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In adults with BMI ≥27 kg/m 2 and type 2 diabetes, adding tirzepatide to a lifestyle intervention increased weight loss at 72 wk. Ann Intern Med 2023; 176:JC129. [PMID: 37931265 DOI: 10.7326/j23-0089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2023] Open
Abstract
SOURCE CITATION Garvey WT, Frias JP, Jastreboff AM, et al; SURMOUNT-2 investigators. Tirzepatide once weekly for the treatment of obesity in people with type 2 diabetes (SURMOUNT-2): a double-blind, randomised, multicentre, placebo-controlled, phase 3 trial. Lancet. 2023;402:613-626. 37385275.
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Abstract
OBJECTIVE In this commentary I will evaluate whether prediabetes should be treated pharmacologically. To consider this question, certain information concerning prediabetes is relevant. BACKGROUND INFORMATION (1) Prediabetes is not independently associated with cardiovascular disease; the other factors in the metabolic syndrome increase that risk; (2) various tests and criteria for diagnosing prediabetes are recommended, yielding prevalences varying from 6% to 38% depending on which are used; (3) one-third of patients with prediabetes revert to normal over time; (4) up to two-thirds of patients with prediabetes do not develop diabetes; (5) people with prediabetes have insulin resistance and impaired insulin secretion; (6) although pharmacological treatment of the dysglycemia temporarily lowers it, when the drugs are discontinued, incident diabetes develops similarly as that in those who received placebos; (7) when the drugs are discontinued, there are no changes in insulin resistance or impaired insulin secretion; (8) incident diabetes was similar at 10 years in people remaining on metformin in the Diabetes Prevention Program Outcome Study compared with those who did not receive the drug; (9) no current drugs will directly increase insulin secretion (except sulfonylureas and glinides which have not been used to treat prediabetes because of hypoglycemia concerns); (10) sufficient weight loss to lower insulin resistance by nutritional means is challenging and especially difficult to maintain. CONCLUSIONS Pharmacological treatment of the dysglycemia of prediabetes is not warranted. On the other hand, the ability of high doses of glucagon-like peptide (GLP)-1 receptor agonists and the combination of a GLP-1 receptor agonist and the glucose-dependent insulinotropic polypeptide (GIP) to lower weight by 15% and 20%, respectively, deserves consideration for the treatment of prediabetes. This amount of weight loss should decrease insulin resistance, allowing endogenous insulin secretion to be more effective and lower the risk for developing diabetes.
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Review of Prediabetes. JAMA 2023; 330:564. [PMID: 37552502 DOI: 10.1001/jama.2023.9959] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/09/2023]
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The Role of Prediabetes in the Metabolic Syndrome: Guilt by Association. Metab Syndr Relat Disord 2023; 21:197-204. [PMID: 37042661 DOI: 10.1089/met.2023.0005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/13/2023] Open
Abstract
The metabolic syndrome (MetS) is a cluster of risk factors for cardiovascular disease (CVD). Prediabetes is defined by either impaired glucose tolerance or by one of the more sensitive or more stringent criterion for impaired fasting glucose (IFG) or HbA1c levels that have been promulgated over the years. IFG is one of the risk factors for CVD included in the definition of the MetS. However, there is very little evidence that IFG is independently associated with CVD regardless of which criterion is used for its diagnosis. The CVD risk of the MetS is related to the other risk factors of central obesity, hypertension, elevated triglyceride, and low high-density lipoprotein cholesterol levels. If the components of the MetS are supposed to be risk factors for CVD, the dysglycemia of prediabetes should not be included in its definition.
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A simplified straightforward protocol for the use of U-500 regular insulin. Diabetes Obes Metab 2023; 25:634-636. [PMID: 36263710 DOI: 10.1111/dom.14896] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Revised: 10/16/2022] [Accepted: 10/17/2022] [Indexed: 02/02/2023]
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In adults with obesity without diabetes, adding tirzepatide to a lifestyle intervention increased weight loss at 72 wk. Ann Intern Med 2022; 175:JC116. [PMID: 36191308 DOI: 10.7326/j22-0072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Jastreboff AM, Aronne LJ, Ahmad NN, et al. Tirzepatide once weekly for the treatment of obesity. N Engl J Med. 2022;387:205-16. 35658024.
