Management of newly diagnosed patients with type 2 diabetes: What are the attitudes of physicians? A SUBITO!AMD survey on the early diabetes treatment in Italy

Early intensive therapy in type 2 diabetes can prevent complications. Nevertheless, metabolic control is often sub-optimal in newly diagnosed patients. This webbased survey aimed to evaluate opinions of physicians about treatment, priorities, and barriers in the care of patients first referred to diabetes clinics. Data on physician attitudes toward therapeutic preferences for two clinical case models (same clinical profile, except HbA1c levels of 8.6 and 7.3% at the first access, respectively) were collected. Participants were asked to rank from 1 (most important) to 6 (least important) a list of priorities and barriers associated with the care of new patients. Overall, 593 physicians participated. In both case models, metformin and education were primary options, although their combination with other classes of drugs varied substantially. Main priorities were ‘‘to teach the patient how to cope with the disease’’ and ‘‘to achieve HbA1c target’’; main barriers were ‘‘lack of time’’ and ‘‘long waiting list’’. At multivariate analyses, physicians from the South of Italy had a twofold higher likelihood to attribute a rank 1–2 to organizational barriers than those operating in the North (South vs. North: OR: 2.4; 95% CI 1.4–4.1; Center vs. North: OR: 2.4; 95% CI 0.9–3.2). In the absence of a widely accepted evidence-based therapeutic algorithm driving the therapeutic choices according to the patient characteristics, prescriptions vary according to physician preferences. Education is perceived as a key-strategy, but organizational barriers and geographic disparities are an obstacle. These findings can drive new strategies to reduce clinical inertia, attitudes variability, and geographic disparities

Insulin requirements and carbohydrate to insulin ratio in normal weight, overweight, and obese women with type 1 diabetes under pump treatment during pregnancy: a lesson from old technologies

Aim:The primary aim of this study was to assess insulin requirements and carbohydrateto insulin ratio (CHO/IR) in normal weight, overweight, and obese pregnant women withtype 1 diabetes across early, middle, and late pregnancy.Methods:In this multicenter, retrospective, observational study we evaluated 86 of 101pregnant Caucasian women with type 1 diabetes under pump treatment. The womenwere trained to calculate CHO/IR daily by dividing CHO grams of every single meal byinsulin units injected. Since the purpose of the study was to identify the CHO/IR able toreach the glycemic target, we only selected the CHO/IR obtained when glycemic valueswere at target. Statistics: SPSS 20.Results:We studied 45 normal weight, 31 overweight, and 10 obese women. Insulinrequirements increased throughout pregnancy (p < 0.0001 and <0.001 respectively) inthe normal and overweight women, while it remained unchanged in the obese women.Insulin requirements were different between groups when expressed as an absolute value,but not when adjusted for body weight. Breakfast CHO/IR decreased progressivelythroughout pregnancy in the normal weight women, from 13.3 (9.8–6.7) at thefirst stageof pregnancy to 6.2 (3.8–8.6) (p = 0.01) at the end stage, and in the overweight womenFrontiers in Endocrinology | www.frontiersin.orgFebruary 2021 | Volume 12 | Article 6108771Edited by:Elena Succurro,University of Magna Graecia, ItalyReviewed by:Cristina Bianchi,Azienda Ospedaliero-UniversitariaPisana, ItalyMaria Grazia Dalfra’,University of Padua, Italy*Correspondence:Camilla [email protected] section:This article was submitted toObesity,a section of the journalFrontiers in EndocrinologyReceived:27 September 2020Accepted:14 January 2021Published:25 February 2021Citation:Festa C,Fresa R,Visalli N,Bitterman O,Giuliani C,Suraci C,Bongiovanni M andNapoli A (2021)Insulin Requirements andCarbohydrate to Insulin Ratio inNormal Weight, Overweight, andObese Women With Type 1Diabetes Under Pump TreatmentDuring Pregnancy: A LessonFrom Old Technologies.Front. Endocrinol. 12:610877.doi: 10.3389/fendo.2021.610877ORIGINAL RESEARCHpublished: 25 February 2021doi: 10.3389/fendo.2021.610877 from 8.5 (7.1–12.6) to 5.2 (4.0–8.1) (p = 0.001), while in the obese women it remainedstable, moving from 6.0 (5.0–7.9) to 5.1 (4.1–7.4) (p = 0.7). Likewise, lunch and dinnerCHO/IR decreased in the normal weight and overweight women (p < 0.03) and not in theobese women. The obese women gained less weight than the others, especially in earlypregnancy when they even lost a median of 1.25 (−1−1.1) kg (p = 0.005). In earlypregnancy, we found a correlation between pregestational BMI and insulin requirements(IU/day) or CHO/IR at each meal (p < 0.001 and p = 0.001, respectively). In latepregnancy, a relationship between pre-gestational BMI and CHO/IR change was found(P = 0.004), as well as between weight gain and CHO/IR change (p=0.02). Thesignificance was lost when both variables were included in the multiple regressionanalysis. There was no difference in pregnancy outcomes except for a higher pre-termdelivery rate in the obese women.Conclusion:Pre-gestational BMI and weight gain may play a role in determining CHO/IRduring pregnancy in women with type 1 diabetes under pump treatment

