Vascular complications in long-term south Indian NIDDM of over 25 years' duration

Single nucleotide variations in the development of diabetic foot ulcer: A narrative review

Diabetes mellitus has become a global health problem, and the number of patients with diabetic foot ulcers (DFU) is rapidly increasing. Currently, DFU still poses great challenges to physicians, as the treatment is complex, with high risks of infection, recurrence, limb amputation, and even death. Therefore, a comprehensive understanding of DFU pathogenesis is of great importance. In this review, we summarized recent findings regarding the DFU development from the perspective of single-nucleotide variations (SNVs). Studies have shown that SNVs located in the genes encoding C-reactive protein, interleukin-6, tumor necrosis factor-alpha, stromal cell-derived factor-1, vascular endothelial growth factor, nuclear factor erythroid-2-related factor 2, sirtuin 1, intercellular adhesion molecule 1, monocyte chemoattractant protein-1, endothelial nitric oxide synthase, heat shock protein 70, hypoxia inducible factor 1 alpha, lysyl oxidase, intelectin 1, mitogen-activated protein kinase 14, toll-like receptors, osteoprotegerin, vitamin D receptor, and fibrinogen may be associated with the development of DFU. However, considering the limitations of the present investigations, future multi-center studies with larger sample sizes, as well as in-depth mechanistic research are warranted.

Prevalence of diabetic retinopathy in self-reported diabetics among various ethnic groups and associated risk factors in North-East India: A hospital-based study

Purpose:

To describe the prevalence and severity of diabetic retinopathy (DR) among different ethnic groups of North-East India and to study the associated risk factors.

Methods:

In this hospital based cross sectional study 7,133 individuals among the age group of 20-79 years, attending the OPD, were screened for presence of Diabetes Mellitus (DM) (HbA1c >7% or previously diagnosed). Among them, 780 (10.94%) had diabetes; they were evaluated for presence of any retinopathy (based on fundus photograph and fluorescein angiography), its grade (based on International DR severity scale), and risk factors. DR patients were further grouped into different ethnicities (Assamese, Bengali, minor tribes, and other immigrants).

Results:

Of the 780 patients with diabetes, 58 patients had type 1 DM and 722 patients had type 2 DM. The overall prevalence of DR was 30.0% with vision-threatening retinopathy and maculopathy being 10.00% and 4.49%, respectively. The prevalence of retinopathy range was the highest in the immigrants’ group (50.00% among type 1 DM and 44.93% among type 2 DM) and lowest in the tribal's groups (16.67% among type 1 DM and 22.35% among type 2 DM). The risk factors showing significant association with DR were longer diabetes duration, older age, family history of diabetes, higher HbA1c level, associated hypertension, hypertriglyceridemia, and pregnancy state (P value <0.05).

Conclusion:

Every third patient with diabetes had some form of DR with Vision Threatening DR (VTDR) affecting every tenth patient. There was also a wide variation in the prevalence of DR among ethnic groups and this difference could not be attributed to variation in the known measurable risk factors among different ethnic groups, thus signifying the role of ethnicity in occurrence and severity of DR.

Expert Group Recommendations on the Effective Use of Bolus Insulin in the Management of Type 2 Diabetes Mellitus

Evidence suggests a major contribution of postprandial glucose (PPG) excursions to the increased risk of micro- and macro-vascular complications in individuals with type 2 diabetes mellitus (T2DM). Administration of bolus insulin remains a very effective therapeutic option for PPG control. The aim of this expert group recommendation document was to provide practical and easy-to-execute guidelines for physicians on the appropriate use of bolus insulin in the management of T2DM. A panel of key opinion leaders from India reviewed and discussed the available clinical evidence and guideline recommendations on the following topics: (1) optimum control of PPG; (2) choice of bolus insulin; and (3) special situations and practical considerations. The expert panel critically analyzed the current literature and clinical practice guidelines and factored their rich clinical experience to develop a set of nine expert group recommendations for the effective use of bolus insulin. These recommendations will not only result in a more evidence-based application of bolus insulin in the clinical setting but also trigger further research and provide a valuable base for the development of future guidelines on the use of bolus insulin in the management of individuals with T2DM.

