health updates

july 2008

July means that many of us are traveling. Please speak to your health care team about changing time zones and how that will affect you. For an hour or so we don’t even change our watches, but for travel abroad we speak to our doctor about losing or gaining 6-8 hours and when to change our insulin intake or take extra. We travel frequently. In the last few months we have been in Oregon, New York, Louisiana, and New Hampshire and flying today can be difficult for anyone with special needs. Please make sure that you tell your carrier if you need a wheel chair to negotiate large airports with multiple terminals. Asking for special meals is iffy because most airlines no longer serve food unless you have to pay for it and then it is better than hypoglycemia but not by much. On a long flight a week or so ago, I came on the plane with sandwiches bought in the airport and were surprised by a food service. It was full of fat and the meat (?) and cheese (?) were not appropriate for someone on a restricted diet. I wound up trying the salad but to tell the truth it was barely edible. Boy was I glad I had brought on a veggie sandwich with a fork, no mayo, no chips, and did not eat a sandwich made days ago and reheated in a microwave. Now for the really important suggestions: 1.What ever you do bring all medications you take with you on the plane. Airports are not the place to look for your brands of insulin, statins, etc. and you never know about bad weather or airplane breakdowns. We missed our flight from Houston to our home because of thunderstorms which closed the airport. We circled for sometime and it was just our luck that many flights had been postponed but ours was not. We sat in the airport for more than 8 hours until we could get 2 seats on a flight home. Thank goodness we had all of our meds, a charged phone and extra money for food. We were, however, met by wheel chairs for my husband and agents did try to get us home the same day we started out and we just made it. By the way if you have a pump or continuous glucose monitor things look better. Security guards actually know what they are and won’t give you a hard time as long as you put you continuous glucose monitor with shoes etc and send them though the X-Ray machines. Bon Voyage!