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Comment on Aleppo et al. The Effect of Discontinuing Continuous Monitoring in Adults With Type 2 Diabetes Treated With Basal Insulin. Diabetes Care 2021;44:2729-2737. Diabetes Care 2022; 45:e84. [PMID: 35349652 DOI: 10.2337/dc21-2705] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
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Historical review of the diagnosis of prediabetes/intermediate hyperglycemia: Case for the international criteria. Diabetes Res Clin Pract 2022; 185:109219. [PMID: 35134465 DOI: 10.1016/j.diabres.2022.109219] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Revised: 12/03/2021] [Accepted: 01/25/2022] [Indexed: 11/29/2022]
Abstract
In 1997, the ADA recommended an IFG criterion for diagnosing prediabetes/intermediate hyperglycemia of FPG concentrations of 6.1-6.9 mmol/L (110-125 mg/dL). In 2003, they lowered it to 5.6-6.9 mmol/L (100-125 mg/dL) to equalize developing diabetes between IGT and IFG. International organizations accepted the first IFG criterion but not the second. The ADA subsequently recommended HbA1c levels for diagnosing prediabetes/intermediate hyperglycemia of 39-47 mmol/mol (5.7-6.4%) based on a model that utilized the composite risk of developing diabetes and CVD. However, the evidence that the intermediate hyperglycemia that defines prediabetes is independently associated with CVD is weak. Rather, the other risk factors for CVD in the metabolic syndrome are responsible. The WHO opined that prediabetes/intermediate hyperglycemia could not be diagnosed by HbA1c levels but the Canadians and Europeans recommended its diagnosis by values of 42-47 mmol/mol (6.0-6.4%). With the ADA criteria, approximately one-half of people are normal on re-testing, one-third spontaneously revert to normal over time and two-thirds never develop diabetes in their lifetimes. The international criteria for prediabetes/intermediate hyperglycemia increase the risk of developing diabetes and might motivate these individuals to more seriously undertake lifestyle interventions as a preventive measure.
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Clinical Overbasalization Revisited. Clin Diabetes 2022; 40:354-355. [PMID: 35983420 PMCID: PMC9331619 DOI: 10.2337/cd21-0132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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A Conversation on an Effective, Straightforward, Quantitative Approach to the Outpatient Use of Insulin. Diabetes Spectr 2022; 35:179-189. [PMID: 35668885 PMCID: PMC9160535 DOI: 10.2337/ds21-0001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
For primary care providers, using insulin can present challenges that can be met by a straightforward approach using the following principles. Depending on when it is injected, each component of the insulin regimen has a maximal effect on a specific period of the 24-hour cycle (e.g., overnight, morning, afternoon, or evening). The glucose pattern in that period determines whether the dose of that component of the insulin regimen requires adjusting. Regarding which insulin types and insulin regimens to use, human insulin (NPH and regular) is as effective as analog insulins, and a two-injection intensified insulin regimen is as effective as a four-injection regimen.
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Correction to the Bergman review. Diabetes Res Clin Pract 2021; 180:108632. [PMID: 33346071 DOI: 10.1016/j.diabres.2020.108632] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Effect of Diabetes-Trained Nurse Practitioners on Glycemic Outcomes: Their Suggested Use in Busy Primary Care Practices. Clin Diabetes 2021; 39:293-296. [PMID: 34421205 PMCID: PMC8329016 DOI: 10.2337/cd20-0102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
A Federally Qualified Health Center received ongoing external support for half-time salaries for two nurse practitioners to treat people with poorly controlled diabetes (A1C >9.0%) in the clinic's diabetes program using approved detailed treatment protocols. Patients were treated for 1 year and graduated from this program if their A1C fell to <7.5%. Ninety-one percent graduated, and treatment was deemed to have failed in 9% who did not achieve an A1C <7.5% by the end of the year of treatment. The suggestion is made to assign a specially trained diabetes nurse or physician assistant to serve many primary care providers at important clinical junctures to improve diabetes outcomes throughout busy primary care practices.
