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
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
Trulicity is a GLP-1 receptor agonist. It increases intracellular cAMP in beta cells leading to glucose-dependent insulin release. It also decreases glucagon secretion and slows gastric emptying.
Trulicity is supplied as a solution for subcutaneous injection. The recommended initiating dose is 0.75 mg once weekly. The maximum recommended dose is 1.5 mg once weekly. Administered once weekly, any time of day, with or without food. Trulicity should be injected subcutaneously in the abdomen, thigh, or upper arm.
FDA
This observational study reveals important long-term trends of type 1 diabetes in regard to kidney function & end stage renal disease (ESRD). Subjects were followed for up to 42 years:
Rates of ESRD are lower when children are diagnosed with DM1 before age 10 than during puberty. Kidney disease is less prevalent in females than males. Diabetic nephropathy peaks at 25 years after diagnosis and remains stable subsequently.
These findings could be shared with parents at the time of child's type 1 diabetes diagnosis.
GT
Authors find that hemodynamic changes are the main contributors to jardiance-induced cardiovascular benefits. Plasma volume contraction and hematocrit rise appear to be key mediators. Reductions in glycemia and uricemia also help in the process. The SGLT-2 inhibitor saga is evolving, and will continue for many years to come.
GT
The study shows the potential use of delayed-release nicotinic acid in improving the gut microbiota and insulin resistance, subsequently reducing the risk of prediabetes and diabetes. The modified niacin was able to reach the ileocolonic site intact and influencing microbiome by enhancing its α-diversity and abundance of Bacteroidetes. More research to come regarding gut flora–insulin resistance–diabetes axis.
GT
The article provides more evidence that diabetes and obesity increase the risk of malignancy, particularly of colorectal, gallbladder, pancreas, kidney, liver, endometrial, postmenopausal breast, ovarian, gastric cardia, thyroid cancer, esophageal adenocarcinoma and multiple myeloma. It is estimated that 430 million adults have diabetes worldwide, while 2.0 billions are overweight or obese. How could this global health problem be meaningfully approached?
GT
ITCA-650 is an osmotic mini-pump that releases exenatide slowly and continuously over a 3-6 month period. It is placed under the skin in the abdomen via a 5 mm incision. This phase-3 clinical trial shows good outcomes as A1c and body weight were reduced significantly by 1.2% and 6.6 pounds.
Improved medication adherence is a critical aspect of diabetes management. Same principle could be used for insulin delivery in the future.
GT
Findings are consistent with the fact that A1c is a more specific test in diagnosing prediabetes and diabetes compared to fasting plasma and 2-hour post challenge glucose tests. Increased specificity of A1c implies a more advanced state of prediabetes at diagnosis.
It is not surprising then to see that rates of cardiovascular disease and all-cause mortality are higher in prediabetics identified by A1c rather than fasting or post stress glucose levels.
GT
In patients with type 2 diabetes a healthy eating pattern including the frequent intake of whole carbohydrates, dairy, white meat, fish, fruits and vegetables was associated with lower fasting plasma glucose, HbA1c, and LDL cholesterol levels as compared with an eating pattern with high consumption of refined carbohydrates, ultraprocessed foods, sweets, and desserts. The carbohydrate use did not differ between the unhealthy and healthy group.
JES