Implementing a guideline for the treatment of type 2 diabetics: results of a Cluster- Randomized Controlled Trial (C-RCT)

<p>Abstract</p> <p>Background</p> <p>In Italy many diabetics still lack adequate care in general practice. We assessed the effectiveness of different strategies for the implementation of an evidence-based guideline for the management of non-complicated type 2 diabetes among General Practitioners (GPs) of Lazio region.</p> <p>Methods</p> <p>Three-arm cluster-randomised controlled trial with GPs as units of randomisation (clusters). 252 GPs were randomised either to an active strategy (training module with administration of the guideline), or to a passive dissemination (administration of the guideline only), or to usual care (control). Data on prescriptions of tests and drugs were collected by existing information systems, whereas patients' data came from GPs' databases. Process outcomes were measured at the cluster level one year after the intervention. Primary outcomes concerned the measurement of glycosilated haemoglobin and the commissioning of micro- and macrovascular complications assessment tests. In order to assess the physicians' drug prescribing behaviour secondary outcomes were also calculated.</p> <p>Results</p> <p>GPs identified 6395 uncomplicated type 2 patients with a high prevalence of cardiovascular risk factors. Data on GPs baseline performance show low proportions of glycosilated haemoglobin assessments. Results of the C-RCT analysis indicate that the active implementation strategy was ineffective relating to all primary outcomes (respectively, OR 1.06 [95% IC: 0.76–1.46]; OR 1.07 [95% IC: 0.80–1.43]; OR 1.4 [95% IC:0.91–2.16]. Similarly, passive dissemination of the guideline showed no effect.</p> <p>Conclusion</p> <p>In our region compliance of GPs with guidelines was not enhanced by a structured learning programme. Implementation through organizational measures appears to be essential to induce behavioural changes.</p> <p>Trial registration</p> <p>ISRCTN80116232</p

Insulin Requirements and Carbohydrate to Insulin Ratio in Normal Weight, Overweight, and Obese Women With Type 1 Diabetes Under Pump Treatment During Pregnancy: A Lesson From Old Technologies

AimThe primary aim of this study was to assess insulin requirements and carbohydrate to insulin ratio (CHO/IR) in normal weight, overweight, and obese pregnant women with type 1 diabetes across early, middle, and late pregnancy.MethodsIn this multicenter, retrospective, observational study we evaluated 86 of 101 pregnant Caucasian women with type 1 diabetes under pump treatment. The women were trained to calculate CHO/IR daily by dividing CHO grams of every single meal by insulin units injected. Since the purpose of the study was to identify the CHO/IR able to reach the glycemic target, we only selected the CHO/IR obtained when glycemic values were at target. Statistics: SPSS 20.ResultsWe studied 45 normal weight, 31 overweight, and 10 obese women. Insulin requirements increased throughout pregnancy (p &amp;lt; 0.0001 and &amp;lt;0.001 respectively) in the normal and overweight women, while it remained unchanged in the obese women. Insulin requirements were different between groups when expressed as an absolute value, but not when adjusted for body weight. Breakfast CHO/IR decreased progressively throughout pregnancy in the normal weight women, from 13.3 (9.8–6.7) at the first stage of pregnancy to 6.2 (3.8–8.6) (p = 0.01) at the end stage, and in the overweight women from 8.5 (7.1–12.6) to 5.2 (4.0–8.1) (p = 0.001), while in the obese women it remained stable, moving from 6.0 (5.0–7.9) to 5.1 (4.1–7.4) (p = 0.7). Likewise, lunch and dinner CHO/IR decreased in the normal weight and overweight women (p &amp;lt; 0.03) and not in the obese women. The obese women gained less weight than the others, especially in early pregnancy when they even lost a median of 1.25 (−1 −1.1) kg (p = 0.005). In early pregnancy, we found a correlation between pregestational BMI and insulin requirements (IU/day) or CHO/IR at each meal (p &amp;lt; 0.001 and p = 0.001, respectively). In late pregnancy, a relationship between pre-gestational BMI and CHO/IR change was found (P = 0.004), as well as between weight gain and CHO/IR change (p=0.02). The significance was lost when both variables were included in the multiple regression analysis. There was no difference in pregnancy outcomes except for a higher pre-term delivery rate in the obese women.ConclusionPre-gestational BMI and weight gain may play a role in determining CHO/IR during pregnancy in women with type 1 diabetes under pump treatment.</jats:sec

The protein tyrosine phosphatase nonreceptor 22 (PTPN22) is associated with high GAD antibody titer in latent autoimmune diabetes in adults: Non Insulin Requiring Autoimmune Diabetes (NIRAD) Study 3.