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Intratrial Exposure to Vitamin D and New-Onset Diabetes Among Adults With Prediabetes: A Secondary Analysis From the Vitamin D and Type 2 Diabetes (D2d) Study. Diabetes Care 2020;43:2916-2922. Diabetes Care 2021; 44:e105. [PMID: 33972322 DOI: 10.2337/dc20-3130] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
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Correction to the Bergman review. Diabetes Res Clin Pract 2021:108729. [PMID: 33675867 DOI: 10.1016/j.diabres.2021.108729] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Accepted: 02/15/2021] [Indexed: 10/22/2022]
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Effective use of computerized insulin dose adjustment algorithms on continuous glucose monitoring results by a clinical pharmacist - Proof-of-concept. J Diabetes 2021; 13:439-441. [PMID: 33399259 DOI: 10.1111/1753-0407.13154] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Revised: 12/15/2020] [Accepted: 01/03/2021] [Indexed: 01/18/2023] Open
Abstract
Highlights A clinical pharmacist using recommendations of Food and Drug Administration-cleared computerized insulin dose adjustment algorithms based on analyses of glucose readings from continuous glucose monitoring (Abbot Free Style Pro) in 13 poorly controlled insulin-requiring diabetic patients increased time in target range of 3.9 to 10.0 mmol/L from 29% to 51% and decreased time in range of >13.9 mmol/L from 43% to 23% (both P = 0.01) after 3 months. Glycated hemoglobin (HbA1c) levels (±SD) fell from 102 (±15) to 67 (±10) mmol/mol (P < 10-6 ).
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Metformin Should Not Be Used to Treat Prediabetes. Diabetes Care 2020; 43:1983-1987. [PMID: 32936780 DOI: 10.2337/dc19-2221] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Accepted: 04/28/2020] [Indexed: 02/03/2023]
Abstract
Based on the results of the Diabetes Prevention Program Outcomes Study (DPPOS), in which metformin significantly decreased the development of diabetes in individuals with baseline fasting plasma glucose (FPG) concentrations of 110-125 vs. 100-109 mg/dL (6.1-6.9 vs. 5.6-6.0 mmol/L) and A1C levels 6.0-6.4% (42-46 mmol/mol) vs. <6.0% and in women with a history of gestational diabetes mellitus, it has been suggested that metformin should be used to treat people with prediabetes. Since the association between prediabetes and cardiovascular disease is due to the associated nonglycemic risk factors in people with prediabetes, not to the slightly increased glycemia, the only reason to treat with metformin is to delay or prevent the development of diabetes. There are three reasons not to do so. First, approximately two-thirds of people with prediabetes do not develop diabetes, even after many years. Second, approximately one-third of people with prediabetes return to normal glucose regulation. Third, people who meet the glycemic criteria for prediabetes are not at risk for the microvascular complications of diabetes and thus metformin treatment will not affect this important outcome. Why put people who are not at risk for the microvascular complications of diabetes on a drug (possibly for the rest of their lives) that has no immediate advantage except to lower subdiabetes glycemia to even lower levels? Rather, individuals at the highest risk for developing diabetes-i.e., those with FPG concentrations of 110-125 mg/dL (6.1-6.9 mmol/L) or A1C levels of 6.0-6.4% (42-46 mmol/mol) or women with a history of gestational diabetes mellitus-should be followed closely and metformin immediately introduced only when they are diagnosed with diabetes.
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The "Cost-Effective" beneficial effect of pioglitazone on cardiovascular disease. Diabetes Res Clin Pract 2020; 165:108223. [PMID: 32473298 DOI: 10.1016/j.diabres.2020.108223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Accepted: 05/14/2020] [Indexed: 11/23/2022]
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Second-generation basal insulins to initiate insulin therapy in type 2 diabetes: A need for clinical evidence before incurring increased costs. Diabetes Obes Metab 2020; 22:719-721. [PMID: 32115843 DOI: 10.1111/dom.14016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Revised: 02/25/2020] [Accepted: 02/25/2020] [Indexed: 12/01/2022]
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Randomized controlled trial comparing hydroxychloroquine with pioglitazone as third-line agents in type 2 diabetic patients failing metformin plus a sulfonylurea: A pilot study. J Diabetes 2020; 12:91-94. [PMID: 31574564 DOI: 10.1111/1753-0407.12989] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2019] [Accepted: 09/17/2019] [Indexed: 11/29/2022] Open
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SGLT-2 inhibitors were not linked to severe or nonsevere UTIs vs DPP-4 inhibitors or GLP-1 agonists. Ann Intern Med 2019; 171:JC70. [PMID: 31842228 DOI: 10.7326/acpj201912170-070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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Response to Umpierrez et al. Diabetes Obes Metab 2019; 21:2344-2345. [PMID: 31210017 DOI: 10.1111/dom.13815] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Revised: 06/04/2019] [Accepted: 06/11/2019] [Indexed: 12/29/2022]
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Delayed response to an injection of U-500 regular insulin is not rare. J Diabetes 2019; 11:519-521. [PMID: 30821052 DOI: 10.1111/1753-0407.12911] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Accepted: 02/26/2019] [Indexed: 11/28/2022] Open
Abstract
Highlights Since the PK/PD of U-500 regular insulin more closely resembles that of NPH insulin, it is commonly given before breakfast and dinner. However, a delayed response in which the major effect of the concentrated insulin takes place overnight occurs in about 10% of patients. This necessitates converting the regimen to a basal/bolus one in which the before breakfast injection serves as the basal insulin and short- or rapid-acting insulin is given before meals to control daytime hyperglycemia.