Headlines are first this month as usual and then come our abstracts that include articles on Diabetes and Depression and Diabetes and Death Risk in Young Adults. Let’s begin. HealthDay, dated June 10 had an article about “extenatide once weekly" appeared to cause additional improvements in A1c and fasting plasma glucose levels in diabetics who had been receiving twice-daily injections of Byetta—the version of the drug currently on the market. This information was presented at the ADA meetings in San Francisco. Other good news was that the patients who participated lost a total of over 9 pounds. “Importantly, the study results also showed that steady-state levels of exenatide may result in improvements in a variety of glucose parameters. If approved extenatide once weekly may provide patients with a treatment option that is on beard 24 hours an day, seven days a week, helping manage their blood sugar, and secondarily, their weight,’ shared Dr. John B. Buse from the University of North Carolina School of Medicine. An experimental injectable type 2 diabetes drug being developed by Sanofi-Aventis was well tolerated and significantly improved blood sugar control compared with a placebo as reported at the ADA meetings. The 542 subjects whose type 2 diabetes was inadequately controlled by metformin was treated by AVE0010 in once daily and twice daily regimes. Both the once and twice daily treatments demonstrated similar reduction in A1c levels. This new GLP-1 agonist not only lowered blood glucose levels but also led to modest weight loss, a highly desirable effect in diabetes treatments as obesity is a leading cause of the disease. Journal Watch, a publication of The New England Journal of Medicine has reported that a combination of aliskiren and losartan reduced albuminuria in patients with type 2 diabetes which was published in Journal Watch Cardiology, June 4, 2008. Aliskiren is an oral rennin inhibitor recently approved for marketing in the U.S. In this preliminary study, aliskiren appeared to provide temporary renal protection when combined with losartan in patients with diabetes. The authors concluded that further studies are needed to demonstrate (1) that dual therapy to block the rein-angiotensin-aldosterone system with aliskiren or similar agents is renoprotective over longer periods of time; and (2) that such renoprotective translates into true reductions in kidney failure of cardiovascular events. The NIH-sponsored ACCORD study involved 10,251 type 2 diabetic patients (mean age 62, median HbA1c, 8.1%) with known cardiovascular disease or at least two added risk factors. Subjects were given intensive therapy or standard therapy. Although glycemic control was significantly better with intensive treatment than standard treatment, the treatment was stopped after an average follow-up of 3.5 years, because mortality was higher in the intensive therapy group than the standard group. Moreover, the groups did not differ significantly in the primary composite outcome of cardiovascular death, nonfatal myocardial infarction or nonfatal stroke. Severe hypoglycemia and weight gain were more common in the intensive treatment group, but the factors mediating the higher mortality with intensive treatment were unclear. The second study —the ADVANCE trial—involved 11,140 patients (mean age 66, HbA1c 7.2%). The intensively treated group received the sulfonylurea gliclazide an initial therapy (with other drugs added as required to reach target HbA1c of 6.5%), and the standard-treatment group received drugs except gliclazide (with no specified target HbA1c). Although HbA1c averaged 6.5% with intensive treatment and 7.3% with standard treatment during 5 years of follow-up, no significant difference was noted between groups for the primary endpoint of cardiovascular death, nonfatal MI, or nonfatal stroke, or for all-cause mortality. The microvascular outcome of new or worsening nephropathy occurred significantly less often in the intensive-treatment group, but severe hypoglycemia was more common with intensive treatment. This study was supported by the maker of gliclazide. The comments concluded that clinicians should aim for reasonable glycemic control in older diabetic patients, but aggressive attempts to normalize HbA1c are not warranted in this patient population. Abstracts: JAMA, 2008;(23):2751-2751-2759. has an article titled Examining a Bidirectional Association Between Depression Symptoms and Diabetes by Sherita Hill Golden, MD,MHS et al. Depressive symptoms are associated with development of type 2 diabetes, but it unclear whether type 2 diabetes is a risk factor for elevated depressive symptoms. The researchers’ objective was to examine the bidirectional association between elevated depressive and type 2 diabetes. This examined the Multi-Ethnic Study of Atherosclerosis, a longitudinal, ethnically diverse cohort study of US men and women aged 45 to 84 year enrolled in 2000-2002 and followed up until 2004-2005. The main outcome measures were elevated depressive symptoms defined by Center for Epidemiologic Studies Depressive Scales (CES-D) score of 16 or higher, use of antidepressant medications, or both. The CES-D score was also modeled continuously. Participants were categorized as normal fasting (<100mg/dL), impaired fasting glucose (100-125 mg/dL), or type 2 diabetes (=126 mg/dL) of receiving treatment). Analysis 1 included 5201 participants without type 2 diabetes at baseline and estimated the relative hazard of incident type 2 diabetes over 3.2 years with and without depressive symptoms. Analysis 2 included 4847 participants without depressive symptoms at baseline and calculated the relative odds of developing depressive symptoms over 3.1 years for those with and without type 2 diabetes. The conclusions reached by the research were as follows: a modest association of baseline depressive symptoms with incident type 2 diabetes existed that was partially explained by lifestyle factors. Impaired fasting glucose and untreated type 2 diabetes were inversely associated with incident depressive symptoms, whereas treated type 2 diabetes showed positive association with depressive symptoms, These associations were not substantially affected by adjustment for potential confounding or mediating factors. Diabetes Care 31: 922-926,2008 has a wake up call for all of us with type 1 diabetes or who treat children and adolescents with the disease titled Acute Complications and Drug Misuse are Important Causes of Death for Children and Young Adults with Type 1 Diabetes by Richard G. Feltbower, OHD et al. The results of this research from the Yorkshire register of Diabetes in Children and Young Adults. The researchers examined mortality rates and cause of death among subjects diagnosed with type 1 diabetes aged =29 years. Subjects with type 1 diabetes from a population-based register in Yorkshire, U.K. diagnosed between 1978 and 2004 were linked to the U.K. National Health Service Central Register for death notifications. Deaths were coded using ICD-9 and ICD-10. Standardized mortality rations (SMRs) were calculated using expected number of deaths from U.K. mortality rates by cause and age of diagnosis. A total of 4,246 individuals were followed up, providing 50,471 person-years of follow-up. Mean follow-up length was 12.8 years for individuals aged 0-14 years and 8.3 for those 15-29 years. Over all 108 patients died, of whom 77(71%) were male. A total of 74 death occurred in individuals aged 0-14 years and 34 in those aged 15-29 years. The SMR was 4.7 overall, similar for males and females, but higher for individuals aged 15-29 years compared wit those 0-14 years. The SMR rose with increasing disease duration. A total of 47 of 108 deaths occurred from diabetes complications, 32 of which were acute and 15 chronic. Twenty-two percent of deaths were attributed to accidents or violence, including six suicides. Sixteen percent of all deaths were related to drug misuse (including insulin but excluding tobacco and alcohol). The researchers concluded that subjects with type 1 diabetes diagnosed under 30 years of age had a 4.7 fold excess mortality risk. Nearly half of the deaths were due to acute or chronic complications of diabetes. Drug misuse-related deaths may be an emerging trend in this population warranting further investigation. BSP