The glucose triad and its role in comprehensive glycaemic control: current status, future management

The prevalence of type 2 diabetes across the world has been described as a global pandemic. Despite significant efforts to limit both the increase in the number of cases and the long-term impact on morbidity and mortality, the total number of people with diabetes is projected to continue to rise and most patients still fail to achieve adequate glycaemic control. Optimal management of type 2 diabetes requires an understanding of the relationships between glycosylated haemoglobin (HbA1c), fasting plasma glucose and postprandial glucose (the glucose triad), and how these change during development and progression of the disease. Early and sustained control of glycaemia remains important in the management of type 2 diabetes. The contribution of postprandial glucose levels to overall glycaemic control and the role of postprandial glucose targets in disease management are currently debated. However, many patients do not reach HbA1C targets set according to published guidelines. As recent data suggest, if driving HbA1C down to lower target levels is not the answer, what other factors involved in glucose homeostasis can or should be targeted? Has the time come to change the treatment paradigm to include awareness of the components of the glucose triad, the existence of glucose variability and their potential influence on the choice of pharmacological treatment? It is becomingly increasingly clear that physicians are likely to have to consider plasma glucose levels both after the overnight fast and after meals as well as the variability of glucose levels, in order to achieve optimal glycaemic control for each patient. When antidiabetic therapy is initiated, physicians may need to consider selection of agents that target both fasting and postprandial hyperglycaemia

Diabetic Peripheral Neuropathy in Type 2 Diabetes Mellitus in Korea

Diabetic peripheral neuropathy (DPN), a common and troublesome complication in patients with type 2 diabetes mellitus (T2DM), contributes to a higher risk of diabetic foot ulcer and lower limb amputation. These situations can negatively impact the quality of life of affected individuals. Despite its high prevalence and clinical importance, most diabetes mellitus patients not only do not recognize the presence of diabetic neuropathy, but also do not report their symptoms to physicians or other health care providers. Therefore, DPN is usually under diagnosed and undertreated. For early detection and appropriate intervention for DPN, a careful history, physical with neurologic examination, and prompt treatment are needed in T2DM patients

Investigating concordance in diabetes diagnosis between primary care charts (electronic medical records) and health administrative data: a retrospective cohort study

<p>Abstract</p> <p>Background</p> <p>Electronic medical records contain valuable clinical information not readily available elsewhere. Accordingly, they hold important potential for contributing to and enhancing chronic disease registries with the goal of improving chronic disease management; however a standard for diagnoses of conditions such as diabetes remains to be developed. The purpose of this study was to establish a validated electronic medical record definition for diabetes.</p> <p>Methods</p> <p>We constructed a retrospective cohort using health administrative data from the Institute for Clinical Evaluative Sciences Ontario Diabetes Database linked with electronic medical records from the Deliver Primary Healthcare Information Project using data from 1 April 2006 - 31 March 2008 (N = 19,443). We systematically examined eight definitions for diabetes diagnosis, both established and proposed.</p> <p>Results</p> <p>The definition that identified the highest number of patients with diabetes (N = 2,180) while limiting to those with the highest probability of having diabetes was: individuals with ≥2 abnormal plasma glucose tests, or diabetes on the problem list, or insulin prescription, or ≥2 oral anti-diabetic agents, or HbA1c ≥6.5%. Compared to the Ontario Diabetes Database, this definition identified 13% more patients while maintaining good sensitivity (75%) and specificity (98%).</p> <p>Conclusions</p> <p>This study establishes the feasibility of developing an electronic medical record standard definition of diabetes and validates an algorithm for use in this context. While the algorithm may need to be tailored to fit available data in different electronic medical records, it contributes to the establishment of validated disease registries with the goal of enhancing research, and enabling quality improvement in clinical care and patient self-management.</p

Increased incidence of glucose disorders during pregnancy is not explained by pre-pregnancy obesity in London, Canada

