A Type 1 Diabetes Genetic Risk Score Predicts Progression of Islet Autoimmunity and Development of Type 1 Diabetes in Individuals at Risk

OBJECTIVE

We tested the ability of a type 1 diabetes (T1D) genetic risk score (GRS) to predict progression of islet autoimmunity and T1D in at-risk individuals.

RESEARCH DESIGN AND METHODS

We studied the 1,244 TrialNet Pathway to Prevention study participants (T1D patients' relatives without diabetes and with one or more positive autoantibodies) who were genotyped with Illumina ImmunoChip (median [range] age at initial autoantibody determination 11.1 years [1.2-51.8], 48% male, 80.5% non-Hispanic white, median follow-up 5.4 years). Of 291 participants with a single positive autoantibody at screening, 157 converted to multiple autoantibody positivity and 55 developed diabetes. Of 953 participants with multiple positive autoantibodies at screening, 419 developed diabetes. We calculated the T1D GRS from 30 T1D-associated single nucleotide polymorphisms. We used multivariable Cox regression models, time-dependent receiver operating characteristic curves, and area under the curve (AUC) measures to evaluate prognostic utility of T1D GRS, age, sex, Diabetes Prevention Trial-Type 1 (DPT-1) Risk Score, positive autoantibody number or type, HLA DR3/DR4-DQ8 status, and race/ethnicity. We used recursive partitioning analyses to identify cut points in continuous variables.

RESULTS

Higher T1D GRS significantly increased the rate of progression to T1D adjusting for DPT-1 Risk Score, age, number of positive autoantibodies, sex, and ethnicity (hazard ratio [HR] 1.29 for a 0.05 increase, 95% CI 1.06-1.6; P = 0.011). Progression to T1D was best predicted by a combined model with GRS, number of positive autoantibodies, DPT-1 Risk Score, and age (7-year time-integrated AUC = 0.79, 5-year AUC = 0.73). Higher GRS was significantly associated with increased progression rate from single to multiple positive autoantibodies after adjusting for age, autoantibody type, ethnicity, and sex (HR 2.27 for GRS >0.295, 95% CI 1.47-3.51; P = 0.0002).

CONCLUSIONS

The T1D GRS independently predicts progression to T1D and improves prediction along T1D stages in autoantibody-positive relatives.

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

Background

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

Methods and Results

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

Conclusions

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

Clinical Trial Registration

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

EVERSUN: a phase 2 trial of alternating sunitinib and everolimus as first-line therapy for advanced renal cell carcinoma

BACKGROUND

We hypothesised that alternating inhibitors of the vascular endothelial growth factor receptor (VEGFR) and mammalian target of rapamycin pathways would delay the development of resistance in advanced renal cell carcinoma (aRCC).

PATIENTS AND METHODS

A single-arm, two-stage, multicentre, phase 2 trial to determine the activity, feasibility, and safety of 12-week cycles of sunitinib 50 mg daily 4 weeks on / 2 weeks off, alternating with everolimus 10 mg daily for 5 weeks on / 1 week off, until disease progression or prohibitive toxicity in favourable or intermediate-risk aRCC. The primary end point was proportion alive and progression-free at 6 months (PFS6m). The secondary end points were feasibility, tumour response, overall survival (OS), and adverse events (AEs). The correlative objective was to assess biomarkers and correlate with clinical outcome.

RESULTS

We recruited 55 eligible participants from September 2010 to August 2012.

DEMOGRAPHICS

mean age 61, 71% male, favourable risk 16%, intermediate risk 84%. Cycle 2 commenced within 14 weeks for 80% of participants; 64% received ≥22 weeks of alternating therapy; 78% received ≥22 weeks of any treatment. PFS6m was 29/55 (53%; 95% confidence interval [CI] 40% to 66%). Tumour response rate was 7/55 (13%; 95% CI 4% to 22%, all partial responses). After median follow-up of 20 months, 47 of 55 (86%) had progressed with a median progression-free survival of 8 months (95% CI 5-10), and 30 of 55 (55%) had died with a median OS of 17 months (95% CI 12-undefined). AEs were consistent with those expected for each single agent. No convincing prognostic biomarkers were identified.

CONCLUSIONS

The EVERSUN regimen was feasible and safe, but its activity did not meet pre-specified values to warrant further research. This supports the current approach of continuing anti-VEGF therapy until progression or prohibitive toxicity before changing treatment.

AUSTRALIAN NEW ZEALAND CLINICAL TRIALS REGISTRY

ACTRN12609000643279.

KLF4 expression and apoptosis-related markers in gastric cancer

PURPOSE

To correlate the expression of Kruppel-like factor 4 (KLF4) with clinicopathological properties of gastric cancer (GC) and to evaluate any possible correlation between KLF4 expression and the expression of apoptosis-related markers p53, Fas, Bcl-2, survivin and FLICE inhibitory protein (Flip-l).

METHODS

Formalin-fixed, paraffin-embedded tissue specimens obtained from 96 patients with GC who had undergone gastric surgery were analyzed for pathological parameters, while KLF4, p53, Fas, Bcl-2, survivin and Flip-l expression was assessed by immunohistochemistry.

RESULTS

TKLF4 immunohistochemical staining was noted in 78.1% of the cases. Strong positivity was found in 15.6% and weak in 62.5% of the samples. Positive expression of p53, Fas, Bcl-2, survivin, Flip-l was found in 56.2%, 44.8%, 15.6%, 41.7% and 38.5% of the samples, respectively. KLF4 expression was significantly associated with p53 nuclear staining and Fas immunoreactivity. p53-positive tumors demonstrated more often high KLF4 staining compared to p53-negative tumors. Fas-positive tumors were associated with decreased KLF4 expression. Logistic regression analysis of apoptosis-related markers to KLF4 expression revealed that Fas positivity significantly decreased the probability of strong KLF4 expression, and inversely, Bcl-2 expression improved the prediction of KLF4 staining. When all 5 predictive variables were considered together (p53, Fas, survivin, Bcl-2, Flip-l) they significantly predicted the type of KLF4 expression in GC cells (p=0.019).

CONCLUSION

Our results suggest that the decrease or loss of KLF4 expression correlates with diffuse-type GC and immunoreactivity to Fas, and are inversely linked with p53 nuclear accumulation. The significance of KLF4 in GC requires further studies and should be more thoroughly investigated for potential use in the evaluation and better stratification of GC patients.

