Sodium Glucose Co-Transporter 2 Inhibitors in the Treatment of Type 2 Diabetes Mellitus

Type 2 diabetes mellitus (T2DM) is a chronic, progressive disease, control of which typically requires multiple therapies. Current guidelines suggest that, in addition to improving glycemic control, antihyperglycemic therapy should be chosen on the basis of its effects on body weight and the risk of hypoglycemia. The newest class of oral antihyperglycemic agents, the sodium glucose cotransporter 2 (SGLT2) inhibitors, reduces renal glucose reabsorption and increases urinary glucose excretion via an insulin-independent mechanism of action. SGLT2 inhibitors have been shown to improve glycemic control and to reduce body weight and systolic blood pressure, and their use is associated with a low risk of hypoglycemia. This paper explains the mechanism of action of SGLT2 inhibitors and reviews published efficacy and safety data from phase 3 clinical trials and pooled analyses for the three SGLT2 inhibitors currently approved by the U.S. Food and Drug Administration for use in patients with T2DM: canagliflozin (Invokana®), dapagliflozin (Farxiga™), and empagliflozin (Jardiance®). Implications for clinical osteopathic practice are discussed

What to Do After Basal Insulin: 3 Tx Strategies for Type 2 Diabetes

While many family physicians have become comfortable with using once-daily basal insulin such as glargine or detemir, what to do after basal insulin is much more complex. This review builds upon an earlier article in this journal, “Insulin for type 2 diabetes: How and when to get started,” by explaining 3 strategies to consider when basal insulin alone isn\u27t enough

Treatment of specific macrovascular beds in patients with diabetes mellitus

In 2007, over 23 million people had diabetes in the United States and death from cardiovascular disease is estimated to occur in 80% of those Americans. Risk factor reduction is the most important therapy for primary and secondary prevention of macrovascular disease in patients with and without diabetes mellitus. Despite this, presentation and response to therapy is often different for patients with diabetes compared to their non-diabetic counterparts. This paper will review the current targets for therapy of cardiovascular disease, peripheral vascular disease, and cerebrovascular disease in patients with diabetes

Insulin Pumps: Beyond Basal-Bolus

Insulin pumps are a major advance in diabetes management, making insulin dosing easier and more accurate and providing great flexibility, safety, and efficacy for people who need basal-bolus insulin therapy. They are the preferred treatment for people with type 1 diabetes and many with type 2 diabetes who require insulin. This article reviews the basics of how insulin pumps work, who benefits from a pump, and how to manage inpatients and outpatients on insulin pumps

Food insecurity is associated with poorer glycemic control in patients receiving free versus fee-based care

© 2018 by the American Diabetes Association. This study examined differences in household food security (HFS), household adult food security (HAFS), and indicators of diabetes management between clients using free and fee-for-service clinics for diabetes care and management. The study’s 166 participants (free clinic, n = 41; fee-for-service clinic, n =125) had a mean age of 53 ± 16 years and were primarily Caucasian (n = 147 [91.9%]). Both HFS (P \u3c0.001) and HAFS (P \u3c0.001) differed between the clinic groups, as did A1C (free clinic 8.7 ± 1.7%; fee-for-service 7.8 ± 1.6%; P = 0.005). A1C increased as HFS (r = 0.293, P \u3c0.001) and HAFS (r = 0.288, P = 0.001) worsened

Diabetes Update: Your Guide to the Latest ADA Standards

The authors highlight the latest changes in the ADA standards and review recommendations of particular relevance for family physicians

Empagliflozin in the Treatment of Type 2 Diabetes: Evidence to Date

In the last decade, researchers have gained a greater understanding of the pathophysiologic mechanisms of type 2 diabetes as a chronic and progressive disease. One of the more recent treatment targets is the kidney. The kidneys become maladaptive in diabetes by increasing the reabsorption of glucose above the normal physiologic renal threshold. This discovery has led to the development of the sodium/glucose cotransporter 2 inhibitors (SGLT2). These agents readjust the renal threshold for glucose reabsorption to a lower level and decrease glucose reabsorption, while increasing urinary glucose when the glucose is above the renal threshold and subsequently lowering plasma glucose. The mechanism of action of the SGLT2 inhibitors is insulin independent, which makes them a novel treatment of diabetes. At the time of preparation of this manuscript, there were three SGLT2 inhibitors available in the US. This manuscript focuses on empagliflozin, the newest SGLT2 inhibitor, the trials in its development, and the clinical data available to date. Further, the authors propose future applications of empagliflozin, including in the treatment of type 1 diabetes, and its potential role in renoprotection

Regional Variations in Physical Fitness and Activity in Healthy and Overweight Ecuadorian Adolescents

