Primary Care Diabetes

Editorial Board

2012-04-01

Should we consider cancer diagnosis in diabetic patients as a complication of diabetes, or is it iatrogenic sequelae?

Jaakko Tuomilehto — 2012-02-13

The risk of cancer is increased in diabetic patients and those with asymptomatic hyperglycaemia . Much of this association is due to high glucose, partially due to the toxic effects of excessive glucose, but hyperglycaemia also offers a pleasant environment for cancer cells that consume much more glucose than normal cells. In animal studies and mechanistic studies it has been shown that hyperinsulinaemia is promoting the growth of cancer cells . In addition it has previously been proposed that the risk of cancer of many forms is increased among people with diabetes treated with certain antidiabetic drugs . On the other hand, results from some studies, but not from all, have suggested that metformin may lower the risk of cancer , and today there are tens of studies ongoing to find out whether metformin can help people with cancer. The final judgment of the potential mitogenic effect of some antidiabetic drugs as well as the putative preventive effect of metformin is still open. We must also keep in mind that all drugs must be tested in many ways regarding the cancer potential and pass these tests clearly before they can be taken to the public market. In the supermarket there are many products that are either proven to cause cancer or have never been properly tested for their cancer potential, but people can buy them freely.

A model of translational research for diabetes prevention in low and middle-income countries: The Diabetes Community Lifestyle Improvement Program (D-CLIP) trial

2011-05-27

Abstract: Aims: The Diabetes Community Lifestyle Improvement Program (D-CLIP) aims to implement and evaluate in a controlled, randomized trial the effectiveness, cost-effectiveness, and sustainability of a culturally appropriate, low-cost, and sustainable lifestyle intervention for the prevention of type 2 diabetes mellitus in India.Methods: D-CLIP, a translational research project adapted from the methods and curriculum developed and tested for efficacy in the Diabetes Prevention Program, utilizes innovated methods (a step-wise model of diabetes prevention with lifestyle and metformin added when needed; inclusion of individuals with isolated glucose tolerance, impaired fasting glucose, and both; classes team-taught by professionals and trained community educators) with the goals of increasing diabetes prevention, community acceptability, and long-term dissemination and sustainability of the program. The study outcomes are: diabetes incidence (primary measure of effectiveness), cost-effectiveness, changes in anthropometric measures, plasma lipids, blood pressure, blood glucose, and HbA1c, Program acceptability and sustainability will be assessed using a mixed methods approach.Conclusion: D-CLIP, a low-cost, community-based, research program, addresses the key components of translational research and can be used as a model for prevention of chronic diseases in other low and middle-income country settings (clinicaltrials.gov number, NCT01283308).

Trends in chronic complications of type 2 diabetic patients from Spanish primary health care centres (GEDAPS study): Ten year-implementation of St. Vincent recommendations

2011-07-15

Abstract: Aims: To assess the implementation of St. Vincent recommendations in Catalonia (Spain) between 1993 and 2003 following a program of Continuous Quality Improvement.Methods: 65 health centres (433 health professionals) took part in the study. From 1993 to 2003, 34 workshops on consensus guidelines and feedback referring to the variables that needed to be improved were carried out. Data collection was obtained concerning, socio-demographic information, and disease characteristics and complications from patients with type 2 diabetes mellitus (DM).Results: Most cardiovascular risk factors improved: glycosilated haemoglobin (HbA1c) was reduced by 0.7% (95% CI: −0.49:−0.90); total cholesterol by 0.54mmol/L (95% CI: −0.53:−0.55); non-high density lipoprotein cholesterol by 0.81mmol/L (95% CI: −0.80:−0.82); systolic blood pressure (SBP) by 6.02mmHg (95% CI: −5.79:−6.25), and diastolic blood pressure (DBP) by 2.65mmHg (95% CI: −2.4:−2.9), with the exception of smoking and obesity, which increased by 2.1% and 5.9%, respectively.Retinopathy and albuminuria decreased by 40.7% and 46% (p<0.001), respectively. The incidence of diabetic foot lesions and amputations decreased by 65.7% and 61.1% (p<0.001), respectively. The prevalence of macrovascular complications showed a slight reduction (p=0.037). Ischemic cardiomyopathy and cerebrovascular accidents decreased by 7.7% and 17.6%, respectively.Conclusions: Our Continuous Quality Improvement program based on St. Vincent recommendations, had a positive impact on cardiovascular risk factors. We observed a reduction of chronic complications in type 2 DM patients.