Technology and pregnancy

In the USA, depending upon the diagnosis criteria used, 135,000-200,000 women annually develop gestational diabetes mellitus, adding to the number of pregnant women already suffering from either type 1 or type 2 diabetes. Maternal hyperglycaemia and the resultant fetal hyperinsulinaemia are central to the pathophysiology of diabetic complications of pregnancy. These complications include congenital malformations and an increase in neonatal intensive care unit admission and birth trauma. In addition, there is an increased rate of accelerated fetal growth, neonatal metabolic complications and risk for stillbirth. Importantly, during the last century there were two breakthroughs in diabetes management and monitoring that changed the course of treatment: the discovery of insulin and the progress in the understanding of glucose monitoring. As technology has evolved, both glucose monitoring and insulin administration can now be achieved in a continuous fashion. In this review of the literature we focus on the utility of new technologies in the management and monitoring of diabetes in pregnancy.

Temporal trends in incidence of Type 1 diabetes between 1986 and 2006 in Brazil

BACKGROUND

Scarce information is available about the variation in the incidence of Type 1 diabetes in the Brazilian population in the last decades.

AIM

The objective of this study was to assess the long-term trends (1986-2006) in the incidence of Type 1 diabetes in Bauru, São Paulo State, Brazil.

SUBJECTS AND METHODS

The annual incidence of Type 1 diabetes (per 100,000 per yr) from 1986 to 2006 was determined in children <or=14 yr of age, using the capture and recapture method.

RESULTS

A total of 176 cases were diagnosed in the study population. The overall incidence was 10.4/100,000 with a range of 2.82/100,000 in 1987 to 18.49/100,000 in 2002 representing a 6.56-fold increase within the same population. The estimated incidence, using the capture and recapture method varied from 2.82/100,000 per yr in 1987 to 27.20/100,000 per yr in 2002, representing a 9.6-fold variation. The global pattern of incidence variation was categorized as high (10-19.99/100,000 per yr), and very high (>or=20/100,000 per yr) in 71.43% of the study-years. Incidence was slightly higher among females, Caucasians, children in the 5-9 yr of age range and belonging to lower socio-economic classes. Most diagnoses were established during the colder months and/or with higher pluviometric indexes.

CONCLUSIONS

The incidence of Type 1 diabetes in children is increasing in Bauru, São Paulo State, Brazil, and the global pattern of incidence was classified as high or very high, mainly in the last 10 yr. All Brazilian regions should be involved in the study.

Efficacy, safety and lack of immunogenicity of insulin aspart compared with regular human insulin for women with gestational diabetes mellitus

AIM

The efficacy and safety of insulin aspart (IAsp), a rapid-acting human insulin analogue, were compared with regular human insulin (HI) as the bolus component of basal-bolus therapy for subjects with gestational diabetes mellitus (GDM).

METHODS

In a randomized, parallel-group, open-labelled trial, 27 women with GDM (age 30.7 +/- 6.3 years, HbA(1c) < 7%) were randomized to receive IAsp (5 min before meal) or HI (30 min before meal). The trial period extended from diagnosis of GDM (18-28 weeks) to 6 weeks postpartum.

RESULTS

Both treatment groups maintained good overall glycaemic control during the study (beginning and end of study HbA(1c)< or = 6%). During the meal test, mean glucose at week 6 (IAsp 4.2 +/- 0.57 mmol/l, HI 4.8 +/- 0.86 mmol/l) was slightly lower than at week 0 (IAsp 4.9 +/- 0.59 mmol/l, HI 5.1 +/- 0.36 mmol/l). However, change from baseline values for average glucose (IAsp -1.09 +/- 0.54 mmol/l, HI -0.54 +/- 0.74 mmol/l; P = 0.003) and C-peptide (IAsp -0.50 +/- 0.67 nmol/l, HI -0.30 +/- 0.70 nmol/l; P = 0.027) were significantly lower after IAsp treatment than HI treatment. No major hypoglycaemic events were reported during the study. Cross-reacting insulin antibody binding increased slightly from baseline in both treatments groups (end of study: IAsp 2.1 +/- 5.4%, HI 6.4 +/- 13.9%), whereas antibodies specific to IAsp or HI remained relatively low (< 1% binding).

CONCLUSION

IAsp was more effective than HI in decreasing postprandial glucose concentrations. Duration of IAsp injection 5 min before a meal rather than 30 min prior to meals offers a more convenient therapy for subjects with GDM. Overall safety and effectiveness of IAsp were comparable to HI in pregnant women with GDM.

Congenital anomaly rate in offspring of mothers with diabetes treated with insulin lispro during pregnancy

AIM

To determine the rate of major congenital anomalies in offspring of a large group of women with diabetes mellitus treated with insulin lispro (Humalog).

METHODS

This multinational, multicentre, retrospective study included mothers with diabetes mellitus (diagnosed prior to conception) who were treated with insulin lispro for at least 1 month before conception and during at least the first trimester of pregnancy. Anomalies were assessed by two independent dysmorphologists not affiliated with the sponsor.

RESULTS

The charts of 496 women were reviewed for 533 pregnancies resulting in 542 offspring (500 live births, 31 spontaneous and seven elective abortions, and four stillbirths). Mothers' characteristics: mean (+/- SD) age was 29.9 (+/- 5.2) years, 85.6% were Caucasian and 97.2% had Type 1 diabetes mellitus. Insulin lispro continued to be the main mealtime insulin for more than 96% of the women during the second and third trimester. The dysmorphologists determined that 27 (5.4%) offspring had major congenital anomalies and 2 (0.4%) offspring had minor congenital anomalies.

CONCLUSIONS

The rate of major congenital anomalies was 5.4% [95% CI (3.45%, 7.44%)] for offspring of mothers with diabetes mellitus treated with insulin lispro before and during pregnancy. The current published rates of major anomalies in infants born to mothers with diabetes treated with insulin are between 2.1 and 10.9%. This suggests that the anomaly rate with insulin lispro treatment does not differ from the published major congenital anomaly rates for other insulin treatments.

The combination oral and nutritional treatment of late-onset diabetes mellitus (CONTROL DM) trial results

OBJECTIVE

To examine the effect of short-term improvements in glycaemic control on brachial artery endothelial function as a marker of cardiovascular health.

METHODS

Persons with Type 2 diabetes who were poorly controlled on oral therapy were randomly assigned to monotherapy with repaglinide or combination therapy with repaglinide plus metformin. Brachial artery flow-mediated vasodilation was assessed by ultrasonography at randomization and following 16 weeks of therapy. The primary outcome was change in brachial artery endothelial function from baseline. Comparison of randomized groups was a secondary aim.

RESULTS

Eighty-six participants were randomized, and 83 were followed to study completion. Post occlusion brachial artery vasodilation was 3.74% at baseline and 3.82% following 16 weeks of therapy (P = 0.77). The treatment effect was 0.08% (95% CI: -0.48%, 0.64%). No difference was seen between treatment groups (P = 0.69). Overall, A1C was reduced from 8.3% to 7.0%, with a greater reduction in the combination therapy group (from 8.4% to 6.7%) than in the monotherapy group (from 8.3% to 7.3%, p for difference between groups = 0.01). Statistically significant reductions were observed in fasting glucose, and plasminogen activator inhibitor-1. Statistically significant increases were observed for fasting insulin, uric acid, weight and BMI.

