Diabetic Retinopathy in 2011: Further Insights From New Epidemiological Studies and Clinical Trials

10.2337/dc11-0225Diabetes Care3441066-1067DICA

A Summary of the ADVANCE Trial

The publication of the U.K. Prospective Diabetes Study (UKPDS) in 1998 helped to shape the management of type 2 diabetes in recent years (1). The study demonstrated several points. First, sulfonylureas are as safe as insulin in controlling blood glucose. Second, metformin reduced cardiovascular disease in an overweight subgroup. Third, the same benefit of glycemic control in reducing microvascular disease (previously noted in type 1 diabetes) is applied equally to patients with type 2 diabetes. A separation in A1C of ∼1% in the UKPDS reduced the risk of microvascular disease (largely diabetic retinopathy) by ∼25%. This reflected the data from the Diabetes Control and Complications Trial, where a separation in A1C of 2% in intensive and standard groups led to a reduction in microvascular disease of ∼50% (2). A fourth demonstration was that there was no significant reduction in macrovascular disease but a trend toward fewer myocardial infarctions with more intensive glucose control. Fifth, using the current treatment of the time (first-generation sulfonylureas, human ultratard insulin, or metformin), it proved impossible to maintain glucose control, which tended to deteriorate throughout the study. It is now generally believed that the progressive fall in endogenous insulin production as β-cell numbers decline makes it difficult, if not impossible, to maintain tight control using standard treatment. Sixth, the UKPDS also showed that in those patients with hypertension, lowering blood pressure (BP) to moderate levels with either captopril or atenolol could reduce microvascular disease (3). In a subsequent study, the UKPDS investigators presented the rates of both micro- and macrovascular disease according to the achieved levels of A1C during the study (4). They showed a linear relationship between A1C and both groups of complications. The implication of the article was that if glycemic control could be tightened below the levels achieved in the UKPDS, then it might be possible to reduce rates, not only of microvascular complications, but also cardiovascular disease as well. The aim of the glucose arm of the Action in Diabetes and Vascular Disease: Preterax and Diamicron MR Controlled Evaluation (ADVANCE) trial (5) was to build on the information gained by the UKPDS and to answer the question as to whether intensifying glucose control to achieve an A1C of <6.5% would provide additional benefit in reducing the risk of both micro- and macrovascular disease. ADVANCE also asked questions about BP lowering in patients with type 2 diabetes. The aims of the BP arm were to establish whether routine provision of BP-lowering therapy produced additional benefits in terms of macro- and microvascular disease, irrespective of baseline BP, and added to the benefits produced by other cardiovascular preventive therapies, including ACE inhibitors

Demographics, insulin use and clinical targets in type 2 diabetes insulin users: comparison of a local integrated diabetes service vs a UK-wide cohort

Insulin-treated patients with type 2 diabetes require specialist multidisciplinary input to achieve treatment targets. We compared the demographics, achievement of combined NICE targets for HbA1c (≤7.5%), blood pressure (<140/80mmHg) and total cholesterol (<4mmol/L), and insulin use between patients from a local integrated diabetes service with those from a representative UK population. A cross-sectional evaluation of individual patient data from six randomly-selected primary care practices in Erewash (Integrated) Diabetes Service was compared with The Health Improvement Network (THIN) UK primary care database. Baseline age (61.5 years vs 65.8 years; p < 0.0001) and duration of insulin use (4.3 vs 6.3 years; p < 0.0001) use were lower in the THIN cohort. Mean HbA1c was similar between the two cohorts but weight, blood pressure, total and LDL cholesterol were significantly lower in the Erewash population compared with THIN. The combined achievement of HbA1c, total cholesterol and blood pressure was 17.5% in the Erewash cohort compared with 9.6% in the THIN cohort (p < 0.0001). There was a higher proportion of insulin users on basal-bolus than on premix in the Erewash cohort (89.3% vs 10.7%) compared with THIN (59.0% vs 41.1%). The proportion of patients who received concurrent oral glucose-lowering therapies in the Erewash integrated service was lower, except for SGLT2 inhibitors (2.5% in the Erewash cohort vs 0.5% in THIN; p < 0.0001). This model of an integrated diabetes service appears to confer better achievement for the NICE defined clinical targets compared with the THIN cohort. Further studies are required to investigate the impact of this service model on health economics, patient pathway and patient experience. Copyright © 2017 John Wiley & Sons

Epidemiology of Micro- and Macrovascular Complications of Type 2 Diabetes in Korea

The prevalence of diabetes in Korea has increased six- to sevenfold over the past 40 years with its complications becoming major causes of morbidity and mortality. The rate of death among patients with diabetes is about twice as high as that among persons without diabetes and the most common cause of death is cardiovascular disease (30.6%). Despite the seriousness of diabetic complications, 30 to 70% of patients receive inadequate care, and only 40% of treated diabetic patients achieve the optimal control with HbA1c level <7% in Korea. In 2006, over 30 to 40% of patients with diabetes have microvascular complications and around 10% of them have macrovascular complications from our national data. Despite there are some debates about intensive glycemic control resulting in the deterioration of macrovascular complication, multifactorial treatment approaches including proper glycemic control are important to prevent diabetic complications. There have been needs for finding proper biomarkers for predicting diabetic complications properly but we still need more longitudinal studies to find this correlation with causal relationship. In this article, we wanted to review the recent status of micro- and macrovascular complications of type 2 diabetes in Korea from integration of many epidemiologic studies