Initiation of insulin among veterans with type 2 diabetes and sustained elevation of A1c

Michael L. Parchman, Chen-Pin Wang — 2011-08-16

Abstract: Aim: To examine if the relationship between insulin initiation and glycemic control among veterans with poorly controlled type 2 diabetes (T2DM) varies by the number of oral-glucose-lowering-medication classes used prior to insulin initiation.Methods: The cohort consisted of veterans with T2DM with at least two glycosolated hemoglobins (A1c) ≥8.0% within a 12-month period but without prior insulin use. The study period was October 1998 until May 2006. Cox regression analyses were used to assess the predictors of the rate of insulin initiation.Results: Among 40,537 who met the inclusion criteria, 17,519 (43.2%) had insulin initiated over a median follow-up period of 58.6 months. The rate of insulin initiation due to 1% increase in A1c increased by 33.6%, 28.8%, 24.2%, 19.7%, 15.4% for patients exposed to 0, 1, 2, 3, 4 classes of oral-glucose-lowering agents. A higher insulin initiation rate was also associated with younger age, more comorbidities, non-Hispanic white race/ethnicity, obesity, longer diabetes duration, and attending endocrinology clinics.Conclusions: Poor glycemic control is associated with increased rates of insulin initiation. This relationship is attenuated by the number of distinct oral-glucose-lowering-medication classes used prior to insulin initiation.

Adherence to hypoglycaemic medication among people with type 2 diabetes in primary care

2011-08-16

Abstract: Aims: To assess levels and correlates of adherence to hypoglycaemic medication among patients offered organised general practice diabetes care.Methods: 60 patients prescribed oral hypoglycaemic medication were recruited to a two-month prospective study. Prescribed doses taken and days on which the prescribed number of doses was taken were measured by MEMS (Medication Event Monitoring System).Results: Overall 99.1% of prescribed doses were taken (median, IQR: 96.8–100%), this was inversely correlated with daily dose frequency (Spearman's rho=0.37, p=0.004). Only 4 patients (6.7%) took less than 90% of prescribed doses. The prescribed dose was taken on 96.4% of days (median, IQR: 89.1–98.2%), this was correlated with age (rho=0.26, p=0.047) and inversely correlated with HbA1c levels (rho=−0.29, p=0.02) and daily dose frequency (rho=−0.33, p=0.009). Adherence to metformin was less than to other hypoglycaemic medication (Z=−3.48, p=0.0005).Conclusions: A dispensing practice with a well-run diabetes service can support high rates of adherence to hypoglycaemic medication. Before changing medication, low adherence might be considered as a possible cause of progressive hyperglycaemia, particularly among patients prescribed metformin more than once a day. Selective monitoring with MEMS may have a clinical as well as a research role in such people.

The effect of short-term use of the Guardian RT continuous glucose monitoring system on fear of hypoglycaemia in patients with type 1 diabetes mellitus

Raymond J. Davey, Kerri Stevens, Timothy W. Jones, Paul A. Fournier — 2011-11-02

Abstract: Aim: This study examines whether the short-term use of a continuous glucose monitor (CGM) can reduce the fear of hypoglycaemia in individuals with type 1 diabetes mellitus (T1DM).Methods: Twelve participants with T1DM were fitted with a Guardian® REAL-Time CGM and assigned to either an alarm (low glucose alarm set at 4.5mmol/L) or no alarm condition for 3 days, with both treatments administered following a counterbalanced study design. The participants completed the Hypoglycaemia Fear Survey on three separate occasions, before their CGM was fitted as well as following the alarm and no alarm conditions.Results: The alarm treatment reduced the incidence of hypoglycaemic episodes (CGM readings≤3.5mmol/L; 1.1±0.5 versus 1.9±0.5; mean±SEM) and the relative time spent below this hypoglycaemic threshold (0.9±0.4% versus 2.6±1.0%) but did not alter the fear of hypoglycaemia (78.6±7.0, 75.8±5.2 and 79.3±5.8 at baseline and following the alarm and no alarm treatments, respectively; p>0.05). CGM overestimated blood glucose levels by 0.8±0.2mmol/L for blood glucose readings less than, or equal to, 5mmol/L.Conclusions: Short-term use of the Guardian® REAL-Time CGM has no clinically significant effect on fear of hypoglycaemia possibly due, in part, to the inaccuracies of CGMs at low blood glucose levels.