CONCLUSIONS

Brachial artery endothelial function was not influenced by short-term improvements in glycaemic control. The CONTROL DM group was successful in lowering A1C. Future research should explore more intensive and longer-lasting improvements in glycaemic control on endothelial function. Some data previously published in abstract form (Diabetes 2001; 50 (Suppl. 2): A217).

Continuous glucose monitoring: a stepping stone in the journey towards a cure for diabetes

Probably the most important advance in the field of diabetes and pregnancy since the discovery of insulin in 1921 is self-monitoring of blood glucose. Within the past 30 years, home monitoring of blood glucose has introduced a more efficient means of tracking patient progress. The advent of continuous glucose monitoring has broadened the horizons for improving patient care. Barriers to intensive therapy such as standard methods of monitoring blood glucose, the risk of hypoglycemia, the limitations of present therapy and inadequate patient education must be overcome in order to improve diabetes management. This paper discusses methods of blood glucose monitoring and its aims at bringing the above mentioned barriers to a minimum in order to maintain normoglycemia, to reduce risks of diabetes-related complications and to optimize the possibility for pregnant women with diabetes of delivering healthy babies.

The safety and efficacy of insulin analogs in pregnancy

Diabetes during pregnancy is accompanied by increasing needs for maternal insulin and ongoing biological changes that cause maternal insulin requirements to reach higher and lower extremes throughout the day than in non-pregnant patients. As maternal hyperglycemia increases the risk of fetal and maternal morbidity, it is essential for the mother to maintain normoglycemia during pregnancy. With the advent of insulin analogs that feature improved absorption and physiological profiles over human insulin, the achievement of normoglycemia throughout pregnancy has become more attainable. This review provides a discussion of the application of the insulin analogs to diabetes during pregnancy and compares the benefits of rapid-acting insulin analogs with long-acting insulin analogs during pregnancy. This review further proposes a treatment protocol for achieving and maintaining normoglycemia throughout pregnancy.

Continuous glucose monitoring for the evaluation and improved control of gestational diabetes mellitus

OBJECTIVES

To compare the daily glycemic profile reflected by continuous versus self-monitoring of blood glucose in women with gestational diabetes mellitus (GDM), and to evaluate possible differences in treatment strategy based on the two monitoring methods.

MATERIALS AND METHODS

The study sample consisted of 57 women with gestational diabetes, 47 in Israel and ten in California. Gestational age ranged from 24 to 32 weeks in the Israeli women, and 32 to 36 weeks in the American women. Data derived from the Continuous Glucose Monitoring (CGM) System (MiniMed) for 72 h were compared to fingerstick glucose measurements (6-8 times a day). During continuous monitoring, patients documented the timing of food intake, insulin injections and hypoglycemic events.

RESULTS

In the Israeli group, 23 women were treated by diet alone, and 24 by diet plus insulin. An average of 763 +/- 62 glucose measurements was recorded for each patient with continuous glucose monitoring. The mean total time of hyperglycemia (glucose level > 140 mg/dl) undetected by the fingerstick method was 132 +/- 31 min/day in the insulin-treated group and 94 +/- 23 min/day in the diet-treated group. Nocturnal hypoglycemic events (glucose levels < 50 mg/dl) were recorded in 14 patients, all insulin-treated. On the basis of the additional information provided by continuous monitoring, the therapeutic regimen (insulin therapy, diet adjustment, or both) was changed in 36 of the 47 patients. All ten American women were treated with insulin. The mean time of undetected hyperglycemia for a total group monitoring time of 30 days was 78 +/- 13 min/day. Eight women had nocturnal hypoglycemia on at least one of the three nights of monitoring for a total of 12 nights. A change in insulin dosage was made in all women on the basis of the data provided by continuous glucose monitoring.

CONCLUSION

Continuous glucose monitoring is helpful for monitoring women with GDM and for adjusting diabetes therapy. It can accurately detect high postprandial blood glucose levels and nocturnal hypoglycemic events that may go unrecognized by intermittent blood glucose monitoring. A large prospective study on maternal and neonatal outcome is needed to determine the clinical implications of this new monitoring technique.

New and future diabetes therapies: are they safe during pregnancy?

Diabetes in pregnancy, whether the woman had diabetes prior to becoming pregnant or developed gestational diabetes, is associated with many complications and risks. In the first trimester, organogenesis can be disrupted by complications due to poor control of the mother's diabetes, leading to fetal malformations or perinatal mortality. Problems with glucose control in the remainder of the pregnancy can also have consequences for the child. These include macrosomia, shoulder dystocia, pre-eclampsia, hypoglycemia and an increased risk for obesity and diabetes in the future. Therefore, aggressive and prompt treatment of the high blood sugar levels, which cause these complications, is necessary. This review looks at the current treatments for pregnancies complicated by diabetes and evaluates the place of new and possible future treatments including diet, exercise, insulin, insulin analogs and oral and inhaled agents.

Clinical evaluation of the GlucoWatch biographer: a continual, non-invasive glucose monitor for patients with diabetes

A device providing frequent, automatic, and non-invasive glucose measurements for persons with diabetes has been developed: the GlucoWatch biographer. This device extracts glucose through intact skin via reverse iontophoresis where it is detected by an amperometric biosensor. The biographer can provide glucose readings every 20 min for 12 h. The performance of this device was evaluated in two large clinical studies in a controlled clinical environment (n=231), and the home environment (n=124). Accuracy of the biographer was evaluated by comparing the automatic biographer readings to serial finger-stick blood glucose (BG) measurements. Biographer performance was comparable in both environments. Mean difference between biographer and finger-stick measurements was -0.01 and 0.26 mmol l(-1) for the clinical and home environments, respectively. The mean absolute value of the relative difference was 1.06 and 1.18 mmol l(-1) for the same studies. Correlation coefficient (r) between biographer and finger-stick measurements was 0.85 and 0.80 for the two studies. In both studies, over 94% of the biographer readings were in the clinically acceptable A+B region of the Clarke Error Grid. A slight positive bias is observed for the biographer readings at low BG levels. Biographer accuracy is relatively constant over all rates of BG changes, except when BG decreases more than 10 mmol l(-1) h(-1), which occurred for only 0.2% of points in the home environment study. Biographer precision, as measured by CV%, is approx. 10%. Skin irritation, characterized by erythema and edema, was either non-existent or mild in >90% of subjects and resolved in virtually all subjects without treatment in several days.