Impact of age at type 2 diabetes mellitus diagnosis on mortality and vascular complications: systematic review and meta-analyses

AIMS/HYPOTHESIS

Few studies examine the association between age at diagnosis and subsequent complications from type 2 diabetes. This paper aims to summarise the risk of mortality, macrovascular complications and microvascular complications associated with age at diagnosis of type 2 diabetes.

METHODS

Data were sourced from MEDLINE and All EBM (Evidence Based Medicine) databases from inception to July 2018. Observational studies, investigating the effect of age at diabetes diagnosis on macrovascular and microvascular diabetes complications in adults with type 2 diabetes were selected according to pre-specified criteria. Two investigators independently extracted data and evaluated all studies. If data were not reported in a comparable format, data were obtained from authors, presented as minimally adjusted ORs (and 95% CIs) per 1 year increase in age at diabetes diagnosis, adjusted for current age for each outcome of interest. The study protocol was recorded with PROSPERO International Prospective Register of Systematic Reviews (CRD42016043593).

RESULTS

Data from 26 observational studies comprising 1,325,493 individuals from 30 countries were included. Random-effects meta-analyses with inverse variance weighting were used to obtain the pooled ORs. Age at diabetes diagnosis was inversely associated with risk of all-cause mortality and macrovascular and microvascular disease (all p < 0.001). Each 1 year increase in age at diabetes diagnosis was associated with a 4%, 3% and 5% decreased risk of all-cause mortality, macrovascular disease and microvascular disease, respectively, adjusted for current age. The effects were consistent for the individual components of the composite outcomes (all p < 0.001).

CONCLUSIONS/INTERPRETATION

Younger, rather than older, age at diabetes diagnosis was associated with higher risk of mortality and vascular disease. Early and sustained interventions to delay type 2 diabetes onset and improve blood glucose levels and cardiovascular risk profiles of those already diagnosed are essential to reduce morbidity and mortality. Graphical abstract.

Variability in the clinical diagnosis of diabetic peripheral neuropathy

AIMS

The aims of this study are to assess the variability in the prevalence of diabetic peripheral neuropathy (DPN), according to the diagnostic and clinical guidelines used.

METHODS

A cross-sectional observational study was conducted of 111 patients with diabetes mellitus. The presence/absence of DPN was determined according to 12 different criteria stipulated in various clinical guidelines (ADA 2018, IWGDF 2016, IDF 2012 and CONUEI 2018). The Cohen's kappa coefficient (κ) was performed to determine the degree of agreement for DPN diagnosis among the different criteria.

RESULTS

The recorded prevalence of DPN ranged from 13.1% (criterion ADA 2018) to 68.5% (criterion IDF 2012). The sensory parameter that was most commonly affected was the non-perception of vibration (68.5%) and the absence of Achilles reflexes (59.4%). IWGDF, based on the use of a monofilament, cotton wisp and tuning fork, was the test with more agreements, presenting good agreement with 2 criteria from ADA 2018 (k=0.845), 1b2 (k=0.817), 2 criteria from IWGDF 2016 (k=0.933), (k=0.817), 1 criteria from IDF 2012 (k=0.845) and 1 criteria from CONUEI 2018 (k=0.860), all p<0.001.

CONCLUSION

The IWGDF criterion based on the use of a monofilament, cotton wisp and tuning fork for the diagnosis presented the highest level of concordance with the other criteria (>0.8).