Glucagon-like peptide 1 (GLP-1) analogue combined with insulin reduces HbA1c and weight with low risk of hypoglycemia and high treatment satisfaction

Marcus Lind, Johan Jendle, Ole Torffvit, Ibe Lager — 2011-10-19

Abstract: Aims: To evaluate the effects of adding glucagon-like peptide-1 (GLP-1) analogue therapy to insulin on glycated hemoglobin (HbA1c), weight, insulin dosage, treatment satisfaction, and risk of hypoglycaemia.Methods: Type 2 diabetes patients with insulin therapy receiving a GLP-1 analogue at 4 Swedish centers were studied. Hypoglycemia was evaluated using glucometers and patient self-report. The Diabetes Treatment Satisfaction Questionnaire (DTSQ) was used to evaluate treatment satisfaction.Results: Among 65 patients studied, 4 discontinued therapy, none due to hypoglycemia, and there were no suspected severe adverse events. Among 61 patients who remained on therapy over a mean of 7.0 months, 40 were treated with liraglutide and 21 with exenatide. HbA1c decreased from a mean of 8.9% (82.4mmol/mol) to 7.9% (71.9mmol/mol) (p<0.001), weight decreased from 111.1kg to 104.0kg (p<0.001) and insulin doses were reduced from 91.1U to 52.2U (p<0.001). There was one patient with severe hypoglycemia. The mean number of asymptomatic hypoglycemia per patient and month, reported for the last month (0.085 below 4.0mmol/l and 0 below 3.0mmol/l) and documented symptomatic hypoglycemia (0.24 below 4.0mmol/l and 0.068 below 3.0mmol/l) was low. The DTSQc showed higher treatment satisfaction than with the previous regimen of 11.9 (scale −18 to +18 points, p<0.001).Conclusions: The addition of GLP-1 analogues to insulin in patients with type 2 diabetes is associated with reductions in HbA1c, weight, and insulin dose, along with a low risk of hypoglycemia and high treatment satisfaction.

Longitudinal change in HbA1c after insulin initiation in primary care patients with type 2 diabetes: A database analysis in UK and Germany

Wolfgang Rathmann, Klaus Strassburger, Teresa Tamayo, Karel Kostev — 2011-11-18

Abstract: Aims: To evaluate the 3-year change in HbA1c values after start of insulin therapy among patients with type 2 diabetes in primary care practices in UK and Germany.Methods: Longitudinal data from general practices in Germany and UK (Disease Analyser, IMS HEALTH) from 2005 to 2009 were analysed, including 779 patients (mean age±SD: 63±11yrs, HbA1c: 8.1±1.3%) in Germany and 646 patients (55±12yrs; 9.3±1.5%) in UK with first time insulin prescriptions in 2005 (index date). The mean individual relative changes in HbA1c over 3 years after index date were adjusted for age, sex, diabetes duration, oral antidiabetics, insulin type, comorbidity and visits using general linear models.Results: The average adjusted HbA1c improvements in the first 12 months in primary care patients were 0.5% (95%CI: 0.4–0.6%) in Germany and 1.0% (0.7–1.3%) in UK. Between 12 and 36 months these improvements in glycemic control were maintained in both patient groups.Discussion: Initiation of insulin therapy in primary care patients in Germany and UK was associated with a similar moderate improvement in glycemic control over the first 12 months. After this period, insulin therapy only maintained HbA1c values without additional improvement in glycemic control.

The relationship between the exposure time of insulin glargine and risk of breast and prostate cancer: An observational study of the time-dependent effects of antidiabetic treatments in patients with diabetes

Marcus Lind, Martin Fahlén, Björn Eliasson, Anders Odén — 2011-11-07

Abstract: Aims: To elucidate methodological questions in assessing the relationship between insulin treatment and cancer, since the risk of tumour growth generally increases with longer exposure time and higher dose of a growth promoting substance.Methods: Continuous hazard functions for risk of breast and prostate cancer were estimated in relation to exposure of insulin glargine among diabetic patients included in the record system, Diab-Base, as well as in the general population in Sweden.Results: In 7942 female diabetic patients, mean follow-up 7.0 years, 2014 patients initiated insulin glargine with a mean follow-up of 3.5 years. Among 11,613 men, mean follow-up 6.9 years, 2760 had a mean follow-up with glargine of 3.4 years. Risk of prostate cancer decreased significantly with longer exposure to insulin glargine (p=0.032), although average risk versus non-glargine was non-significantly higher (HR 1.37, 95% CI 0.78–2.39). The breast cancer risk did not change with longer exposure to insulin glargine (p=0.35) and the mean risk was similar for glargine and non-glargine (p=0.12). With higher dose of insulin glargine, there was an increase in risk of prostate (p=0.037) and breast cancer (p=0.019). In diabetics, the mean risk of prostate cancer was decreased (HR 0.68, 95% CI 0.59–0.79) but similar for breast cancer (HR 0.95, 95% CI 0.78–1.14) compared to the general population and did not change with longer diabetes duration (p=0.68 and p=0.53 respectively).Conclusions: Analysing continuous hazard functions for cancer risk in relation to exposure time to an antidiabetic agent is an important complementary tool in diabetes and cancer research.