Continuous glucose monitoring during pregnancy complicated by gestational diabetes mellitus

Postprandial glucose has been reported to be the best predictor of neonatal macrosomia. Therefore, self-blood glucose monitoring (SBGM) protocols for diabetic pregnant women stress the importance of measuring blood glucose after meals. However, there is controversy in the literature. Traditionally, glucose monitoring has been prescribed at 2 hours after eating to coincide with the times a patient is at increased risk of hypoglycemia. Human regular insulin peaks at 2 to 3 hours after injection; thus, checking blood glucose at the 2-hour point is a relic of strategies to prevent hypoglycemia. In pregnancy, the emphasis has been on measuring during times when blood glucose levels are highest. One hour after the start of the meal has been shown to be the time of peak postprandial response in 90% of pregnant woman. Because glucose excursions may reach their maximum at varying times, based on the size and number of meals ingested, SBGM alone may not capture the full extent of total daily postprandial hyperglycemia. Because intermittent blood glucose monitoring underestimates the number of hyperglycemic events, a more accurate determination of postprandial glucose levels is necessary to decrease the risk of macrosomia in gestational diabetes mellitus. Continuous glucose monitoring may facilitate the detection of all postprandial peaks, including those due to unscheduled meals, and may provide an opportunity for better intervention by providing the complete glucose profile.

Birth weight as a predictor of type 2 diabetes mellitus: the U-shaped curve

Recent findings have sparked intense interest in birth weight as a predictor of type 2 diabetes mellitus. In some populations, there is an inverse association between birth size and disease; however, in the Pima Indians, a population with very high rates of gestational diabetes, high birth weight and low birth weight are associated with diabetes. This results in a U-shaped curve with higher diabetes rates in both tails of the distribution. Similarly, there are reports of an inverse association between stature and prevalence of gestational diabetes, but, in California Latina women with gestational diabetes, there is a positive association between stature and glucose concentration. Could these disparate findings also represent the two ends of a U-shaped curve? The disparities are likely due to differences in the environment, both in utero and postnatally, that different groups experience.

Declining insulin requirement in the late first trimester of diabetic pregnancy

OBJECTIVE

To investigate whether pregnancies complicated by type 1 diabetes are associated with a decrease in first-trimester insulin requirement.

RESEARCH DESIGN AND METHODS

We examined the weekly insulin requirement (as units per kilogram per day) during the first trimester of pregnancy in diabetic women in the Diabetes in Early Pregnancy Study (DIEP) with accurate gestational dating, regular glucose monitoring, daily insulin-dose recording, and monthly glycohemoglobin measurements.

RESULTS

In pregnancies that resulted in live-born full-term singleton infants, a significant 18% increase in mean weekly dosage was observed between weeks 3 and 7 (P = 0.000), followed by a significant 9% decline from week 7 through week 15 (P = 0.000). Further testing localized a significant change in insulin dose in the interval beginning weeks 7-8 and ending weeks 11-12 (P = 0.014). Within this interval, the maximum decrease was between weeks 9 and 10 (mean), 10 and 11 (median), and 8 and 9 (most frequent maximal decrease). To determine whether prior poor glucose control exaggerated these trends, we categorized the women based on their glycohemoglobin values: <2 SDs above the mean of a normal population (subgroup 1), 2-4 SDs (subgroup 2), and >4 SDs (subgroup 3) at baseline. Late first-trimester declines in dosage were statistically significant in subgroup 2 (P = 0.002) and subgroups 2 and 3 together (P = 0.003). Similarly, women with BMI >27.0 had a greater initial insulin rise and then fall compared with leaner women.

CONCLUSIONS

Observations in the DIEP cohort disclose a mid-first-trimester decline in insulin requirement in type 1 diabetic pregnant women. Possible explanations include overinsulinization of previously poorly controlled diabetes, a transient decline in progesterone secretion during the late first-trimester luteo-placental shift in progesterone secretion, or other hormonal shifts. Clinicians should anticipate a clinically meaningful reduction in insulin requirement in the 5-week interval between weeks 7 and 12 of gestation.

Medical emergencies in the patient with diabetes during pregnancy

Although the outcome of pregnancies complicated by diabetes is now approaching the success seen in the normal healthy pregnant population, this improvement is only realized when careful attention is paid to the metabolic, hemodynamic, and vascular perturbations associated with the changes of pregnancy. The diabetic woman must not only pay attention to nutrition but also blunt moment-to-moment swings in blood glucose by taking frequent does of insulin. In addition, she must be under constant surveillance for a host of other complications of pregnancy, such as hypertension, retinopathy, infection, acidosis, thyroid dysfunction, nephropathy, and sudden death in utero. Any or all of these problems become medical emergencies if left untreated. Rigorous vigilance to sustain normoglycemia and normotension, examination of the retina, culture of urine, assays for ketosis, measurements of thyroid function, and monitoring of renal function and fetal status are paramount in the management of pregnancy complicated by diabetes.

Controversies in the diagnosis and treatment of gestational diabetes

Uncontrolled gestational diabetes is associated with infant macrosomia and a lifelong risk of developing diabetes. Prompt diagnosis and aggressive management is therefore critical. All pregnant women should be screened for carbohydrate intolerance. Women with even minor abnormalities in blood sugar levels should be trained to monitor their glucose levels, rigorously control their diet, and use insulin if necessary. Exercise is also very beneficial.

Repaglinide/troglitazone combination therapy: improved glycemic control in type 2 diabetes

OBJECTIVE

This multicenter open-label clinical trial compared the efficacy and safety of repaglinide/troglitazone combination therapy, repaglinide monotherapy, and troglitazone monotherapy in type 2 diabetes that had been inadequately controlled by sulfonylureas, acarbose, or metformin alone.

RESEARCH DESIGN AND METHODS

Patients with type 2 diabetes (n = 256) who had inadequate glycemic control (HbA1c > or =7.0%) during previous monotherapy were randomly assigned to receive repaglinide (0.5-4.0 mg at meals), troglitazone (200-600 mg once daily), or a combination of repaglinide (1-4 mg at meals) and troglitazone (200-600 mg once daily). After a 4-6 week washout period, the trial assessed 22 weeks of treatment: 3 weeks (weeks 0-2) of forced titration, 11 weeks of fixed-dose treatment (weeks 3-13), and 8 weeks (weeks 14-21) of titration to maximum dose. Changes in HbA1c and fasting plasma glucose (FPG) values were measured.

RESULTS

The combination therapy showed a significant reduction in mean HbA1c values (-1.7%) that was greater than with either type of monotherapy Repaglinide monotherapy resulted in a reduction of HbA1c values that was significantly greater than troglitazone (-0.8 vs. -0.4%) (P < 0.05). Combination therapy was more effective in reducing FPG values (-80 mg/dl) than either repaglinide (-43 mg/dl) or troglitazone (-46 mg/dl) monotherapies. Adverse events were similar in all groups.