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Review: Rapid-acting analogues do not differ from regular human insulin for mortality or HbA1c in type 2 diabetes. Ann Intern Med 2019; 170:JC39. [PMID: 30986829 DOI: 10.7326/acpj201904160-039] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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Effect of Remote Glucose Monitoring Utilizing Computerized Insulin Dose Adjustment Algorithms: A Pilot Project. Diabetes Ther 2019; 10:523-533. [PMID: 30721451 PMCID: PMC6437238 DOI: 10.1007/s13300-019-0565-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2018] [Indexed: 01/22/2023] Open
Abstract
INTRODUCTION Primary care physicians are often challenged to adjust insulin doses. To facilitate this process, we evaluated in a safety net clinic the work flow and glycemic effects of remote glucose monitoring utilizing Federal Drug Administration (FDA) cleared, Conformité Européenne (CE) registered software that contained computerized algorithms for insulin dose adjustments to help clinicians make dosing decisions for insulin-requiring patients. METHODS Patients taking insulin for at least 6 months with HbA1c levels of at least 8.0% measured glucose levels with a meter attached to their smartphones. Readings were automatically transmitted to a secure, Health Insurance Portability and Accountability Act (HIPAA)-approved server. Values were analyzed every 2-3 weeks and reports, including recommendations for insulin dose changes, were sent to a clinic nurse practitioner (NP) who modified or accepted the recommendations. A staff person contacted patients with the new doses determined by the NP. RESULTS Insulin regimens included basal alone (N = 11), basal/bolus (N = 14), and self-mixed/split (N = 3). Baseline HbA1 levels of 10.0% fell to 8.1% at 3 months (N = 28) and 7.6% at 6 months (N = 17) without any clinic visits for dose adjustments. There were 268 reports which allowed providers to see 268 other patients during these avoided clinic visits. The NP agreed with 82% of the recommendations. The total doses of insulin increased by 24%. No patient experienced severe hypoglycemia or visited an emergency department for hypoglycemia. CONCLUSION Remote glucose monitoring utilizing computerized insulin dose adjustment algorithms saved time for both providers and patients while effectively improving glycemia. FUNDING The Leonard M. Lipman Charitable Trust and Mellitus Health.
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Corrigendum to "An updated meta-analysis of pioglitazone exposure and bladder cancer and comparison to the drug's effect on cardiovascular disease and non-alcoholic steatohepatitis" [Diab. Res. Clin. Pract. 135 (2018) 102-110]. Diabetes Res Clin Pract 2018; 142:408-409. [PMID: 29935912 DOI: 10.1016/j.diabres.2018.06.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Erratum: Delayed Response to U-500 Regular Insulin. Clinical Diabetes 2018;36: 77-79 (DOI: 10.2337/cd16-0058). Clin Diabetes 2018; 36:208. [PMID: 29688235 PMCID: PMC5898164 DOI: 10.2337/cd18-er01] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
[This corrects the article on p. 77 in vol. 36, PMID: 29382984.].
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Abstract
IN BRIEF Insulin dose adjustment decisions in 20 simulated patients by nine primary care physicians (PCPs) and nine endocrinologists were compared to the algorithms used in a diabetes program in a large safety-net clinic. The number of dose changes was similar in the PCP and endocrinologist groups; however, the amounts of the dose changes in the PCP group were significantly closer to the diabetes program algorithms than the amounts in the endocrinologist group. Time constraints, rather than lack of ability, seem to be the major barrier to PCPs treating patients with insulin.
