I am happy to contribute to the editorial by Lisa Eramo published in Medical Economics, January 2018. The article is important as it raises physician awareness of Merit-based Incentive Payment System (MIPS) under which hypertension management falls. MIPS, part of 2015 MACRA, will go into effect in 2019.
GT
This meta-analysis of four major clinical trials (ELIXA, LEADER, SUSTAIN 6, EXSCEL) reveals safety of GLP-1 agonists, bur more importantly their cardiovascular benefits on mortality, myocardial infarction and stroke in adults with type 2 diabetes.
The next natural step would be the quest for oral version of GLP-1 agonist given its positive profile on appetite, glucagon, insulin, glucose metabolism, proteinuria and cardiovascular system.
GT
Among patients with type 2 diabetes initiating second-line diabetes therapy, the short-term cardiovascular outcomes of GLP-1 receptor agonists, SGLT-2 inhibitors, and DPP-4 inhibitors were similar. Higher cardiovascular risk was associated with use of sulfonylureas or basal insulin compared with newer drug classes. Clinicians may consider prescribing GLP-1 receptor agonists, SGLT-2 inhibitors, or DPP-4 inhibitors more routinely after metformin rather than sulfonylureas or basal insulin.
JAMA
Patients with diabetes mellitus are at increased risk for bone fragility fracture secondary to multiple mechanisms. Hyperglycemia can induce true dilutional hyponatremia. Hyponatremia is associated with gait instability, osteoporosis, and increased falls and bone fractures, and studies suggest that compromised bone quality with hyponatremia may be independent of plasma osmolality. Analyses of this research support the hypothesis that hyponatremia is an additional risk factor for osteoporosis and fragility fracture among patients with diabetes mellitus.
JES
This major observational study suggests that statins reduce the risk of diabetic neuropathy, diabetic foot ulcers, and more importantly the risk of diabetic retinopathy. Risk reduction ranges from 10% to 45%. This could be due to statin-induced decreased microvascular inflammation. About 38,000 patients were followed for 7.5 years.
GT
The automated insulin pump has already shown great results in type 1 diabetes in an ambulatory setting. This study shows that it is as useful in type 2 diabetes patients treated in the hospital. Patients utilizing the “artificial pancreas” had better glycemic control, without an increased risk of hypoglycemia. I anticipate that closed-loop, automated insulin devices will become the “standard of care” for hospitalized patients with type 1 and type 2 diabetes in the future.
GT
Old drug, new approach. Verapamil has classically been used to treat hypertension and cardiac arrhythmias. This randomized phase 2 clinical trial shows a novel use of the drug by improving pancreatic beta cell function in recently diagnosed type 1 diabetes. Verapamil helped patients use lower doses of insulin as well as experiencing less hypoglycemia. These are exciting and promising results.
GT
In Sweden from 1998 through 2014, mortality and the incidence of cardiovascular outcomes declined substantially among persons with diabetes, although fatal outcomes declined less among those with type 2 diabetes than among controls.
Patients with type 1 diabetes had roughly 40% greater reduction in cardiovascular outcomes than controls, and patients with type 2 diabetes had roughly 20% greater reduction than controls. Reductions in fatal outcomes were similar in patients with type 1 diabetes and controls, whereas patients with type 2 diabetes had smaller reductions in fatal outcomes than controls.
NEJM
Among patients with type 1 diabetes who were receiving insulin, the proportion of patients who achieved a glycated hemoglobin level lower than 7.0% with no severe hypoglycemia or diabetic ketoacidosis was larger in the group that received sotagliflozin than in the placebo group. However, the rate of diabetic ketoacidosis was higher in the sotagliflozin group.
NEJM
The study finds that the longer the duration of diabetes and prediabetes in early adulthood, the higher the risk of progressive subclinical atherosclerosis and cardiac pump dysfunction, in both phases of contractility and relaxation. About 3,600 patients of age 18-30 were followed for 25 years. This is yet another reason to screen and intervene aggressively young individuals for both prediabetes and diabetes.