CONCLUSIONS

Combination therapy with repaglinide and troglitazone leads to better glycemic control than monotherapy with either agent alone. Repaglinide monotherapy was more effective in lowering HbA1c levels than troglitazone monotherapy Repaglinide/troglitazone combination therapy was effective and did not show unexpected adverse events.

Comparison of the effect of saturated and monounsaturated fat on postprandial plasma glucose and insulin concentration in women with gestational diabetes mellitus

The goal of this study was to determine whether the type of fat plays a role in the glucose response to a meal, independent of the carbohydrate content. Ten gestational diabetic women (gestational weeks 29-34) who were well controlled on diet alone were randomized as to the order in which they would eat a meal, after overnight fast, containing saturated fat (SF) or monounsaturated fat (MUFA). Blood was drawn at 0, 60, 120, and 180 min for plasma glucose, insulin, lipid profile (triglycerides, total cholesterol, HDL-cholesterol, LDL-cholesterol, VLDL-cholesterol) and free fatty acids. After 2 weeks, each patient received the other type of meal. The test meal was composed of 20% of the total daily caloric needs based on ideal body weight. The area under the curve showed a significantly lower glucose concentration for SF meal (p = 0.001). Serum insulin concentrations followed the glucose response with the peak at the 60-min time point and a significantly lower concentration at the 180-min time point in the SF than in the MUFA group. The present study demonstrated that the addition of SF to the meal resulted in lower postprandial glucose and insulin than when the meal contained MUFA. Thus, SF may be useful in controlling postprandial glucose.

Reactivation of type 1 diabetes in patients receiving human fetal pancreatic tissue transplants without immunosuppression

BACKGROUND

Type 1 diabetes is a cell-mediated autoimmune disease. Successful transplantation of human fetal pancreatic tissue into type 1 diabetic patients must address both autoimmunity and allograft rejection. We investigated whether humoral and cellular responses to islet antigens could be demonstrated in the peripheral blood of type 1 diabetic subjects receiving human fetal pancreatic tissue transplants.

METHODS

We investigated peripheral blood mononuclear cell (PBMC) responses, using cellular immunoblotting, and autoantibody responses to islet proteins, before transplant and at 3-month intervals after transplant, of nine long-term type 1 diabetes patients (mean disease duration of 21 years) receiving human fetal pancreatic tissue subcutaneously into the abdominal wall without immunosuppression.

RESULTS

Before transplant, all nine subjects were islet cell autoantibody (ICA)-negative and seven out of nine subjects were glutamic acid decarboxylase autoantibody (GADAb)-positive. After transplant, all subjects became ICA(+) and the two patients who were GADAb(-) before transplant became GADAb(+) after transplant. Maximum PBMC reactivity to separated human fetal pancreatic proteins was observed in four patients 3 months after transplant, in one patient at 6 months, in two patients at 9 months, and in one patient at 12 months after transplant. One subject, who had PBMC reactivity to multiple islet proteins before transplant, continued to respond to multiple islet proteins throughout the study.

CONCLUSIONS

We conclude that the development in the peripheral blood of ICA, GADAb, and PBMC reactivity to human fetal pancreatic proteins in the trans plant recipients is most consistent with reactivation of the type 1 diabetes disease process.

Peripheral blood mononuclear cell responses from type 1 diabetic patients and subjects at-risk for type 1 diabetes to human fetal pancreatic tissue proteins

BACKGROUND

Fetal pancreatic tissue has been suggested to be less immunogenic than adult islets. Thus, transplantation of human fetal pancreatic tissue as treatment for type 1 diabetes has been gaining interest. To investigate this question, we tested the peripheral blood mononuclear cell (PBMC) responses from different subject populations to human adult islet proteins (AIP) versus human fetal pancreatic proteins (FPP).

METHODS

PBMC responses to FPP and AIP from normal controls (n=14), newly diagnosed type 1 diabetes patients (n=5), long-term type 1 diabetes patients (n=9), and subjects at-risk for development of type 1 diabetes (n=3) were studied.

RESULTS

We observed that normal controls demonstrated PBMC reactivity to 0-3 molecular weight regions (mwr) for both the AIP (mean+/-SD, 0.8+/-1.1) and the FPP (0.6+/-0.7). In contrast, newly diagnosed type 1 diabetic patients (<1 year) demonstrated PBMC responses to 9-16 mwr for the AIP (12.8+/-2.5) and 0-14 mwr for the FPP (6.8+/-5.0). The PBMCs from long-term type 1 diabetes patients (> 3 years) were responsive to 2-11 mwr for AIP (6.0+/-2.8) and 0-11 mwr for FPP (4.9+/-4.0). Three nondiabetic ICA positive subjects at-risk for development of type 1 diabetes demonstrated positive PBMC reactivity to 9-18 mwr for the AIP (12.7+/-3.9) and 4-18 mwr for the FPP (10.0+/-5.9).

CONCLUSIONS

We conclude that human fetal pancreatic proteins are not significantly less stimulatory than human adult islet proteins to PBMCs of subjects with or at risk for type 1 diabetes.

Use of insulin aspart, a fast-acting insulin analog, as the mealtime insulin in the management of patients with type 1 diabetes

OBJECTIVE

To compare long-term glycemic control and safety of using insulin aspart (IAsp) with that of regular human insulin (HI).

RESEARCH DESIGN AND METHODS

This was a multicenter randomized open-label 6-month study (882 subjects) with a 6-month extension period (714 subjects) that enrolled subjects with type 1 diabetes. Subjects administered IAsp immediately before meals or regular HI 30 min before meals; basal NPH insulin was taken as a single bedtime dose in the majority of subjects. Glycemic control was assessed with HbA1c values and 8-point blood glucose profiles at 3-month intervals.

RESULTS

Mean postprandial blood glucose levels (mg/dl +/- SEM) were significantly lower for subjects in the IAsp group compared with subjects in the HI group after breakfast (156 +/- 3.4 vs. 185 +/- 4.7), lunch (137 +/- 3.1 vs. 162 +/- 4.1), and dinner (153 +/- 3.1 vs. 168 +/- 4.1), when assessed after 6 months of treatment. Mean HbA1c values (% +/- SEM) were slightly, but significantly, lower for the IAsp group (7.78% +/- 0.03) than for the regular HI group (7.93% +/- 0.05, P = 0.005) at 6 months. Similar postprandial blood glucose and HbA1c values were observed at 12 months. Adverse events and overall hypoglycemic episodes were similar for both treatment groups.

CONCLUSIONS

Postprandial glycemic control was significantly better with IAsp compared with HI after 6 and 12 months of treatment. The improvement was not obtained at an increased risk of hypoglycemia. HbA1c was slightly, but significantly, lower for IAsp compared with HI at 6 and 12 months.