My 40-year journey in diabetes research: The power of collaboration

This article describes a 40 year journey in diabetes research of an Indian diabetologist, starting as an undergraduate medical student. The article describes how collaborations with multiple stake-holders is necessary if one is to advance one's research from the simple studies that one starts with and take it to higher and higher levels. It is also essential that the seeds for doing research are planted early in a medico's life even during undergraduate days, as only then will more doctors take up medical research as a career. Finally, the article demonstrates how it is possible to do good quality research in India if one has the passion and sustained interest in the field even if one is not in a university or academic setup.

Age, age at diagnosis and diabetes duration are all associated with vascular complications in type 2 diabetes

BACKGROUND

Type 2 diabetes (T2DM) is increasingly diagnosed in younger patients. The trajectory of complications in patients diagnosed at a younger or older age is not well understood. We examine the associations between age, age at diagnosis and diabetes duration and vascular complications in patients with T2DM.

METHODS

A cross-sectional study of pre-specified demographic and clinical data, from 3419 adults with T2DM participating in the Australian National Diabetes Audit (2015). Factors associated with diabetes complications were analysed using logistic regression.

RESULTS

Mean (±SD) current age was 62.9±12.5years, age at diagnosis was 49.4±12.3years and mean diabetes duration was 13.5±9.4years. Macrovascular complications were more prevalent in patients who were older at diabetes diagnosis whereas microvascular complications were more prevalent in patients who were younger at diabetes diagnosis. Age, age at diagnosis and diabetes duration were all independently associated with increased risk of macrovascular complications after adjustment for sex, smoking, BMI and microvascular complications (all p<0.001). In contrast, only diabetes duration was independently associated with microvascular complications after adjustment for sex, smoking, BMI and macrovascular complications (p<0.001).

CONCLUSIONS

Age, age at diagnosis, and diabetes duration were all independently associated with macrovascular complications whereas only diabetes duration was independently associated with microvascular complications.

Epidemiology of microvascular complications of diabetes in South Asians and comparison with other ethnicities

Type 2 diabetes mellitus is widely prevalent in South Asians, and has a significant effect on health, as well as the economies of South Asian countries, particularly when the disease is associated with complications. There are certain characteristics associated with the South Asian phenotype that make South Asians especially prone to diabetes, as well as its complications. Microvascular complications cause considerable morbidity and mortality. There are significant differences in the epidemiology of microvascular complications between South Asians and people of other races. There is evidence of higher prevalence of nephropathy and retinopathy in South Asians compared with Caucasians; however, recent studies indicate that this trend seems to be leveling off. Importantly, diabetic neuropathy occurs less frequently in South Asians compared with Caucasians. These observations have important implications in managing South Asian patients with diabetes and microvascular complications.

The role of triglyceride in cardiovascular disease in asian patients with type 2 diabetes--a systematic review

In Asian populations, diabetes mellitus is increasing and has become an important health problem in recent decades. Cardiovascular disease (CVD) is one of the most important complications and the most common cause of death in diabetic patients. Among the risk factors of CVD, elevated low-density lipoprotein cholesterol has been a major concern. Studies suggested that serum triglyceride may also play a role in predicting CVD in patients with type 2 diabetes mellitus, but the association is still debated. In this review, we summarized published studies focusing on the relationship between serum triglyceride and CVD disease in Asian diabetic patients. Ten studies conducted in six different Asian countries (three from Hong Kong, two from Taiwan, tow from Japan, one from Indonesia, one from South India, and one from South Korea) were summarized and discussed. CVD was subdivided into coronary heart disease, stroke, and peripheral arterial disease. Of the ten studies analyzed, one focused on CVD, five on coronary heart disease, three on stroke, three on peripheral arterial disease, and one on mortality from CVD. Studies from Hong Kong, Taiwan, and Japan suggested that triglyceride is a significant and independent risk factor for coronary heart disease, but not a significant risk factor for stroke (studies conducted in Japan and South Korea) or peripheral arterial disease (studies conducted in Taiwan, Indonesia, and South India). Although serum triglyceride may be a significant risk factor for coronary heart disease in Asian diabetic patients, clinical trials evaluating whether lowering triglycerides using fibrates can reduce the risk of coronary heart disease in these patients need to be initiated.