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An updated meta-analysis of pioglitazone exposure and bladder cancer and comparison to the drug's effect on cardiovascular disease and non-alcoholic steatohepatitis. Diabetes Res Clin Pract 2018; 135:102-110. [PMID: 29146119 DOI: 10.1016/j.diabres.2017.11.002] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2017] [Accepted: 11/07/2017] [Indexed: 01/06/2023]
Abstract
AIM We performed a meta-analysis of epidemiological studies evaluating exposure to pioglitazone and the risk for bladder cancer and compared these results to the drug's effects on cardiovascular disease (CVD) and non-alcoholic steatohepatitis (NASH). METHODS Pubmed and Embase were searched for cohort and case control studies for all years through 2016. RESULTS Data from 17 papers were analyzed. In cohort studies, 822 of 357,888 pioglitazone-exposed patients (0.23%) developed bladder cancer while 7691 of 2,898,682 unexposed (0.26%) did. In case control studies, 3219 of 1,146,916 patients (0.28%) developed bladder cancer. A random effects model showed no significant association between ever vs never use or with cumulative doses of pioglitazone. However, there was a significant association with 1-2 years (HR = 1.28 [1.08-1.55]) and >2 years (HR = 1.42 [1.14-1.77]) of exposure. The numbers needed to treat for one additional case of bladder cancer ranged from 899 to 6380 while to benefit CVD and NASH, 4-256 and 2-12, respectively. CONCLUSIONS Given the very small prevalence of bladder cancer in diabetic patients exposed (or not) to pioglitazone (<0.3%) and the much greater beneficial effects of the drug on CVD and NASH, the use of pioglitazone should be resurrected.
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Diabetic retinopathy is not present in non-diabetic older overweight/obese African Americans. Diabetes Res Clin Pract 2017; 126:322. [PMID: 28062174 DOI: 10.1016/j.diabres.2016.12.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2016] [Accepted: 12/07/2016] [Indexed: 11/27/2022]
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Diabetic retinopathy is not present in newly diagnosed diabetic patients. Diabetologia 2016; 59:2727. [PMID: 27743135 DOI: 10.1007/s00125-016-4131-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2016] [Accepted: 09/28/2016] [Indexed: 10/20/2022]
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Pioglitazone (Actos) and bladder cancer: Legal system triumphs over the evidence. J Diabetes Complications 2016; 30:981-5. [PMID: 27133452 DOI: 10.1016/j.jdiacomp.2016.04.004] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2015] [Revised: 04/05/2016] [Accepted: 04/06/2016] [Indexed: 01/11/2023]
Abstract
In preclinical studies, pioglitazone was associated with bladder cancer in male rats (but not in female rats, mice dogs or monkeys). Because of this association, the Federal Drug Administration requested a large 10year epidemiological study to evaluate whether there was an association between bladder cancer and exposure to pioglitazone in patients. A 5-year interim report published in 2011 showed no significant association between ever vs never exposure to the drug but a significant association in patients exposed to pioglitazone for >2years. Importantly, the final 10year report did not confirm the 5year interim report finding no association between bladder cancer and pioglitazone, even after >4years of exposure to the drug. However, as would be expected, following the 5-year interim report, many epidemiological studies were carried out and civil litigation lawsuits began to be filed. Of the 23 epidemiological studies that have been published to date, 18 showed no association between bladder cancer and pioglitazone (5 with a combination of rosiglitazone and pioglitazone). Of the five that did show a significant association with pioglitazone, three could not be confirmed in the same population and in one of them there were significantly more risk factors for bladder cancer in the patients exposed to pioglitazone. In the fourth one, a significant association became non-significant when patients >79years were included. In the fifth one, detection bias was a major flaw. Currently, >11,000 legal cases have been filed, many of which claim emotional distress due to the fear of bladder cancer. To limit their legal costs, the pharmaceutical company has established a 2.4 billion dollar settlement pool. So much for evidence-based medicine.
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Abstract
IN BRIEF Insulin therapy is challenging for providers as well as for patients. This article describes a set of principles underlying appropriate insulin treatment and a detailed discussion of how to use them.
