As always, we begin sharing headlines with you and then we will share abstracts from medical journals. This month we will be sharing articles about awareness and treatment of dyslipidemia in young adults with type 1 diabetes, the challenge of achieving national cholesterol goals in patients with diabetes, and a randomized multicenter trial comparing the GlucoWatch biographer with standard glucose monitoring in children with type 1 diabetes.
The FDA has approved two monitoring products useful for diabetics. Hypoguard USA Inc.’s Advance Microdraw System may now be used to draw a blood sample from the palm instead of finger tips and Xilas Medical Inc.’s TempTouch home infrared temperature probe also received clearance. It can measure foot temperature fluctuations as these are indicative of foot problems. TempTemp can give an early warning of inflammation which happens before an ulcer breaks the skin surface.
Sleeping for less than six hours or for more than nine hours each night is associated with an increased risk of diabetes and impaired glucose tolerance as reported in the week of April 25, 2005 Archives of Internal Medicine. Dr. Daniel Gottlieb and his group enrolled 1,486 subjects, aged 53 to 93 years in their study. The subjects completed questionnaires regarding sleeping patterns and underwent fasting glucose and glucose tolerance testing. Compared with subjects who slept seven to eight hours per night, the risk of diabetes was increased 2.5-fold in those sleeping five or less hours, 1.66-fold for those sleeping six hours, and 1.70-fold for those sleeping nine or more hours. The corresponding increased risks of developing impaired glucose tolerance were 1.33, 1.58, and 1.88-fold. Blood glucose levels were not significantly affected by insomnia. The authors suggest that persons who sleep nine or more hours a night may be doing so because of some underlying condition that may not be diagnosed but that puts them at increased risk of diabetes. They also suggest that adequate levels of sleep should be tested as a non-drug treatments strategy in patients with diabetes or impaired glucose tolerance.
The Archives of Internal Medicine 2005;165:321-326 has an article of interest to all of us who go off our diets or who continue to gain weight when we know that losing weight would make us healthier. Annika Rosengreen, MD, PhD et all looked at the relationship between BMI, other cardiovascular risk factors, and hospitalization for dementia. This is a longitudinal study of 7402 men, 47 to 55 years old without prior stroke or myocardial infarction derived from a population sample of 9998 men who were prospectively followed until 1998. The relationship between BMI and dementia as a primary diagnosis was J-shaped and men with a BMI between 20.00 and 22.49 had the highest risk. Subsequently, after adjustment for smoking, blood pressure, serum cholesterol, diabetes mellitus, and social class, the risk increased linearly in men who had a BMI of 22.50 to 24.49, and 30.00 or greater. Men with a BMI less than 20.00 had a nonsignificant elevated risk. With these results the authors concluded that overweight and obesity could be major preventable factors in the development of dementia.
The Archives of Internal Medicine 2005;165:466-469 has an article about Anemia with impaired erythropoietin response in diabetic patients by Merlin C. Thomas, MBChB, PhD et al. Diabetes is associated with an increased prevalence of anemia, particularly in patients with neuropathy. In this study the researchers undertook a survey to determine the relationship between anemia and the renal production of erythropoietin in diabetic patients. The clinical data of 722 patients were obtained, including markers of diabetic complications. Erythropoietin levels were measured in the same samples. Patients with a full blood cell count, iron indexes, and renal function within the normal range were used to define the reference range for this population. Anemic patients had erythropoietin levels within this range were defined as having an “inappropriate erythropoietin response to anemia." Of the 722 patients, 168 had anemia, of which 130 had erythropoietin in levels inappropriately within the normal range. Although 55.4% of anemic patients had moderate renal impairment, erythropoietin levels were also inappropriately low in the 69.2% of anemic patients with normal renal function. However, most of these patients had kidney disease, as denoted by albuminuria. They concluded that the failure to produce erythropoietin in response to a declining hemoglobin level is a common contributor to anemia in patients with diabetes. This seems to be a manifestation of kidney disease, in the presence or absence of renal impairment.