Do obese children with diabetic ketoacidosis have type 1 or type 2 diabetes?

2012-01-09

Abstract: Objective: Many obese children with unprovoked diabetic ketoacidosis (DKA) display clinical features of type 2 diabetes during follow up. We describe the clinical presentation, autoimmune markers and the long-term course of obese and lean children with DKA.Research design and methods: We reviewed the medical records on the initial acute hospitalization and outpatient follow-up care of 21 newly diagnosed obese and 20 lean children with unprovoked DKA at Emory University affiliated children's hospitals between 1/2003 and 12/2006.Results: Obese children with DKA were older and predominantly male, had acanthosis nigricans, and had lower prevalence of autoantibodies to islet cells and glutamic acid decarboxylase than lean children. Half of the obese, but none of the lean children with DKA achieve near-normoglycemia remission and discontinued insulin therapy during follow-up. Time to achieve remission was 2.2±2.3months. There were no differences on clinical presentation between obese children who achieved near-normoglycemia remission versus those who did not. The addition of metformin to insulin therapy shortly after resolution of DKA resulted in lower hemoglobin A1c (HbA1c) levels, higher rates of near-normoglycemia remission, and lower frequency of DKA recurrence. Near-normoglycemia remission, however, was of short duration and the majority of obese patients required reinstitution of insulin treatment within 15months of follow-up.Conclusion: In contrast to lean children with DKA, many obese children with unprovoked DKA display clinical and immunologic features of type 2 diabetes during follow-up. The addition of metformin to insulin therapy shortly after resolution of DKA improves glycemic control, facilitates achieving near-normoglycemia remission and prevents DKA recurrence in obese children with DKA.

The effectiveness and cost of single and multi-factorial cardiovascular risk factor modification to guideline targets in type 2 diabetes

A. Prescott, J.E. Bailey, K.J. Kelly, T. Munyombwe, A. Gray, L.K.M. Summers — 2012-01-06

Abstract: Aims: Cardiovascular disease is the main cause of morbidity and mortality in type 2 diabetes (T2DM), at huge cost to the NHS. We investigated the potential effect on population cardiovascular risk and associated costs of single and multi-factorial intervention, to target levels, in individuals with T2DM.Methods: Baseline population means and proportions for cardiovascular risk factors were calculated for 159 patients with T2DM from 3 general practices. Predicted 10year cardiovascular risk, and associated costs were calculated using the LIP2687 risk calculator, based on Framingham and UKPDS equations. Systolic blood pressure, HbA1C, total cholesterol and HDL-cholesterol were altered to NICE and SIGN target levels and the model run again. The difference in outcomes was observed.Results: 45%, 76% and 38% of patients met NICE targets for cholesterol, systolic blood pressure and HbA1c, respectively. As expected, comparing the two guidelines, fewer patients met the ‘stricter’ targets (P=0.0001). Treatment-to-target produced no significant difference in cardiovascular risk or costs, although greater reductions in outcomes were seen with multi-factorial intervention.Conclusion: This small study suggests that intervention in only those patients with the highest cardiovascular risk brings little reduction in population cardiovascular risk and associated health costs. Multi-factorial intervention in all patients with T2DM, regardless of baseline values, is likely to bring greater reductions. This raises the question as to whether the current emphasis on treatment to target should be modified to encourage multi-factorial intervention in all patients with T2DM, even those with baseline values below target levels.

Factors associated with preventive care practice among adults with diabetes

Hon K. Yuen — 2012-01-16

Abstract: Adherence to annual preventive care (foot, eye, and dental examinations) in this group of study participants with diabetes (n=253) was suboptimal. Participants were 2.6–5.8 times more likely to have a specific preventive care in the past 12 months if they were told to do so by a health care professional.

World Diabetes Congress, Dubai—4th–8th December, 2011—Commentary from a UK perspective

Rhys Williams — 2012-02-02

Am I getting smaller or are conference centres getting bigger? Montreal's was huge. This one in Dubai was gigantic. No wonder the staff need to ride around on motorised tricycles! Over 15,000 delegates converged on the Dubai Convention Centre. Despite this, many of the sessions were surprisingly sparsely attended, an effect, I imagine, at least in part resulting from the temptation of high powered shopping amongst the crazy buildings of down-town Dubai. (This is a place where architects seem to be desperately trying to out-do one another with their latest bizarre designs.)

Primary Care Diabetes Europe: Colophon

2012-02-10

Society News 6/1

2012-02-13