Heat-shock protein 70 gene polymorphism is associated with the severity of diabetic foot ulcer and the outcome of surgical treatment

Background

Foot ulcer is a significant cause of morbidity in diabetics. Genetic make-up can determine inflammatory and healing responses. This study examined the hypothesis that specific polymorphisms of the heat-shock protein 70 gene could predispose to the severity of diabetic foot ulceration.

Methods

Some 106 consecutive diabetic patients (101 evaluable) with foot ulceration admitted to a tertiary care hospital were managed according to a standard protocol. DNA was extracted from venous blood and examined by polymerase chain reaction–restriction fragment length analysis for two specific polymorphisms: G1538A in the HSPA1B and C2437T in the HSPA1L gene.

Results

HSPA1B genotyping showed that 70 patients were AG and 30 GG (one not amplified). The AG genotype was significantly associated with the severity of foot ulceration (Wagner grade) (P = 0·008, χ2 test), need for amputation (relative risk 2·02, 95 per cent confidence interval 1·02 to 4·01; P = 0·025) and median length of hospital stay (8 versus 5 days for GG; P = 0·043). HSPA1L genotypes (78 TT, 22 CT, one CC) did not show any significant association with these parameters.

Conclusion

The HSPA1B genotype, was associated with the severity of diabetic foot ulceration, need for amputation and duration of hospitalization in these patients.

Current scenario of diabetes in India

India, a country experiencing rapid socioeconomic progress and urbanization, carries a considerable share of the global diabetes burden. Studies in different parts of India have demonstrated an escalating prevalence of diabetes not only in urban populations, but also in rural populations as a result of the urbanization of lifestyle parameters. The prevalence of prediabetes is also high. Recent studies have shown a rapid conversion of impaired glucose tolerance to diabetes in the southern states of India, where the prevalence of diabetes among adults has reached approximately 20% in urban populations and approximately 10% in rural populations. Because of the considerable disparity in the availability and affordability of diabetes care, as well as low awareness of the disease, the glycemic outcome in treated patients is far from ideal. Lower age at onset and a lack of good glycemic control are likely to increase the occurrence of vascular complications. The economic burden of treating diabetes and its complications is considerable. It is appropriate that the Indian Government has initiated a national program for the management and prevention of diabetes and related metabolic disorders. Lifestyle modification is an effective tool for the primary prevention of diabetes in Asian Indians. The primary prevention of diabetes is urgently needed in India to curb the rising burden of diabetes.

Postprandial Myocardial Perfusion in Healthy Subjects and in Type 2 Diabetic Patients

Background— In diabetic patients, postprandial hyperglycemia is a more powerful risk factor for cardiovascular disease than fasting hyperglycemia itself. A negative influence of acute hyperglycemia on systemic endothelial function (brachial artery) has been shown. However, myocardial perfusion during postprandial hyperglycemia has not been investigated.

Methods and Results— We evaluated the effects of a standardized mixed meal on myocardial perfusion in 20 healthy subjects and 20 consecutive patients with type 2 diabetes mellitus without macrovascular or microvascular complications. Myocardial perfusion was assessed in fasting and postprandial states by myocardial contrast echocardiography. Fasting myocardial flow velocity (β, 0.65±0.27 versus 0.67±0.24; P =NS), myocardial blood volume (MBV; 8.3±1.2 versus 8.4±2; P =NS), and myocardial blood flow (5.4±1.5 versus 5.6±2; P =NS) did not differ between control subjects and diabetic patients. In the postprandial state, β (0.67±0.24 versus 0.92±0.35; P <0.01), MBV (8.4±2 versus 10.9±2.7; P <0.01), and myocardial blood flow (5.6±2 versus 9.9±2.8; P <0.01) increased significantly in control subjects. In diabetic patients, β increased (0.65±0.27 versus 0.8±0.24; P <0.01) but MBV (8.3±1.2 versus 4.3±1.3; P <0.01) and myocardial blood flow (5.4±1.5 versus 3.4±0.9; P <0.01) decreased significantly. Changes in MBV (expressed as [(MBV postprandial −MBV fasting )/MBV fasting ]×100) were significantly correlated with postprandial glycemia levels in diabetic patients.