<p>Abstract</p> <p>Background</p> <p>The increasing incidence of impaired glucose tolerance (IGT), gestational diabetes (GDM) and type 2 diabetes (T2D) during pregnancy was hypothesized to be associated with increases in pre-pregnancy body mass index (BMI). The aims were to 1) determine the prevalence of IGT/GDM/T2 D over a 10 year period; 2) examine the relationship between maternal overweight/obesity and IGT/GDM/T2D; and 3) examine the extent to which maternal metabolic complications impact maternal and fetal pregnancy outcomes.</p> <p>Methods</p> <p>Data arose from a perinatal database which contains maternal characteristics and perinatal outcome for all singleton infants born in London, Canada between January 1, 2000 and December 31, 2009. Univariable and multivariable odds ratios (OR) were estimated using logistic regression with IGT/GDM/T2 D being the outcome of interest.</p> <p>Results</p> <p>A total of 36,597 women were included in the analyses. Population incidence of IGT, GDM and T2 D rose from 0.7%, 2.9% and 0.5% in 2000 to 1.2%, 4.2% and 0.9% in 2009. The univariable OR for IGT, GDM and T2 D were 1.65, 1.52 and 2.06, respectively, over the ten year period. After controlling for maternal age, parity and pre-pregnancy BMI the OR did not decrease. Although there was a positive relationship between pre-pregnancy BMI and prevalence of IGT/GDM/T2 D, this did not explain the time trends in the latter. Diagnosis of IGT/GDM/T2 D increased the risk of having an Apgar score <7 at 5 minutes, which was partially explained by gestational hypertension, high placental ratio, gestational age and large for gestational age babies.</p> <p>Conclusions</p> <p>We found a significant increase in the incidence of IGT/GDM/T2 D for the decade between 2000-2009 which was not explained by rising prevalence of maternal overweight/obesity.</p

Hypoglycaemia in Type 2 diabetes

The primary cause of hypoglycaemia in Type 2 diabetes is diabetes medication—in particular, those which raise insulin levels independently of blood glucose, such as sulphonylureas (SUs) and exogenous insulin. The risk of hypoglycaemia is increased in older patients, those with longer diabetes duration, lesser insulin reserve and perhaps in the drive for strict glycaemic control. Differing definitions, data collection methods, drug type/regimen and patient populations make comparing rates of hypoglycaemia difficult. It is clear that patients taking insulin have the highest rates of self-reported severe hypoglycaemia (25% in patients who have been taking insulin for > 5 years). SUs are associated with significantly lower rates of severe hypoglycaemia. However, large numbers of patients take SUs in the UK, and it is estimated that each year > 5000 patients will experience a severe event caused by their SU therapy which will require emergency intervention. Hypoglycaemia has substantial clinical impact, in terms of mortality, morbidity and quality of life. The cost implications of severe episodes—both direct hospital costs and indirect costs—are considerable: it is estimated that each hospital admission for severe hypoglycaemia costs around £1000. Hypoglycaemia and fear of hypoglycaemia limit the ability of current diabetes medications to achieve and maintain optimal levels of glycaemic control. Newer therapies, which focus on the incretin axis, may carry a lower risk of hypoglycaemia. Their use, and more prudent use of older therapies with low risk of hypoglycaemia, may help patients achieve improved glucose control for longer, and reduce the risk of diabetic complications

International Diabetes Federation guideline for management of postmeal glucose: a review of recommendations

Diabetes is a significant and growing concern, with over 246 million people around the world living with the disease and another 308 million with impaired glucose tolerance. Depending on the resources of different nations, intervention has generally focused on optimizing overall glycaemic control as assessed by glycated haemoglobin (HbA1c) and fasting plasma glucose (FPG) values. Nevertheless, increasing evidence supports the importance of controlling all three members of the glucose triad, namely HbA1c, FPG and postmeal glucose (PMG) in order to improve outcome in diabetes. As part of its global mission to promote diabetes care and prevention and to find a cure, the International Diabetes Federation (IDF) recently developed a guideline that reviews evidence to date on PMG and the development of diabetic complications. Based on an extensive database search of the literature, and guided by a Steering and Development Committee including experts from around the world, the IDF Guideline for Management of Postmeal Glucose offers recommendations for appropriate clinical management of PMG. These recommendations are intended to help clinicians and organizations in developing strategies for effective management of PMG in individuals with Type 1 and Type 2 diabetes. The following review highlights the recommendations of the guideline, the supporting evidence provided and the major conclusions drawn. The full guideline is available for download at http://www.idf.org

Effective lifestyle interventions to improve type II diabetes self-management for those with schizophrenia or schizoaffective disorder: a systematic review