Background: Insufficient physical activity (PA) and excessive sedentary behavior (SB) are the main contributors to adolescent obesity. However, it is uncertain whether recent economic growth and urbanization in Ecuador are contributing to an obesogenic environment. This study assessed the relationships among fitness, PA, SB, and perceived social support for PA in adolescents from urban (Quito) and rural (Loja) Ecuador. Methods: Fitness was estimated using 3-min step test and PA and SB participation and social support for PA were self-reported in 407 adolescents. T-tests and analysis of variance assessed differences by sex, obesity status, and region of Ecuador. Pearson correlations assessed relationships among PA, SB, fitness, and social support. Results: Males and rural adolescents (48.3 ± 9.4 and 47.1 ± 9.6 mL/kg/min) were more fit than females and urban adolescents (41.1 ± 7.5 and 39.7 ± 6.1 mL/kg/min). Fitness was negatively correlated with obesity only in rural Ecuador. Few adolescents reported ≥60 min/day of PA (8.4%) or ≤2 h/day of SB (30.2%), with greater SB participation in rural Ecuador. Weak correlations were observed among fitness, PA, SB, and parental/peer support for PA (r = −0.18 to 0.19; p \u3c 0.05). Conclusion: While fitness varied by sex, weight status, and region, SB participation and parent/peer support for PA, not PA participation itself, predicted fitness in rural Ecuadorean adolescents

Real and Perceived Discordance in Physicians and U.S. Adults’ Beliefs Regarding the Causes and Controllability of Type 2 Diabetes

Discordance between physicians and patients’ health beliefs can impede health communication efforts. However, little research considers physicians’ perceptions of patient beliefs, despite the importance of perceptions in shaping communication. In the current work, we examine instances of actual and perceived discordance between physicians and U.S. adults’ beliefs regarding the causes and controllability of type 2 diabetes. 229 family physicians completed an online survey measuring their health beliefs and perceptions of their patients’ beliefs. Physicians’ responses were contrasted against beliefs from a national survey sample of 1,168 U.S. adults. T-tests assessed whether (a) physicians’ beliefs diverged from the national sample’s beliefs (actual discordance), (b) physicians perceived that their health beliefs diverged from their patients’ beliefs (perceived discordance), and (c) physicians’ perceptions of patient beliefs diverged from the national sample’s beliefs (accuracy of perceived discordance). Findings revealed evidence of actual discordance; compared to the national sample, physicians were more likely to attribute type 2 diabetes to genes (versus lifestyle factors) and perceived greater control over developing diabetes. Moreover, although physicians perceived discordance between their own and their patients’ beliefs, data from the national sample suggested that these gaps were less substantial than physicians expected. In particular, findings showed that physicians generally overestimated discordance, expecting that people would be less likely to (1) attribute the development of diabetes to lifestyle factors (versus genes), and (2) perceive control over developing diabetes, than was actually reported. Implications of actual and perceived discordance for effective health communication and patient education are discussed

Cardiometabolic Risk Factors, Metabolic Syndrome and Pre-Diabetes in Adolescents in the Sierra Region of Ecuador

Background: Excess weight (overweight and obesity) is the major modifiable risk factor for type 2 diabetes mellitus (T2DM) and other non-communicable diseases. However, excess weight may not be as predictive of diabetes risk as once thought. While excess weight and other obesity-related non-communicable diseases are of growing concern in low-middle income countries in Latin America, there is limited research on risk factors associated with T2DM in adolescents. This study investigated prevalence of overweight, obesity, prediabetes, diabetes and metabolic syndrome in adolescents in Ecuador. Methods: A cross-sectional study was conducted with 433 adolescents from two schools in a small urban center in southern Ecuador and two schools in a large urban center in Quito. Risk factors were measured, including: height, weight, BMI, waist-to-hip ratio, fasting glucose, lipid panel, and HbA1c. Multivariate analysis of variance (MANOVA) was separately applied to risk factors and demographic factors as a set of dependent variables with sex, location and their interaction included as predictors. An independent t test was run on the data at 95% confidence intervals for the mean difference. The values for the triglycerides, LDL and VLDL were positively skewed. A Mann–Whitney U test was run on these data. Results: Using IOTF standards, 9.8% were overweight and 1.9% were obese. Only 1.6% of the sample met the criteria for prediabetes by fasting glucose but 12.4% of the sample met the criteria for prediabetes by HbA1c. None of the participants met criteria for diabetes. There were 2.3% of the participants that met the IDF criteria for metabolic syndrome. Adolescents from the larger urban center had higher rates of prediabetes, higher mean HbA1c, blood pressure, lipid values, and lower HDL levels. Conclusions: Use of HbA1c identifed more adolescents with prediabetes than FBG. The HbA1c measure is an attractive screening tool for prediabetes in developing countries. Although rates of obesity in Ecuadorian adolescents are low there is significant evidence to suggest that prediabetes is permeating the smaller urban centers. Traditional screening tools may underestimate this risk