Conclusions— Postprandial hyperglycemia determines myocardial perfusion defects in type 2 diabetic patients. They are secondary to deterioration in microvascular function causing a decrease in MBV. In diabetic patients without microvascular or macrovascular complications, postprandial myocardial perfusion defects may represent an early marker of the atherogenic process in the coronary circulation; hence, its reversal constitutes a potential goal of treatment.

Epidemiology of diabetic retinopathy and macular oedema: a systematic review

AIMS

To systematically review the literature on the prevalence and incidence of diabetic retinopathy (DR) and macular oedema (MO).

METHODS

A search of the bibliographic databases (Medline, Embase, CINAHL) was conducted up to October 2001. Selected relevant studies were scrutinized and included in the review.

RESULTS

A total of 359 studies were included. The studies were reported in nearly 100 different journals and in over 50 countries. The majority of the studies were US-based, with large studies such as the Wisconsin Epidemiologic Study of Diabetic Retinopathy dominating the literature. The studies were quite dated and highly heterogeneous in nature in terms of patient selection with variable inclusion criteria (age range, gender, diabetes duration and type, ethnicity, comorbidity, and DR status, assessment, and classification).

CONCLUSIONS

There are inconsistencies between epidemiological studies, and differences in study methods may contribute to conflicting reports of prevalence and incidence of DR and MO in diabetic populations. As new therapies for DR and its associated complications emerge, the need to capture and monitor new epidemiological data becomes increasingly important to be able to assess the impact and effectiveness of these therapies. Robust, longitudinal capture of patient data is, therefore, essential to evaluate the impact of current practice on the epidemiology of diabetic eye complications.

Prevalence of peripheral neuropathy in type 2 diabetic patients attending a diabetes center in Turkey

The aim of this study was to determine the prevalence and risk factors for neuropathy in type 2 diabetic patients attending a major Turkish diabetes center. Eight hundred and sixty-six consecutive type 2 diabetic patients were included in the study. A single observer performed biothesiometry studies on these patients. The presence of diabetic neuropathy was investigated using neurological symptom scale (NSS) and neurological disability score (NDS) performed. Neuropathy was determined with standardized neurological examinations and defined as the presence of abnormal NSS and NDS together with abnormal sensory or motor signs and symptoms as well as decreased great toe vibration perception. Overall, 60% (n = 520) of the patients were diagnosed as having neuropathy. The prevalence of neuropathy increased with age (p < 0.001) and duration of diabetes (p < 0.001). Multiple logistic regression analysis revealed the duration of diabetes (p < 0.001) and HbA1c levels (p < 0.001) as the risk factors for neuropathy. The overall prevalence of neuropathy in Turkish type 2 diabetic population was 60%. Age, duration of diabetes, and poor glycemic control were considered to be the risk factors for neuropathy.

Postprandial hyperglycaemia in type 2 diabetes: pathophysiological aspects, teleological notions and flags for clinical practice