Reactivation of type 1 diabetes in patients receiving human fetal pancreatic tissue transplants without immunosuppression

BACKGROUND

Insulin-dependent (type 1) diabetes is a cell-mediated autoimmune disease. Successful transplantation of human fetal pancreatic tissue into type 1 diabetic patients must address both autoimmunity and allograft rejection. We investigated whether humoral and cellular responses to islet antigens could be demonstrated in the peripheral blood of type 1 diabetic subjects receiving human fetal pancreatic tissue transplants.

METHODS

We investigated peripheral blood mononuclear cell (PBMC) responses, using cellular immunoblotting, and autoantibody responses to islet proteins, before transplantation and at 3-month intervals after transplantation. Our study population included nine long-term type 1 diabetes patients (mean disease duration of 21 years) receiving human fetal pancreatic tissue subcutaneously into the abdominal wall without immunosuppression.

RESULTS

Before transplantation, all nine subjects tested negative for islet cell autoantibody (ICA), and seven of nine subjects tested positive for glutamic acid decarboxylase autoantibody (GADAb). After transplantation, all subjects became ICA(+), and the two patients who were GADAb(-) before transplantation, became GADAb(+) after transplantation. Maximum PBMC reactivity to separated human fetal pancreatic proteins was observed in four patients at 3 months, in one patient at 6 months, in two patients at 9 months, and in one patient at 12 months after transplantation. One subject, who had PBMC reactivity to multiple islet proteins before transplantation, continued to respond to multiple islet proteins throughout the study.

CONCLUSIONS

We conclude that the development in the peripheral blood of ICA, GADAb, and PBMC reactivity to human fetal pancreatic proteins in the transplant recipients is most consistent with reactivation of the type 1 diabetes disease process.

Repaglinide in type 2 diabetes: a 24-week, fixed-dose efficacy and safety study

In this 24-week multicenter, double-blind, randomized, fixed-dose trial, 361 patients having type 2 diabetes received daily preprandial treatment with placebo (n = 75), repaglinide 1 mg (n = 140), or repaglinide 4 mg (n = 146). By a last-observation carried-forward calculation, repaglinide 1 mg or 4 mg treatment decreased mean fasting plasma glucose (FPG) values (by -47 mg/dL or -49 mg/dL) while the placebo group had increased FPG values (by 19 mg/dL). For the repaglinide treatment groups at the end of the study, changes in HbA1c from baseline values ranged from 1.8 to 1.9 percentage points lower than the placebo group. There were no events of severe hypoglycemia. Nearly all hypoglycemic symptom episodes had blood glucose levels above 45 mg/dL. Repaglinide was well tolerated in a preprandial fixed-dose regimen of 1 mg or 4 mg, assigned without adjustment for clinical parameters.

Optimization of insulin therapy in patients with gestational diabetes

OBJECTIVE

To discuss the new criteria for screening and diagnosis of gestational diabetes and present recommendations for patient management.

METHODS

Various strategies for detecting gestational diabetes historically and currently are reviewed, and approaches for optimizing patient and neonatal outcome are discussed.

RESULTS

Rather than testing for gestational diabetes selectively, universal screening of pregnant women between 24 and 28 weeks of gestation with use of a glucose challenge test and 1-hour assessment has been shown to decrease the rate of occurrence of neonatal macrosomia. Performance of both preprandial and postprandial self-monitoring of blood glucose levels helps to prevent pronounced postprandial glucose excursions and minimize the risk of neonatal macrosomia. In comparison with regular human insulin, insulin lispro has yielded significantly better metabolic control and a reduction in hypoglycemic episodes before breakfast in patients with gestational diabetes.

CONCLUSION

Women with gestational diabetes who are not optimally managed with diet and exercise need insulin therapy. Insulin lispro is associated with fewer hypoglycemic events and attenuates the postprandial response greater than does regular human insulin.

Medical nutritional therapy in pregnant women with pregestational diabetes mellitus

OBJECTIVE

Diabetic women now can have the same chances as nondiabetic women to have a healthy infant. The reduction of risk associated with pregnancies complicated by diabetes can only be assured if normoglycemia is achieved before and during pregnancy. This review is intended to provide guidelines and scientific evidence for the optimal diet for the Type 1 or Type 2 diabetic woman.

METHODS

The literature over the past 10 years is presented. Those diets which achieved the best outcome of pregnancies complicated by diabetes (as evidenced by term delivery of a healthy, normal weight infant) are then outlined.

RESULTS

Diets which provide adequate calories without causing postprandial hyperglycemia or premeal ketosis are found to be based on body weight and gestational week of the pregnancy. Quantity of carbohydrate in the meal plan emerges as the most important component in achieving and maintaining glucose control.

CONCLUSIONS

The medical nutritional therapy for the Type 1 and Type 2 diabetic woman is a necessary component of the overall strategy to achieve and maintain normoglycemia and thus achieve the best outcome of pregnancy.

Treatment of women with an abnormal glucose challenge test (but a normal oral glucose tolerance test) decreases the prevalence of macrosomia

Infant macrosomia is a serious medical concern. Pregnant women who do not meet the specific diagnosis for gestational diabetes may still have glucose-mediated macrosomia. In Santa Barbara County all pregnant women are screened for gestational diabetes at 24-28 weeks with a 50-g, 1-hr glucose challenge test (GCT). All patients who fail this test are placed on a standard euglycemic diet (40% carbohydrate, 20% protein, 40% fat) and perform home glucose monitoring of fasting and postprandial glucose levels. The objective of this study was to examine the effectiveness of this treatment program in decreasing infant macrosomia, maternal and infant morbidity, maternal complications, and operative delivery. We studied 103 women who had a positive GCT, but a negative 100-g, 3-hr oral glucose tolerance test (OGTT). The women were randomly assigned to either experimental or control groups with experimental women receiving dietary counseling and home glucose monitoring instruction (HBGM). HBGM diaries were reviewed weekly by clinic nurses. All women had hemoglobin A1c (HbA1c) tests at 28 and 32 weeks. Maternal and fetal charts were reviewed to determine delivery type and complications, indications for cesarean section (C-section), and infant gestational age, gender, Apgar scores, birth weight, morbidities, and congenital anomalies. Of the 103 women, 5 women required insulin treatment, 1 woman had an abortion, and 14 women were indeterminate regarding compliance or were control women who received diet counseling and HBGM. The results are based on 83 women--48 control and 35 experimental. There were no significant differences between the groups for age, parity, or weight at 28-30 weeks or 37 weeks to delivery, or HbA1c at 28 weeks. HbA1c was significantly higher in control women at 32 weeks. Birth weight expressed in grams or as a percentile specific for gender, ethnicity, and gestational age was significantly higher in control infants. Birth weight was significantly correlated with maternal intake weight, weight at 28-30 weeks, and weight at delivery and with HbA1c at 32 weeks' gestation. There were no significant differences between groups for maternal complications. Groups were significantly different for mode of delivery with experimental women having more induced vaginal deliveries but fewer repeat C-sections than control women. Groups were not different for primary C-sections. Women who fail the GCT, but not the OGTT and thus do not receive the diagnosis of GDM are still at risk for delivering a macrosomic infant and operative delivery. Our program of treatment for all women who fail the GCT improves outcome by reducing infant birth weight and the number of cesarean sections.