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Effect of long term vitamin D supplementation on biomarkers of inflammation in Latino and African-American subjects with pre-diabetes and hypovitaminosis D. Horm Metab Res 2015; 47:280-3. [PMID: 25011019 PMCID: PMC4648252 DOI: 10.1055/s-0034-1383652] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Low vitamin D levels are associated with minority subjects, the metabolic syndrome, and inflammation. The effect of vitamin D supplementation on markers of inflammation has not been well studied. The aim of the study was to evaluate the effects of high doses of vitamin D supplementation for 1 year on serum biomarkers of inflammation in Latino and African-American subjects with pre-diabetes and hypovitaminosis D. Latino (n=69) and African-American (n=11) subjects who had both pre-diabetes and hypovitaminosis D with a mean age of 52.0 years, a BMI of 32.7 kg/m(2), and 70% of whom were females, were randomized to receive weekly doses (mean±SD) of vitamin D (85 300 IU±16 000) or placebo oil for 1 year. Serum levels of interleukin-6, tumor necrosis factor, highly sensitive C-reactive protein), plasminogen activator inhibitor 1, and insulin-like growth factor-1 were measured at baseline, 6, and 12 months. Serum 25-OH vitamin D levels of 22 ng/ml at baseline quickly rose to nearly 70 ng/ml in subjects receiving vitamin D and did not change in the placebo group. Two-way repeated measures ANOVA showed no differences between the 2 groups in any of the 5 selected parameters. High dose vitamin D supplementation for 1 year in minority subjects with pre-diabetes and hypovitaminosis D failed to affect serum biomarkers of inflammation.Clinical trial reg. no.: NCT00876928, clinicaltrials.gov.
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Response to comment on Kahn and Davidson. The reality of type 2 diabetes prevention. Diabetes Care 2014;37:943-949. Diabetes Care 2014; 37:e276-7. [PMID: 25414407 DOI: 10.2337/dc14-1927] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
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Response to comment on Grunberger "insulin analogs-are they worth it? Yes!" Diabetes Care 2014;37:1767-1770 and Davidson "insulin analogs-is there a compelling case to use them? No!" Diabetes Care 2014;37:1771-1774. Diabetes Care 2014; 37:e231. [PMID: 25249689 DOI: 10.2337/dc14-1605] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
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Clinical review: Effect of vitamin D3 supplementation on improving glucose homeostasis and preventing diabetes: a systematic review and meta-analysis. J Clin Endocrinol Metab 2014; 99:3551-60. [PMID: 25062463 PMCID: PMC4483466 DOI: 10.1210/jc.2014-2136] [Citation(s) in RCA: 188] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
CONTEXT Observational studies report consistent associations between low vitamin D concentration and increased glycemia and risk of type 2 diabetes, but results of randomized controlled trials (RCTs) are mixed. OBJECTIVE The objective of the study was to systematically review RCTs that report on the effects of vitamin D supplementation on glucose homeostasis or diabetes prevention. DATA SOURCES Sources of data for the study were MEDLINE, EMBASE, SCOPUS, Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects, Health Technology Assessment, and Science Citation Index from inception to June 2013. STUDY SELECTION Study selection was trials that compared vitamin D3 supplementation with placebo or a non-vitamin D supplement in adults with normal glucose tolerance, prediabetes, or type 2 diabetes. DATA EXTRACTION AND SYNTHESIS Two reviewers collected data and assessed trial quality using the Cochrane Risk of Bias tool. Random-effects models were used to estimate mean differences (MDs) and odds ratios. The main outcomes of interest were homeostasis model assessment of insulin resistance, homeostasis model assessment of β-cell function, hemoglobin A1c levels, fasting blood glucose, incident diabetes, and adverse events. DATA SYNTHESIS Thirty-five trials (43 407 patients) with variable risk of bias were included. Vitamin D had no significant effects on insulin resistance [homeostasis model assessment of insulin resistance: MD -0.04; 95% confidence interval (CI) -0.30 to 0.22, I-squared statistic (I(2)) = 45%], insulin secretion (homeostasis model of β-cell function: MD 1.64; 95% CI -25.94 to 29.22, I(2) = 40%), or hemoglobin A1c (MD -0.05%; 95% CI -0.12 to 0.03, I(2) = 55%) compared with controls. Four RCTs reported on the progression to new diabetes and found no effect of vitamin D (odds ratio 1.02; 95% CI 0.94 to 1.10, I(2) = 0%). Adverse events were rare, and there was no evidence of publication bias. CONCLUSIONS Evidence from available trials shows no effect of vitamin D3 supplementation on glucose homeostasis or diabetes prevention. Definitive conclusions may be limited in the context of the moderate degree of heterogeneity, variable risk of bias, and short-term follow-up duration of the available evidence to date.