OBJECTIVE: We previously demonstrated the presence of two different populations among individuals with adult-onset autoimmune diabetes: those having either a high titer or a low titer of antibodies to GAD (GADAs). Protein tyrosine phosphatase nonreceptor type 22 (PTPN22) has been identified as a new susceptibility gene for type 1 diabetes and other autoimmune diseases. The aim of the present study was to evaluate whether the phenotypic heterogeneity of adult-onset autoimmune diabetes based on the GADA titer is associated with the PTPN22 C1858T polymorphism. RESEARCH DESIGN AND METHODS: Analysis for the C1858T polymorphism using the TaqMan assay was performed in 250 subjects with adult-onset autoimmune diabetes, divided into two subgroups with low (<or=32 arbitrary units) or high (>32 arbitrary units) GADA titers and 450 subjects with classic type 2 diabetes (from the Non Insulin Requiring Autoimmune Diabetes [NIRAD] Study cohort of 5,330 subjects with adult-onset diabetes) and in 558 subjects with juvenile-onset type 1 diabetes and 545 normoglycemic subjects. RESULTS: Genotype, allele, and phenotype distributions of the PTPN22 C1858T variant revealed similar frequencies in autoimmune diabetes with high GADA titer and juvenile-onset type 1 diabetes. An increase in TT and CT genotypes was observed in individuals with a high GADA titer compared with a low GADA titer, those with type 2 diabetes, and control subjects (P < 0.002 for all comparisons). The PTPN22 1858T allele and phenotype frequencies were increased in high GADA titer compared with a low GADA titer, type 2 diabetic, and control subjects (P < 0.001 for all comparisons, odds ratio 2.6). CONCLUSIONS: In adult-onset autoimmune diabetes, the PTPN22 1858T variant is associated only with a high GADA titer, providing evidence of a genetic background to clinical heterogeneity identified by GADA titer

Position Statement on the management of continuous subcutaneous insulin infusion (CSII): The Italian Lazio experience

This document has been developed by a group of Italian diabetologists with extensive experience in continuous subcutaneous insulin infusion (CSII) therapy to provide indications for the clinical management of CSII in diabetic patients (both type 1 and type 2) based on delivery mode operating in Italy. Although the potential benefits of pump therapy in achieving glycemic goals is now accepted, such results cannot be obtained without specific knowledge and skills being conveyed to patients during ad hoc educational training. To ensure that these new technologies reach their full effectiveness, as demonstrated theoretically and clinically, a careful assessment of the overall therapeutic and educational process is required, in both qualitative and quantitative terms. Therefore, to ensure the cost-effectiveness of insulin pump therapy and to justify reimbursement of therapy costs by the National Health System in Italy, in this article we present a model for diabetes and healthcare centers to follow that provides for different levels of expertise in the field of CSII therapy. This model will guarantee the provision of excellent care during insulin pump therapies, thus representing the basis for a successful outcome and expansion of this form of insulin treatment in patients with diabetes while also keeping costs under control

Age- and gender-related differences in LDL-cholesterol management in outpatients with type 2 diabetes mellitus

Background. Dyslipidemia contribute to the excess of coronary heart disease (CHD) risk observed in women with type 2 diabetes (T2DM). Low density lipoprotein-cholesterol (LDL-C) is the major target for CHD prevention, and T2DM women seem to reach LDL-C targets less frequently than men. Aim. To explore age-and gender-related differences in LDL-C management in a large sample of outpatients with T2DM. Results. Overall, 415.294 patients (45.3% women) from 236 diabetes centers in Italy were included. Women were older and more obese, with longer diabetes duration, higher total-cholesterol, LDL-C, and HDL-C serum levels compared to men (P < 0.0001). Lipid profile was monitored in similar to 75% of subjects, women being monitored less frequently than men, irrespective of age. More women did not reach the LDL-C target as compared to men, particularly in the subgroup treated with lipid-lowering medications. The between-genders gap in reaching LDL-C targets increased with age and diabetes duration, favouring men in all groups. Conclusions. LDL-C management is worst in women with T2DM, who are monitored and reach targets less frequently than T2DM men. Similarly to men, they do not receive medications despite high LDL-C. These gender discrepancies increase with age and diabetes duration, exposing older women to higher CHD risk