Noninvasive glucose monitoring: comprehensive clinical results. Cygnus Research Team

CONTEXT

Intensive diabetes management using frequent blood glucose measurements to guide therapy has been shown to significantly improve short- and long-term outcomes. Development of a device that makes possible frequent, automatic, painless, and accurate measurements of glucose would facilitate intensive management.

OBJECTIVE

To determine the accuracy of the GlucoWatch automatic glucose biographer (Cygnus Inc) compared with that of serial blood glucose measurements.

DESIGN

Multicenter comparative study of the GlucoWatch biographer and the HemoCue blood glucose analyzer (Aktiebolaget Leo) performed between August 29 and October 17, 1998. Participants wore up to 2 biographers during the 15-hour study session and performed 2 fingersticks per hour for comparative blood glucose measurements. The biographers were calibrated with a single HemoCue measurement after a 3-hour warm-up period. Diet and insulin were manipulated to produce a broad glycemic range during the study.

SETTING

Controlled clinical environment at 2 diabetes centers and 3 contract research organizations in the United States.

PARTICIPANTS

A total of 92 subjects (mean [SD] age, 42.1 [15.1] years; 59.8% women) with type 1 or 2 diabetes requiring treatment with insulin.

MAIN OUTCOME MEASURES

Mean error, mean absolute error, correlation, slope, and intercept using Deming regression, and clinical significance of differences between biographer readings and blood glucose measurements using the Clarke error grid.

RESULTS

Results showed close tracking of blood glucose over a range of 2.2 to 22.2 mmol/L (40-400 mg/dL) for up to 12 hours using a single point calibration. The biographer readings lagged behind serial blood glucose values by a mean of 18 minutes. An analysis of 2167 data pairs shows a linear relationship (r = 0.88; slope = 1.03; intercept = -0.33 mmol/L [-6 mg/dL]) between biographer readings and serial glucose measurements. The mean absolute error between the 2 measurements was 15.6% (mean error [SD], -0.07 [1.82] mmol/L [-1 [33] mg/dL]), and 96.8% of the data fell in the therapeutically relevant regions of the error grid analysis.

CONCLUSION

These results demonstrate close agreement between GlucoWatch biographer readings and blood glucose measurements using repeated fingerstick blood samples. The automatic, frequent, and noninvasive measurements obtained with the biographer provides more information about glucose levels than the current standard of care.

Metabolic and immunologic effects of insulin lispro in gestational diabetes

OBJECTIVE

To compare the immunologic response to insulin lispro with that to regular human insulin, thereby assuring its safety for use in women with gestational diabetes, and to verify that it is effective.

RESEARCH DESIGN AND METHODS

We compared the metabolic and immunologic effects of insulin lispro and regular human insulin in 42 women >18 years of age diagnosed with gestational diabetes by oral glucose tolerance testing at 14-32 weeks of gestation. Patients were randomized to receive regular human insulin or insulin lispro before consuming a test meal. Serum insulin, blood glucose, and C-peptide concentrations were measured. Throughout the remainder of gestation, patients received premeal insulin lispro or regular human insulin combined with basal insulin and performed blood glucose self-monitoring before and after each meal. Insulin antibodies and HbA1c were determined at enrollment and 6 weeks later. In addition, 10 patients received continuous intravenous insulin (4 lispro, 6 regular human insulin) and dextrose infusions intrapartum to assess placental insulin transfer.

RESULTS

Anti-insulin antibody levels were similar in the two groups. Insulin lispro was not detectable in the cord blood. During a meal test, areas under the curve for glucose, insulin, and C-peptide were significantly lower in the lispro group. Mean fasting and postprandial glucose concentrations and end point HbA1c were similar in the two groups. The lispro group demonstrated fewer hypoglycemic episodes (symptoms and blood glucose concentrations <55 mg/dl). No fetal or neonatal abnormalities were noted in either treatment group.

CONCLUSIONS

Insulin lispro may be considered a treatment option for women with gestational diabetes.

Type 2 diabetes: the epidemic of the new millennium

The increasing prevalence of obesity, which has reached epidemic proportions, raises the likelihood that a similar increase in diabetes will follow. Linkage between the two conditions is clear. Overweight is not only an important risk factor for the development of diabetes, but also has a significant impact on progression and complications. Diagnostic criteria for the recognition of diabetes and for monitoring of the disease process will become increasingly important. The role of laboratory evaluation needs to be reassessed in light of new concepts regarding classification and diagnostic criteria. The relative utility of glucose and glycosylated protein measurements should be addressed, particularly the relationship between laboratory findings and clinical guidelines. Blood glucose monitoring depends on establishment of the threshold for diagnosis. Additional issues are bedside monitoring, the goal of noninvasive glucose sensors and targeting of therapy. The laboratory scientist is likely to play a key role in the application of advances in the detection and management of diabetes.

Utility of a short-term 25% carbohydrate diet on improving glycemic control in type 2 diabetes mellitus

OBJECTIVE

To determine if introduction of a low carbohydrate diet might be a useful option for type 2 diabetic patients who do not achieve glucose target levels despite conventional treatment.

METHODS

Subjects with type 2 diabetes, either treated with diet alone (n=9) or second generation sulfonylurea agents (n= 19), which were discontinued, were placed on a diet based on ideal body weight and comprised of 25% carbohydrate. After a mean of 8 weeks, they were then switched to a caloricly equivalent diet, but composed of 55% carbohydrate.

RESULTS

Compared to baseline diet, after 8 weeks of a 25% diet, subjects showed significantly improved glycemia as evidenced by fasting blood glucose values (p<0.005) and hemoglobin A1c levels (p<0.05). Those previously treated with oral hypoglycemic agents showed, in addition, a significant decrease in weight and diastolic blood pressure despite the discontinuation of the oral agent. When then placed on a 55% carbohydrate diet, the hemoglobin A1c rose significantly over the ensuing next 12 weeks (p<0.05).

CONCLUSION

A low carbohydrate, caloricly-restricted diet has beneficial short-term effects in subjects with type 2 who have failed either diet or sulfonylurea therapy and may obviate the necessity for insulin. Our study also affirms the need for reassessing the role of diet whenever type 2 diabetic patients manifests hyperglycemia, despite conventional oral treatment or diet management.