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Rationale, design, and implementation of a cluster randomized trial using certified diabetes educators to intensify treatment for glycemia, blood pressure and lipid control: REMEDIES 4D. Contemp Clin Trials 2014; 39:124-31. [DOI: 10.1016/j.cct.2014.07.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2014] [Revised: 07/08/2014] [Accepted: 07/10/2014] [Indexed: 01/27/2023]
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Response to comment on Kahn and Davidson. The reality of type 2 diabetes prevention. Diabetes care 2014;37:943-949. Diabetes Care 2014; 37:e187. [PMID: 25061154 DOI: 10.2337/dc14-1134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
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Epidemiological ramifications of diagnosing diabetes with HbA1c levels. J Diabetes Complications 2014; 28:464-9. [PMID: 24768273 PMCID: PMC4287398 DOI: 10.1016/j.jdiacomp.2014.03.016] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2013] [Revised: 03/24/2014] [Accepted: 03/26/2014] [Indexed: 12/23/2022]
Abstract
AIMS To compare the prevalence of diabetes by history and using the fasting plasma glucose (FPG) criterion alone, the HbA1c criterion alone or either one in those not known to have diabetes. METHODS Analysis of NHANES population ≥20years old from 1999 through 2010. RESULTS In those diagnosed by laboratory tests, 86% met the FPG criterion and 53% met the HbA1c criterion. The prevalence of diabetes (history or laboratory test) was significantly increased when the FPG criterion was used compared with the HbA1c criterion in the entire (11.5% vs 10.5%, P=0.018) and Caucasian (10.6% vs 9.2%, P=0.022) populations. In contrast, there were no significant differences in the prevalence when only the FPG criterion was used compared with only the HbA1c criterion in Hispanics (12.9% vs 12.1% P=0.386) and African Americans (14.5 vs 14.3%, P=0.960). Using history and either criterion in those not known to have it, diabetes increased by 61% in this 12year period in adults ≥20years old. CONCLUSIONS Using the FPG rather than the HbA1c criterion to diagnose diabetes in those without a history significantly increased the total prevalence of diabetes in Caucasians but not in African Americans or Hispanics.
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Abstract
The availability of insulin analogs has offered insulin replacement strategies that are proposed to more closely mimic normal human physiology. Specifically, there are a considerable number of reports demonstrating that prandial insulin analogs (lispro, aspart, glulisine) have pharmacokinetic and pharmacodynamic profiles closer to normal, with resulting faster onset and offset of insulin effect when compared with regular human insulin. In addition, basal insulin analogs (glargine, detemir) have been reported to offer longer duration of action, less variability, more predictability, less hypoglycemia (especially nocturnal), and a favorable effect on weight. However, an argument against use of analog insulins as compared with use of regular or NPH insulin is one that states that the effectiveness and risk of hypoglycemia are the only two valid clinical outcomes that should be used to compare the analog and human insulins. Thus, there remains a debate in some circles that analog insulins are no more effective than human insulins, yet at a much higher financial cost. To provide an in-depth understanding of both sides of the argument, we provide a discussion of this topic as part of this two-part point-counterpoint narrative. In the counterpoint narrative presented here, Dr. Davidson provides his argument and defends his opinion that outside of a few exceptions, analog insulins provide no clinical benefit compared with human insulins but cost much more. In the preceding point narrative, Dr. Grunberger provides a defense of analog insulins and their value in clinical management and suggests that when evaluating the “cost” of therapy, a much more global assessment is needed.
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Abstract
Efforts to reduce the burden of type 2 diabetes include attempts to prevent or delay the onset of the disease. Landmark clinical trials have shown that lifestyle modification programs focused on weight loss can delay the onset of type 2 diabetes in subjects at high risk of developing the disease. Building on this knowledge, many community-based studies have attempted to replicate the trial results and, simultaneously, payers have begun to cover diabetes prevention services. This article focuses on the evidence supporting the premise that community prevention efforts will be successful. Unfortunately, no study has shown that diabetes can be delayed or prevented in a community setting, and efforts to replicate the weight loss achieved in the trials have been mostly disappointing. Furthermore, both the clinical trials and the community-based prevention studies have not shown a beneficial effect on any diabetes-related clinical outcome. While the goal of diabetes prevention is extremely important, the absence of any persuasive evidence for the effectiveness of community programs calls into question whether the use of public funds or national prevention initiatives should be supported at this time.