Type 2 diabetes subjects carry an excess risk for micro- and macrovascular disease and a higher cardiovascular morbidity and mortality rate. The beneficial impact of tight glycaemic control-evidenced by the integrated marker of fasting glucose and postprandial glucose values, the HbA1c-for the prevention of microvascular complications is definitely confirmed. Over the past few years, several studies have identified postprandial hyperglycaemia as a better predictor of cardiovascular or even of all-cause mortality, as well as an independent risk factor for atherosclerosis. The continuous glucose monitoring could offer a rationale means for the detection of postprandial hyperglycaemia and ultimately for its effective management. Advances in technology keep a promise for a reliable, convenient and closer to the idea of the artificial endocrine pancreas glucose sensor. Subcutaneous glucose levels charted by one of the new sensors were found to be well correlated with venous glucose measurements. Intervention for a healthy lifestyle is frequently hampered by patients' poor compliance. The availability of diverse antidiabetic agents provides options for targeting the glycaemic goal and a choice more fitted to the particularized pathophysiology of each individual subject. Drugs targeting postprandial glycaemia may prove to represent the 'sine qua non' for the 'return' of postprandial glucose values at a 'non-deleterious' threshold, either as monotherapy for the early stages of the disease or as combination therapy later in the progression of diabetes.

Oral modified insulin (HIM2) in patients with type 1 diabetes mellitus: results from a phase I/II clinical trial

An effective, orally administered insulin product would be of substantial benefit in the treatment of patients with diabetes mellitus. This phase I/II clinical trial was the first to investigate the safety and effectiveness of a single oral dose of a modified human insulin in controlling postprandial plasma glucose levels in patients with type 1 diabetes mellitus who were receiving basal continuous subcutaneous insulin infusion (CSII) therapy. Fourteen patients with type 1 diabetes mellitus were evaluated in an open-label, 2-center, dose-escalation, nonrandomized study of oral hexyl-insulin monoconjugate 2 (HIM2). After an overnight fast and prior to receiving a standardized meal (50% carbohydrates, 30% fat, 20% proteins; 650 calories), the patients received either no additional insulin (day 1), or 0.5 to 1.0 mg/kg of HIM2 (day 2). All patients received a basal insulin regimen by CSII throughout the study. Blood samples were collected for determination of glucose and insulin levels for 240 minutes post-dose. The postprandial glucose excursion versus time curves showed clear reductions in glucose values after both HIM2 doses (day 2) relative to no treatment (day 1), although the differences in the reductions were not statistically significant. When the data for both HIM2 doses were pooled, a statistically significant effect of HIM2 on glucose excursion (as measured by AUCex(30-240)) was observed. Mean +/- SD values for AUCex(30-240) were 501.35 +/- 124.1 mg. h/dL after no treatment and 375.81 +/- 215.5 mg. h/dL after HIM2 (Wilcoxon signed-rank test, P =.042). The results of this study suggest that oral HIM2, when added to a basal insulin regimen, was safe and may prove effective in controlling postprandial hyperglycemia in patients with type 1 diabetes mellitus. Further clinical investigation is necessary.

Control of postprandial plasma glucose by an oral insulin product (HIM2) in patients with type 2 diabetes

OBJECTIVE

The objectives of this exploratory study were to assess the postprandial glucose-lowering effects and evaluate the safety and tolerability of single, escalating doses of an oral insulin product, hexyl-insulin monoconjugate 2 (HIM2), in patients with type 2 diabetes. Subcutaneous insulin and oral placebo were also administered for comparison.

RESEARCH DESIGN AND METHODS

Eighteen patients with type 2 diabetes were enrolled in this randomized, single-blind, placebo-controlled, three-way crossover, dose-escalation study. A single dose of each of the following study drugs was administered to each patient on 3 separate days: oral HIM2 (at one of three dose levels: 0.375, 0.5, or 1.0 mg/kg), subcutaneous regular insulin (8 units Humulin R), and oral placebo. At 30 min after dosing, patients ingested a standardized test meal (16 oz/720 calories of Boost Plus). Serial blood samples were collected for determination of plasma glucose and insulin concentrations during the 4-h postdose period.