The Diabetes in Early Pregnancy Study: beta-hydroxybutyrate levels in type 1 diabetic pregnancy compared with normal pregnancy. NICHD-Diabetes in Early Pregnancy Study Group (DIEP). National Institute of Child Health and Development

OBJECTIVE

The objective was to assess relationships between beta-hydroxybutyrate (beta-OHB) level and pregnancy outcome in human pregnancy in light of the fact that high levels of beta-OHB cause malformations and growth retardation in in vitro studies.

RESEARCH DESIGN AND METHODS

We analyzed beta-OHB in prospectively collected specimens from the National Institute of Child Health and Human Development-Diabetes in Early Pregnancy Study, in gestational weeks 6-12 in diabetic (n = 204-239) and nondiabetic (n = 316-332) pregnant women.

RESULTS

Levels of beta-OHB in diabetic women were 2.5-fold higher than in nondiabetic pregnant women at 6 weeks' gestation and declined to 1.6-fold above nondiabetic women by 12 weeks' gestation (P < 0.0001 at all times). beta-OHB was positively correlated with glucose levels (P < 0.0001) in diabetic mothers, probably reflecting degree of diabetic control. beta-OHB correlated inversely with glucose (P < 0.0003) (gestational week 6 only) in nondiabetic mothers, possibly reflecting caloric intake. beta-OHB tended to be lower (not higher) in diabetic and nondiabetic mothers with malformed infants or pregnancy losses, but the difference was not statistically significant. beta-OHB in diabetic mothers at 8, 10, and 12 weeks correlated inversely with birth weight (P = 0.004-0.02), even after adjusting for maternal glucose levels. beta-OHB levels were also generally lower in diabetic mothers of macrosomic infants, and week 12 ultrasound crown-rump measurements were inversely related to beta-OHB levels.

CONCLUSIONS

The lst trimester beta-OHB is significantly higher in diabetic than nondiabetic pregnant women. In both groups, beta-OHB tended to be lower, not higher, in mothers who had a malformed infant or pregnancy loss. beta-OHB was inversely related to crown-rump length and birth weight. The modest beta-OHB elevation in the 1st trimester of reasonably well-controlled diabetic pregnancy is not associated with malformations, probably because beta-OHB levels causing malformations in embryo culture models are 20- to 40-fold higher. The mechanism of the beta-OHB association with impaired fetal growth is unknown.

Physiological reduction in fasting plasma glucose concentration in the first trimester of normal pregnancy: the diabetes in early pregnancy study

Previous studies indicate that fasting plasma glucose decreases during gestation, but the timing and extent are not consistent from study to study. We had an opportunity to examine this question in the normal pregnancy cohort of women studied in the Diabetes in Early Pregnancy Study. Subjects were monitored to identify pregnancy by human chorionic gonadotropin testing, enrolled within 21 days of conception, and screened to rule out gestational diabetes at the juncture of the second and third trimesters. All subjects were instructed to fast overnight for 10 to 12 hours. Three hundred sixty-one women were studied between 6 and 12 weeks of gestation. A median decrease in plasma glucose of 2 mg/dL was observed between weeks 6 and 10 (P=.007). In a smaller group of subjects evaluated through the third trimester, little further glucose reduction was observed. A reduction in glycosylated hemoglobin levels between 10 and 20 weeks (P=.002) followed the earlier reduction in first trimester glucose levels. Analysis by body mass index (BMI) showed a smaller first trimester reduction with increasing BMI, and none among severely obese women (BMI > 29.9 kg/m2). The decline in fasting plasma glucose in pregnancy begins early in the first trimester, well before fetal glucose requirements can contribute to the decline in the glucose level. Thereafter, plasma glucose levels decrease little. These results suggest that in the setting in which this study was performed (an overnight fast) maternal physiologic adjustments account for a reduction in plasma glucose early in the first trimester of pregnancy, and possibly even later in gestation as well.

American Diabetes Association's Fourth International Workshop-Conference on Gestational Diabetes Mellitus: summary and discussion. Therapeutic interventions

This review summarizes Session IV: Therapeutic Interventions of the Fourth International Gestational Diabetes Workshop and suggests intervention protocols based on the presentations at this meeting and the literature. The opinions of the six presenters and their interpretation of the review of the literature in their specific areas, the synthesis of the 30 abstracts presented at this symposium on therapeutic interventions, and my interpretations of the literature to date on these strategies are discussed. Also, the suggested intervention protocols are outlined as to medical nutritional therapy, weight gain, insulin prescriptions, and the utility of an exercise program for gestational diabetes mellitus. The goals of an intervention protocol for the gestational diabetic women are to achieve and maintain normoglycemia and thus to minimize the risk of maternal or fetal morbidity.

A placebo-controlled, randomized study of glimepiride in patients with type 2 diabetes mellitus for whom diet therapy is unsuccessful

This multicenter, randomized, placebo-controlled study of glimepiride, a new oral sulfonylurea, was conducted in patients with type 2 diabetes for whom dietary treatment was unsuccessful (fasting plasma glucose [FPG] = 151-300 mg/dL) during a 1-week screening period. Patients were randomized to receive glimepiride (n = 123) or placebo (n = 126) once daily for a 10-week dose-titration period, then maintained on an individually determined optimal dose (1-8 mg of glimepiride or placebo) for 12 weeks. Glimepiride lowered FPG by 46 mg/dL, hemoglobin A1C (HbA1C) by 1.4%, and 2-hour postprandial glucose by 72 mg/dL more than placebo. Glimepiride improved postprandial insulin and C-peptide responses without producing clinically meaningful increases in fasting insulin or C-peptide levels. Good glycemic control (HbA1C < or = 7.2%) was achieved by 69% of the patients taking glimepiride versus 32% of those taking placebo. The overall incidence of adverse events was similar in both groups. No clinically noteworthy abnormal laboratory values or hypoglycemia (blood glucose < 60 mg/dL) occurred. Glimepiride is safe and effective for treatment of patients with type 2 diabetes for whom diet therapy is unsuccessful.

Effect of increasing glucose concentrations on Sertoli cell viability in the nonobese diabetic mouse

Spermatogenesis is severely altered in the nonobese diabetic (NOD) mouse in the presence of diabetes. When insulin is administered early in the development of diabetic changes, blunting of the testicular damage results, suggesting a direct causal effect of hyperglycemia on the testicular alterations. In view of the key role of Sertoli cells in supporting spermatogenic maturation, it has been speculated that the testicular damage may be mediated via Sertoli cell effects. The present study utilized Sertoli cell cultures to test the effects of different glucose levels on cellular viability. Sertoli cells from NOD and control mice were able to survive at glucose concentrations up to 38 mM, when maintained in culture at constant pH. With higher concentrations, there was a progressive loss of viability, comparable in the test and control animals. Further studies will be needed to determine the specific effect of hyperglycemia on Sertoli cells and the association with spermatogenic alterations in the NOD mouse.