GT
It is not always easy to distinguish LADA from type 1 or type 2 diabetes. Common parameters utilized are BMI, age, family history, HLA-typing, clinical presentation, glucose variability and severity, insulin production, C-peptide levels, as well as autoantibodies against glutamic acid decarboxylase (GAD65), pancreatic islet cells (ICA) or insulin (IAA).
The article shows that other inflammatory markers could also be useful in differentiating the diagnoses. Such markers are; adiponectin, soluble tumor necrosis factor-α receptor 2 (sTNFR2), interleukin-6 (IL-6), hs-CRP, and total leukocyte number. More research is needed on how to incorporate the additional tests in clinical practice.
GT
Protein tyrosine phosphatase 1B (PTP1b) was first discovered in 1988. It is a counter-regulator to insulin and leptin signaling pathways. Given current endemic of insulin resistance via obesity and type 2 diabetes, it is natural to search for drugs that improve insulin and leptin sensitivities. PTP1b suppression is one of those options.
Here is a phase 2 clinical trial on an antisense inhibition of PTP1b (IONIS-PTP-1BRx). Results are promising but not profound: A1c and body weight dropped by 0.7% and 6 lbs in 27 to 36 weeks. No major adverse events were seen. A clearer picture of the drug will emerge in the future trials. At the same time the search for the other perfect PTP1b continues.
GT
The study reveals that the hybrid closed loop device, MiniMed 670g, helps in reducing A1c by 0.75% compared to standard insulin pumps. For those transitioning to it, carbohydrate to insulin ratio needs to be adjusted immediately. This semi-automated system, differently called semi-artificial pancreas, is a significant advancement in the field of type 1 diabetes. The device was approved by FDA in September 2016.
GT
ADA recommendations are released each January. Below is a succinct ACP review of guidelines in screening, treatment goals, lifestyle intervention, and drug approach to dyslipidemia in the setting of diabetes mellitus. LDL-cholesterol is still a main target. Charts depict indications and doses of statins, the mainstay therapy to diabetic lipid disorders.
GT
This prospective cohort study reveals an inverse relationship between blood vitamin D25 levels and risk of diabetes. Future research will show if this connection is causative in nature. Certainly there is some physiological and pathophysiological explanation: pancreatic beta cells are known to have vitamin D receptors, that upon VitD metabolites stimulation they produce and release insulin. Secondly, low vitamin d is also a proinflammatory state, an independent risk factor for diabetes development.
GT
Circadian rhythm and cortisol dysregulations have been associated with higher predisposition toward development of diabetes, obesity and metabolic syndrome. Subsequently it is of no surprise that night shift work, a form of circadian and cortisol anomaly, is also shown to raise the risk of diabetes mellitus.
GT
This is a nice epidemiological study of childhood overweight and obesity as it pertains to development of type 2 diabetes in adulthood. Authors have observed that heavy children who are no longer overweight after age 13 are not at increased risk of diabetes as adults. On the contrary, the longer the duration of high BMI during puberty, the higher the probability of developing early diabetes mellitus.
GT
Diabetic retinopathy occurs when high levels of blood sugar lead to damage in the blood vessels of the retina, the light-sensitive tissue in the back of the eye. Diabetic retinopathy is the most common cause of vision loss among the more than 30 million Americans living with diabetes and the leading cause of vision impairment and blindness among working-age adults.
FDA
ADA standards are released each January. Here is a succinct ACP review of guidelines in screening, diagnosis, treatment goals, lifestyle intervention, and drug approach to hypertension in the setting of diabetes mellitus. The chart depicts nicely the flow process of how to initiate and intensify the pharmacological therapy.
GT
The Dexcom G6 is a patch device, about the size of a quarter, that is applied to the skin of the abdomen and contains a small sensor that continuously measures the amount of glucose in body fluid.
The device transmits real-time glucose readings every five minutes to a compatible display device such as a mobile medical app on a cell phone. The patch device should be replaced every 10 days.
The Dexcom G6 version is factory calibrated and does not require users to calibrate the sensor with fingerstick blood glucose measurements. In addition, it has an updated sensor probe that minimizes interference with the pain reliever acetaminophen.
FDA