RESULTS

The mean glucose area under the curve for 0 to 240 min (AUC(0-240)) values were lower following administration of 0.5 and 1.0 mg/kg HIM2 vs. placebo (1,097.1 vs. 1,196.9 and 801.1 vs. 992.1 mg x h(-1) x dl(-1), respectively). This difference was statistically significant at the 1.0-mg/kg HIM2 dose level. Insulin exposure, as measured by insulin AUC(0-240) values, for the 0.375-, 0.5-, and 1.0-mg/kg dose levels of HIM2 were 169.9, 193.1, and 230.8 micro U x h(-1) x ml(-1), respectively; insulin AUC(0-240) values for placebo were 165.8, 196.1, and 169.2 micro U x h(-1) x ml(-1), respectively. The mean glucose AUC(0-240) values were similar following administration of 0.5 and 1.0 mg/kg HIM2 vs. subcutaneous insulin (1,097.1 vs. 1,048.0 and 801.1 vs. 875.2 mg x h(-1) x dl(-1), respectively). For pooled data from the 0.5- and 1.0-mg/kg dose groups, the HIM2/subcutaneous insulin ratios for the 2-h postprandial glucose concentration (0.97, 95% CI 0.90-1.06), maximum postprandial glucose concentration (0.99, 95% CI 0.93-1.06), and glucose AUC(0-240) (0.98, 95% CI 0.9-1.06) were within 10% of unity, implying glucodynamic equivalence. Although HIM2 (0.5 and 1.0 mg/kg) and subcutaneous insulin (8 units) provided comparable control of postprandial plasma glucose concentrations, HIM2 resulted in peripheral insulin concentrations that were lower than subcutaneous insulin (mean insulin AUC(0-240) of 193.1 vs. 233.6 and 230.8 vs. 270.3 micro U x h(-1) x ml(-1), respectively).

CONCLUSIONS

Single, oral doses of HIM2 were safe and well tolerated. HIM2 (0.5 and 1.0 mg/kg) was more effective than placebo and as effective as subcutaneous regular insulin (8 units) at controlling postprandial glycemia with respect to the following parameters: 2-h postprandial glucose concentration, maximum glucose concentration, and glucose AUC(0-240). This occurred even though peripheral insulin concentrations were lower following the administration of HIM2 (0.5 and 1.0 mg/kg) than subcutaneous insulin. Thus, HIM2 therapy may control postprandial glycemia without causing peripheral hyperinsulinemia in patients with type 2 diabetes.

An international study of the effects of rosiglitazone plus sulphonylurea in patients with type 2 diabetes

This was an open-label, randomised 26-week study to determine the effects of adding 4 mg rosiglitazone (Avandia) daily to existing sulphonylurea (SU) therapy in patients with type 2 diabetes from India, Brazil, The Philippines, Thailand, Argentina and Tunisia. Of the 348 patients, 175 received 2 mg rosiglitazone twice daily plus SU (RSG+SU) and 173 received SU alone (at their normal dose). The RSG+SU group showed a significant reduction in HbA1c (mean HbA1c 9.05% at baseline, 7.92% at 26 weeks, mean change -1.13 (95% Cl -1.37, -0.89)). Mean HbA1c essentially remained unchanged in the control group (8.9 to 9.0%). The RSG+SU group showed a significant decrease in fasting plasma glucose concentration (FPG) (mean FPG 198.7 mg/dl at baseline, 160.3 mg/dl at 26 weeks, mean change -38.4 (95% Cl -47.1, -29.7)) while the controls showed a non-significant increase from 194 to 200 mg/dl. Significantly more patients in the RSG+SU group achieved FPG < 140 mg/dl, > or = 0.7% decrease in HbA1c, and > or = 30 mg/dl decrease in FPG between baseline and week 26 than the controls (p = 0.0001 in each case). Adverse events were similar in both groups; more patients in the RSG+SU group reported hypoglycaemia, but most cases were mild. This study shows that adding rosiglitazone to existing SU treatment improves glycaemic control and is well-tolerated in patients with type 2 diabetes from a wide range of non-Western countries.