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Community screening for pre-diabetes and diabetes using HbA1c levels in high-risk African Americans and Latinos. Ethn Dis 2014; 24:195-199. [PMID: 24804366 PMCID: PMC4287403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023] Open
Abstract
OBJECTIVE To evaluate community screening using HbA1c levels in high risk African Americans and Latinos in those not known to have diabetes. DESIGN HbA1c levels were measured in 1542 African Americans and Latinos aged > or = 40 years with one or more of the following risk factors: family history in first degree relatives, waist circumference > or = 40 inches in males or > or = 35 inches in females, and hypertension, either treatment for or a measured BP of > or = 140/ 90 mm Hg. Oral glucose tolerance tests (OGTT) were offered to those meeting the HbA1c criterion for pre-diabetes. SETTING Churches, community health fares, senior citizen sites. PARTICIPANTS People without known diabetes. MAIN OUTCOME MEASURES Proportion of people meeting the HbA1c criteria for prediabetes (5.8-6.4%) and diabetes (> or = 6.5%). RESULTS 32% had one, 50% had two and 18% had three risk factors. By HbA1c criteria, 40% had pre-diabetes and 25% had diabetes. Increased waist circumference was the most common risk factor followed by a positive family history, and lastly, hypertension. Each individual risk factor was significantly (P < .001) and progressively more common as glycemia increased. Each additional risk factor increased the odds of pre-diabetes or diabetes by 2- to 4-fold. In individuals with pre-diabetes who underwent an OGTT, 59% were normal, 35% had pre-diabetes and only 6% had diabetes. CONCLUSIONS Community screening of high risk African Americans and Latinos with HbA1c levels identifies a large proportion of people with pre-diabetes and diabetes. Those identified with pre-diabetes are unlikely to meet the OGTT criteria for diabetes.
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Response to comment on: Davidson et al. High-dose vitamin D supplementation in people with prediabetes and hypovitaminosis D. Diabetes Care 2013;36:260-266. Diabetes Care 2013; 36:e72. [PMID: 23613612 PMCID: PMC3631822 DOI: 10.2337/dc12-2225] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
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Abstract
OBJECTIVE Low vitamin D levels predict the development of diabetes. This double-blind, randomized, control study in subjects with prediabetes and hypovitaminosis D evaluated whether high doses of vitamin D for 1 year affected insulin secretion, insulin sensitivity, and the development of diabetes. RESEARCH DESIGN AND METHODS A total of 1,551 subjects ≥40 years of age not known to have diabetes were screened with A1C levels. Subjects with A1C levels of 5.8-6.9% underwent an oral glucose tolerance test (OGTT). Subjects with prediabetes and 25-OH vitamin D (25-OHD) levels <30 ng/mL were randomized to receive weekly placebo (n = 53) or vitamin D (n = 56) with doses based on body weight and baseline 25-OHD levels. OGTTs were performed 3, 6, 9, and 12 months later. Insulin secretion and sensitivity were measured, and the proportion of subjects developing diabetes was assessed. RESULTS 25-OHD levels rapidly rose from 22 to nearly 70 ng/mL after vitamin D supplementation with a mean weekly dose of 88,865 IU. There were no differences between the placebo and vitamin D groups regarding fasting plasma glucose, 2-h glucose, or insulin secretion and sensitivity or in the percent developing diabetes or returning to normal glucose tolerance. No subjects experienced increased serum or urinary calcium levels. At 12 months, A1C levels were significantly slightly less (0.2%) in the vitamin D group. CONCLUSIONS In individuals with prediabetes and hypovitaminosis D, doses of vitamin D supplementation designed to raise serum 25-OHD levels into the upper-normal range for 1 year had no effect on insulin secretion, insulin sensitivity, or the development of diabetes compared with placebo administration.
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Comment on: Tam et al. Defining insulin resistance from hyperinsulinemic-euglycemic clamps. Diabetes Care 2012;35:1605-1610. Diabetes Care 2013; 36:e10. [PMID: 23264293 PMCID: PMC3526235 DOI: 10.2337/dc12-1354] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
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