - Supriya Kulkarni
- Division of Diabetes, Endocrinology, and Metabolism, Department of Internal Medicine, University of Nebraska Medical Center
| | - Meredith Ross
- Division of Diabetes, Endocrinology, and Metabolism, Department of Internal Medicine, University of Nebraska Medical Center
| | - Vijay Shivaswamy
- Division of Diabetes, Endocrinology, and Metabolism, Department of Internal Medicine, University of Nebraska Medical Center
- VA Nebraska-Western Iowa Health Care System, Omaha, NE, USA
- Correspondence: Vijay Shivaswamy, Division of Diabetes, Endocrinology, and Metabolism, Department of Internal Medicine, University of Nebraska Medical Center, 984130 Nebraska Medical Center, Omaha, NE 68198-4130, USA, Tel +1 402 559 6208, Fax +1 402 559 9504, Email
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