The Berlin Declaration: A call to action to improve early actions related to type 2 diabetes. How can specialist care help?

Beneficial effects of liraglutide on peripheral blood vessels

Background/Aim. Macroangiopathy is the major cause of death and disability in type 2 diabetic patients. Studies have shown that liraglutide, a glucagon-like peptide 1 (GLP-1) receptor agonist, can protect cardiovascular system by inhibiting chronic inflammation of diabetes. However, a study about the effects of liraglutide on peripheral blood vessels and peripheral blood leukocytes has not been reported yet. The aim of this study was to determine vasculoprotective effect, vascular protection and mechanism of action of liraglutide in addition to its hypoglycemic effect. Methods. A total of 60 hospitalized patients with type 2 diabetes were recruited from December 2013 to December 2014 at the First Affiliated Hospital of Dalian Medical University, PR China. Before the treatment with liraglutide, height and weight were measured to calculate body mass index (BMI). Blood urea nitrogen (BUN) and so on were detected. Homeostasis model assessment of insulin resistance (HOMA-IR) and islet ? cell function (HOMA-?) were computed. After applying liraglutide for three months, all indexes were measured again. The effects of liraglutide on these indexes were analyzed by paired sample t-test. Results. After the treatment with liraglutide, values of glycosylated hemoglobin ? HbA1c (8.46 ? 1.62 vs. 7.26 ? 1.40%) and 2h postprandial blood glucose ? 2hPBG (11.95 vs. 9.6 mmol/L) decreased significantly (p < 0.05). Body weight (87.3 vs. 82.5 kg) and BMI (30.37 vs. 28.63 kg/m2) decreased by 5.5% and 5.7%, respectively (p < 0.05). Also, levels of triglycerides (TG) (2.57 ? 1.54 vs. 1.81 ? 0.70 mmol/L) and LDL-cholesterol (2.92 ? 0.78 vs. 1.89 ? 0.66 mmol/L) reduced significantly (p < 0.05). Ankle-brachial index (ABI) decreased from 1.24 ? 0.10 to 1.14 ? 0.06 cm/s by 8%, while brachial-ankle pulse wave velocity (ba-PWV) decreased from 1,442.15 ? 196.26 to 1,316.85 ? 146.63 cm/s by 8.7%, and both differences were statistically significant (p < 0.001). Conclusion. Liraglutide, with a good hypoglycemic effect, can significantly reduce postprandial blood glucose and HbA1c, but cannot significantly improve fasting plasma glucose, insulin resistance and islet ? cell function. It also considerably decreased body weight, BMI and TG. Liraglutide can significantly lower ba-PWV and ABI to protect peripheral blood vessels.

Are There Different Viewpoints About the Management of Type 2 Diabetes Mellitus and Comorbidities? A Multidisciplinary Spanish Qualitative Research

INTRODUCTION

The aim of this study was to explore the vision of a large multidisciplinary group of physicians treating type 2 diabetes mellitus (T2DM) in Spain, with a special focus on controversial management aspects. The perceptions of primary care (PC) physicians and hospital care (HC) specialists were compared.

METHODS

This was a mixed survey that included Delphi-like statements and opinion, attitude and behaviour (OAB) questions. The Delphi-like statements were assessed on the basis of the degree of agreement among respondents, and a descriptive analysis was performed on the answers to the OAB questions.

RESULTS

A total of 296 participants responded to the first wave of the survey, of whom 293 responded to the second wave (211 from PC and 80 from HC, with two respondents for whom there were no data on specialty). A high degree of consensus (CNS ≥ 0.8) was obtained in all the statements. A proactive approach to detect prediabetes or T2DM in asymptomatic people was highly supported (80.4% of agreement). Introducing early treatment intensification was considered to favour the durability of glycaemic control and to delay the progression of the disease (80.4%). There was agreement on the statement that glycaemic variability constitutes a risk factor for chronic complications, although differences in the perceptions of HC physicians and PC specialists were identified (86.3 vs. 80.1%, respectively). More HC physicans than PC specialists considered comorbidities to affect the ability to self-care (95 vs. 82.9%, respectively).

CONCLUSIONS

The survey revealed that there was a high, albeit not universal, degree of agreement amongst PC physicians and HC specialists in relation to prevention, screening and diagnosis of T2DM; early treatment intensification; dysglycaemias; and the management of patients with comorbidities. The statement on the management of patients with comorbidities elicited the highest difference between PC physicans and HC specialists. The results of this survey indicate that there is room for improvement in terms of implementing strategies in these areas.