Barriers to following dietary recommendations in Type 2 diabetes

Aims  To evaluate barriers to following dietary recommendations in patients with Type 2 diabetes. Methods  We conducted focus groups and surveys in urban and suburban VA and academic medical centres. For the written survey, a self-administered questionnaire was mailed to a random sample of 446 patients with diabetes. For the focus groups, six groups of patients with diabetes (three urban, three suburban) were conducted, with 6–12 participants in each group. The focus groups explored barriers across various types of diabetes self-management; we extracted all comments relevant to barriers that limited patients’ ability to follow a recommended diet. Results  The written survey measured the burden of diabetes therapies (on a seven-point rating scale). Moderate diet was seen as a greater burden than oral agents (median 1 vs. 0, P  = 0.001), but less of a burden than insulin (median 1 vs. 4, P  < 0.001). A strict diet aimed at weight loss was rated as being similarly burdensome to insulin (median 4 vs. 4, P  = NS). Despite this, self-reported adherence was much higher for both pills and insulin than it was for a moderate diet. In the focus groups, the most commonly identified barrier was the cost (14/14 reviews), followed by small portion sizes (13/14 reviews), support and family issues (13/14 reviews), and quality of life and lifestyle issues (12/14 reviews). Patients in the urban site, who were predominantly African-American, noted greater difficulties communicating with their provider about diet and social circumstances, and also that the rigid schedule of a diabetes diet was problematic. Conclusions  Barriers to adherence to dietary therapies are numerous, but some, such as cost, and in the urban setting, communication with providers, are potentially remediable. Interventions aimed at improving patients’ ability to modify their diet need to specifically address these areas. Furthermore, treatment guidelines need to consider patients’ preferences and barriers when setting goals for treatment. Diabet. Med. (2004)Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/73213/1/j.1464-5491.2004.01342.x.pd

Glycemic Effects of Once-a-Day Rapid-Acting Insulin Analogue Addition on a Basal Insulin Analogue in Korean Subjects with Poorly Controlled Type 2 Diabetes Mellitus

BackgroundThe present study investigates the efficacy in glycemic control by adding once-a-day glulisine to glargine as a basal plus regimen and factors influencing glycemic control with the basal plus regimen in Korean subjects with type 2 diabetes.MethodsIn the present retrospective study, subjects previously treated with the basal plus regimens for at least 6 months were reviewed. Changes in glycemic profiles and clinical parameters were evaluated.ResultsA total of 87 subjects were ultimately enrolled in this study. At baseline, mean glycated hemoglobin (A1c) and glycated albumin were 8.5% (8.0% to 9.6%) and 25.2±7.6%, respectively. After treatment with the basal plus regimen, patients had significant reductions of A1c at 6 months (0.8±0.1%, P<0.001) and their postprandial glucose levels were decreased by 48.7±10.3 mg/dL (P<0.001). Multiple logistic regression showed old age (odds ratio [OR], 1.25; 95% confidence interval [CI], 1.02 to 1.55), high initial A1c (OR, 22.21; 95% CI, 2.44 to 201.78), and lower amounts of glargine (OR, 0.85; 95% CI, 0.76 to 0.99), and glimepiride (OR, 0.23; 95% CI, 0.06 to 0.93) at baseline were independently associated with good responders whose A1c reduction was more than 0.5%.ConclusionThe authors suggest a basal plus regimen may be effective in reducing glucose levels of subjects with old age, high initial A1c, and patients on low doses of glimepiride and glargine. Despite the use of high doses of hypoglycemic agents, elderly patients with poorly-controlled diabetes are preferred for early initiation of the basal plus regimen

Clinical Experience of an Iontophoresis Based Glucose Measuring System

Currently finger pricking is the common method of blood glucose measurement in patients with diabetes mellitus. However, diabetes patients have proven to be reluctant to check their glucose profiles regularly because of the discomfort associated with this technique. Recently, a non-invasive and continuous Reverse Iontophoresis based Glucose Monitoring Device (RIGMD) was developed in Korea. The study was conducted during the period November 2003-January 2004 on 19 in-patients. Glucose measurements were performed using RIGMD between 10 a.m. and 4 p.m. Concurrent plasma glucose levels were checked hourly and subsequently compared with RIGMD data. The mean error of RIGMD measurements was -3.45±52.99 mg/dL with a mean absolute relative error of 20±15.16%. Measurements obtained by RIGMD were correlated with plasma glucose levels (correlation coefficient; 0.784 (p<0.05)) and this correlation was independent of time of data collection. However, after excluding confounding variables this correlation coefficient exhibited a tendency to increase. 98.9% of the results were clinically acceptable by Clarke error grid analysis. We concluded that RIGMD does not have the reliability and accuracy required to wholly replace conventional methods. However, further technical advancements that reduce its shortcomings would make this device useful for the management of diabetes