<p>Abstract</p> <p>Background</p> <p>The prevalence of type II diabetes among individuals suffering from schizophrenia or schizoaffective disorders is more than double that of the general population. By 2005, North American professional medical associations of Psychiatry, Diabetes, and Endocrinology responded by recommending continuous metabolic monitoring for this population to control complications from obesity and diabetes. However, these recommendations do not identify the types of effective treatment for people with schizophrenia who have type II diabetes. To fill this gap, this systematic evidence review identifies effective lifestyle interventions that enhance quality care in individuals who are suffering from type II diabetes and schizophrenia or other schizoaffective disorders.</p> <p>Methods</p> <p>A systematic search from Medline, CINAHL, PsycINFO, and ISI Web of Science was conducted. Of the 1810 unique papers that were retrieved, four met the inclusion/exclusion criteria and were analyzed.</p> <p>Results</p> <p>The results indicate that diabetes education is effective when it incorporates diet and exercise components, while using a design that addresses challenges such as cognition, motivation, and weight gain that may result from antipsychotics.</p> <p>Conclusions</p> <p>This paper begins to point to effective interventions that will improve type II diabetes management for people with schizophrenia or other schizoaffective disorders.</p

Metformin treatment in diabetes and heart failure: when academic equipoise meets clinical reality

<p>Abstract</p> <p>Objective</p> <p>Metformin has had a 'black box' contraindication in diabetic patients with heart failure (HF), but many believe it to be the treatment of choice in this setting. Therefore, we attempted to conduct a pilot study to evaluate the feasibility of undertaking a large randomized controlled trial with clinical endpoints.</p> <p>Study Design</p> <p>The pilot study was a randomized double blinded placebo controlled trial. Patients with HF and type 2 diabetes were screened in hospitals and HF clinics in Edmonton, Alberta, Canada (population ~1 million). Major exclusion criteria included the current use of insulin or high dose metformin, decreased renal function, or a glycosylated hemoglobin <7%. Patients were to be randomized to 1500 mg of metformin daily or matching placebo and followed for 6 months for a variety of functional outcomes, as well as clinical events.</p> <p>Results</p> <p>Fifty-eight patients were screened over a six month period and all were excluded. Because of futility with respect to enrollment, the pilot study was abandoned. The mean age of screened patients was 77 (SD 9) years and 57% were male. The main reasons for exclusion were: use of insulin therapy (n = 23; 40%), glycosylated hemoglobin <7% (n = 17; 29%) and current use of high dose metformin (n = 12; 21%). Overall, contraindicated metformin therapy was the most commonly prescribed oral antihyperglycemic agent (n = 27; 51%). On average, patients were receiving 1,706 mg (SD 488 mg) of metformin daily and 12 (44%) used only metformin.</p> <p>Conclusion</p> <p>Despite uncertainty in the scientific literature, there does not appear to be clinical uncertainty with regards to the safety or effectiveness of metformin in HF making a definitive randomized trial virtually impossible.</p> <p>Trial registration</p> <p>ClinicalTrials.gov Identifier: NCT00325910</p

The effectiveness and efficiency of diabetes screening in Ontario, Canada: a population-based cohort study

<p>Abstract</p> <p>Background</p> <p>Little is known about the efficiency and effectiveness of the current level of diabetes screening activity in Ontario where there is universal access to health services. Our study aims were to: (i) determine how often Ontarians are screened for diabetes; (ii) estimate screening efficiency based on the number needed to screen (NNS) to diagnosis one diabetes case; (iii) examine the population effectiveness of screening as estimated by the number of undiagnosed diabetes cases.</p> <p>Methods</p> <p>Ontario respondents of the Canadian Community Health Survey who agreed to have their responses linked to health care data (n = 37,400) provided the cohort. The five-year probabilities of glucose testing and diabetes diagnoses were estimated using a Cox Proportional Hazards Model. We defined NNS as the ratio of diabetes tests to number of diabetes diagnoses over the study period. We estimated the number of undiagnosed diabetes by dividing the number not tested at the end of study period by the NNS.</p> <p>Results</p> <p>80% of women and 66% of men had a blood glucose test within 5 years. The efficiency of screening was estimated by a NNS of 14 among men and 22 among women. 127,100 cases of undiagnosed diabetes were estimated, representing 1.4% of the Ontario adult population. Increasing age, hypertension, immigrant and non-white ethnicity, and number of general practitioner visits were associated with an increased likelihood of having a glucose test (LR χ2 p < 0.001). Low income men were less likely to be tested.</p> <p>Conclusions</p> <p>Diabetes screening was high in this population-based cohort of Ontarians. Screening efficiency varied considerably in the population. Undiagnosed diabetes continues to be prevalent and remains concentrated in the highest risk groups for diabetes, especially among men.</p