Evidence gap on antihyperglycemic pharmacotherapy in frail older adults : A systematic review

Background

Although antihyperglycemic pharmacotherapy in frail older adults with type 2 diabetes mellitus (T2DM) is challenging, recommendations from international guidelines are mainly based on indirect evidence from trials not including frail participants.

Objective

This systematic review investigated the effectiveness and safety of pharmacotherapy in frail older adults with T2DM.

Material and methods

Randomized (RCT) and non-randomized prospective clinical trials (non-RCT) were searched in three electronic databases (Medline, Embase, Central) up to October 2018. Trials in older adults with T2DM who were assessed as significantly or severely impaired by defined cut-off scores of assessment instruments on frailty, activities of daily living or physical functional impairment were included.

Results

Two reviewers independently screened 17,391 references for inclusion and assessed risk of bias with ROBINS‑I. Five non-RCTs and no RCT were identified. Treatment of T2DM without insulin compared to insulin could be associated with increased improvement in cardiac functions in patients with cardiac resynchronization therapy and with decreased falls in frail older women. While better glycemic control with low variability and low HbA1c (hemoglobin A1c) values (<7%) was associated with better maintenance of physical function in community-dwelling older persons, higher HbA1c values (8–8.9%) were associated with a reduction in the composite outcome of death or functional decline in community-dwelling diabetic older adults with need for skilled assistance. Due to serious risk of bias in all studies, results should be considered with caution.

Conclusion

Well-designed, large-scale RCTs including this important group of patients are required to assess the effectiveness and safety of pharmacotherapy and HbA1c targets.

Electronic supplementary material

The online version of this article (10.1007/s00391-020-01724-3) contains supplementary material, which is available to authorized users.

Cardiometabolic-Based Chronic Disease, Addressing Knowledge and Clinical Practice Gaps: JACC State-of-the-Art Review

In the second part of this JACC State-of-the-Art Review, an early and sustainable preventive care plan is described for cardiometabolic-based chronic disease. This plan can improve cardiometabolic health by targeting early mechanistic events to decrease the risk for certain cardiovascular diseases (e.g., coronary heart disease, heart failure, and atrial fibrillation). Included are various prevention modalities, intensive lifestyle interventions, pharmacotherapy and cardiovascular outcome trial evidence, and bariatric/metabolic procedures. A tactical approach of implementing published clinical practice guidelines/algorithms for early behavioral, adiposity, and dysglycemia targeting is emphasized, as well as relevant educational and research implications.

Series: Implications of the recent CVOTs in type 2 diabetes: Impact on guidelines: The endocrinologist point of view

The management of type 2 diabetes mellitus (T2DM) essentially consists in controlling hyperglycaemia, together with other vascular risk factors, in order to reduce the incidence and severity of diabetic complications. Whereas glucose control using classical glucose-lowering agents (except perhaps metformin) largely fails to reduce cardiovascular disease (CVD), two new pharmacological classes, glucagon-like peptide-1 receptor agonists (GLP-1RAs) and sodium-glucose cotransporter type 2 inhibitors (SGLT2is), have proven their ability to reduce major cardiovascular events in patients with established CVD. Furthermore, SGLT2is reduced the risk of hospitalisation for heart failure and the progression of renal disease. According to the 2018 ADA-EASD consensus report, the choice of a second agent to be added to metformin should now be driven by the presence or not of atherosclerotic CVD, heart failure or renal disease, all conditions that should promote the use of a SGLT2i or a GLP-1 RA with proven efficacy. Thus endocrinologists have to face a new paradigm in the management of T2DM, with a shift from a primary objective of glucose control without inducing hypoglycaemia and weight gain to a goal of cardiovascular and renal protection, largely independent of glucose control. Of note, however, the latter remains crucial to reduce the risk of microangiopathy.

Dietary inulin alleviates diverse stages of type 2 diabetes mellitus via anti-inflammation and modulating gut microbiota in db/db mice

Type 2 diabetes mellitus (T2DM) is closely correlated with chronic low-grade inflammation and gut dysbiosis. Prebiotic inulin (INU) is conducive to modulate gut dysbiosis. However, the impact of dietary inulin on the diverse stages of T2DM remains largely unknown. In the present study, according to the fasting blood glucose (FBG) and oral glucose tolerance tests (OGTT), mice were randomly divided into six groups (15 mice per group): pre-diabetic group (PDM group); inulin-treated pre-diabetic group (INU/PDM group); early diabetic group (EDM group); inulin-treated early diabetic group (INU/EDM group); diabetic group (DM group); inulin-treated diabetic group (INU/DM group). All animal experiments were approved by the Ethics Committee of the General Hospital of Ningxia Medical University (No. 2016-232). After 6 weeks of inulin intervention, the mice were euthanized and the associated indicators were investigated. Dietary inulin significantly reduced FBG, body weights (BWs), glycated hemoglobin (GHb), blood lipid, plasma lipopolysaccharide (LPS), interleukin (IL)-6, tumor necrosis factor (TNF)-α and IL-17A in the three inulin-treated groups compared to the untreated groups. But for IL-17A, there remained no significant difference between the PDM group and the INU/PDM group. Moreover, the anti-inflammatory IL-10 showed significant alteration in the INU/PDM and INU/EDM groups, but no significant alteration in the INU/DM group. Sequencing analysis of the gut microbiota showed an elevation in the relative abundance of Cyanobacteria and Bacteroides and a reduction in the relative abundance of Ruminiclostridium_6 in three inulin-treated different stages of T2DM groups, as well as a reduction in the relative abundance of Deferribacteres and Tenericutes in the INU/DM group. A reduction in the relative abundance of Mucispirillum was detected in the INU/PDM and INU/EDM groups. Correlation analysis revealed that Cyanobacteria and Bacteroides abundance were positively correlated with IL-10; Deferribacteres, Tenericutes, Mucispirillum and Ruminiclostridium_6 abundance were closely related to IL-6, TNF-α or IL-17A respectively. Additionally, Mucispirillum and Ruminiclostridium_6 abundance were positively correlated with LPS. Taken together, dietary inulin alleviated the diverse stages of T2DM via suppressing inflammation and modulating gut microbiota.

Core competencies for diabetes educators: A scoping review

AIMS

Diabetes educators (DEs) play a major role in diabetes education and management. The aims of this scoping review were to compile the currently identified core competencies for DEs and, to review the currently used criteria to assess DEs' core competencies.

METHODS

A scoping review was conducted using the methodology of the Joanna Briggs Institute. Five databases (Ovid, CINAHL, Scopus, Web of Science and PubMed) were searched. Keywords as well as inclusion and exclusion criteria were identified as search strategies and study selection for this review.

RESULTS

A total of (n = 22) publications comprising sixteen peer-reviewed studies and six professional-organisations (grey literature) were selected for review, as they listed the core competencies of DEs. The most common core competencies were related to knowledge and skills in diabetes self-management education, knowledge of pathophysiology and epidemiology, teaching skills, clinical skills and cultural competency. Evidently, an appropriate tool for assessing DEs' competencies is currently unavailable.

CONCLUSIONS

Given the importance of diabetes education in the care of people living with diabetes, it is imperative that DEs possess competencies in diabetes education and management. The review also identified the need to develop a globally applicable core competency assessment tool for DEs.

Cardiovascular outcome studies in type 2 diabetes: Comparison between SGLT2 inhibitors and GLP-1 receptor agonists

Sodium-glucose cotransporter type 2 inhibitors (SGLT2is) and glucagon-like peptide-1 receptor agonists (GLP-1RAs) are two pharmacological classes that have proven their efficacy to reduce major cardiovascular events (MACEs) in patients with type 2 diabetes mellitus (T2DM) and established cardiovascular disease in large prospective cardiovascular outcome trials (CVOTs): EMPA-REG OUTCOME (empagliflozin), CANVAS (canagliflozin), LEADER (liraglutide) and SUSTAIN 6 (semaglutide). Some heterogeneity appears to exist between the various agents within the two pharmacological classes. Whether these positive results could be extrapolated to patients without cardiovascular disease is still unknown. The underlying mechanisms remain a matter of debate but appear to differ between SGLT2is and GLP-1RAs. One crucial question is which patient's characteristics should be taken into account to guide the choice between a SGLT2i or a GLP-1RA according to a personalized approach. Heart failure should encourage the use of a SGLT2i whereas moderate to severe chronic kidney disease should favour the prescription of a GLP-1RA. Despite the results of recent CVOTs, numerous patients who are good candidates for benefiting of these agents do not receive them in clinical practice. Currently, there is a paradigm shift in T2DM management, moving from a primary objective of glucose control to a cardiovascular and renal protection.