Risk scores predict atherosclerotic lesions in young people by C. Alex McMahan et al in Archive of Internal Medicine, 2005;165:883-890 is the basis of our last headline. Atherosclerosis begins in childhood and progresses through young adulthood to form lesions that cause coronary heart disease. These preclinical lesions are associated with coronary heart disease risk factors in young persons. The Pathobiological Determinants of Atherosclerosis in Youth study collected arteries and samples of blood and other tissues from persons aged 15 to 34 years who died of external causes and underwent autopsy in forensic laboratories. They measured the coronary heart disease heart disease risk factors and atherosclerotic lesions in the coronary arteries. They developed risk scores, normalized so that a 1-unit increase was equivalent to a 1-year increase in age, to estimate the probability of advances atherosclerotic lesions in the CAs and the abdominal aorta from age, sex, serum lipoprotein concentrations, smoking, hypertension, obesity, and hyperglycemia. Odds ratios for a 1-unit increase in the risk scores were 1.18 for the CAs and 1.29 for the CAs for abdominal aorta. These risk factors had good discrimination and were calibrated. The presence of abdominal lesions increased the likelihood of having CA lesions. The researchers concluded that risk scores calculated from traditional coronary heart disease risk factors provide a tool for identifying young people with a high probably of having advanced atherosclerotic lesions.
Now for our abstracts. Awareness and treatment of dyslipidemia in young adults with type 1 diabetes by R. Paul Wadwa, MD et al in Diabetes Care 28:105101056, 2005 is our first abstract. It is known that dyslipidemia is a preventable major risk factor for coronary Heart disease (CHD). Type 1 diabetics have an increased risk for CHD yet little is known about the treatment of this population. From 2000 to 2002, the Coronary Artery Calcification in Type 1 Diabetes study obtained fasting lipid profiles in 1,416 individuals ages 19-56 years with no history of CHD: 652 type 1 diabetic patients and 764 nondiabetic control subjects. These data combined with patient questionnaire results were used to determine prevalence of dyslipidemia and adequacy of pharmacological treatment. For all subjects, dyslipidemia was defines using National Cholesterol Education Program Adult Panel III criteria. The researchers founds that type 1 diabetic subjects had significantly less dyslipidemia than nondiabetic control subjects, and a higher percentage of those with abnormal lipids were aware , on medication for, and in control of their lipid levels. Of those on treatment, control was achieved in 41% of type 1 diabetics subjects and 15% of nondiabetic participants. They concluded that dyslipidemia, a major risk factor for CHD, remains largely undiagnosed and untreated in high-risk populations, such as patients with type 1 diabetes.
Our next article in Diabetes Care 28:1029-1034, 2005 is titled The challenge of achieving national cholesterol goals in patients with diabetes by Amanda G. Kennedy, PHARMD,BCPS et al. This study analyzed lipid results from a large community-based population of patients with diabetes to assess the feasibility of attaining the standard and new optimal LDL-based lipid goals using currently available lipid-lowering medications. Patients with diabetes who were interviewed as part of the Vermont Diabetes Information System trial with a reported LDL were analyzed. Patients were categorized into high-risk and very-high-risk cardiovascular status. For patients not at the LDL goal, the required changes in therapy to achieve the goal were assessed. Of the entire cohort, 49.4% had a LDL < 100mg/dl. According to the National Cholesterol Education Program, 29.4% of the patients were very-high-risk and have an option LDL goal of <70 mg/dl. Only 15.7% of very-high-risk patients had an LDL <70 mg/dl. Based on their analysis of high-risk patients, 17 of 459 would require more than two lipid-lowering drugs to achieve an LDL <100mg/dl. In the very-high-risk group, they estimated that 26.2 % of patients will not reach LDL <70 mg/dl with two lipid-lowering medications. The researchers concluded that in many patients with diabetes and cardiovascular disease, it will be difficult to attain an LDL goal of <70mg/dl. Approximately 25% of patents will require more than two lipid-lowering drugs at maximal doses to attain this goal, assuming 100% tolerance of lipid-lowering medications.
Our last abstract is A randomized multicenter trial comparing the GlucoWatch Biographer with standard glucose monitoring in children with type 1 diabetes by The Diabetes Research in Children Network Study Group. The study assesses whether use of the GlucoWatch G2 Biographer (GW2B) in addition to standard monitoring lowers HbA1c and reduced hypoglycemia compared to standard glucose monitoring alone. Two hundred subjects aged 7 to <18 with type 1 diabetes were randomly assigned to five centers to standard glucose monitoring or standard glucose monitoring plus GW2B use for 6 months.. Study outcomes included HbA1c values obtained at 6 months and occurrence of severe hypoglycemia. The mean HbA1c at baseline was 8.0% in both groups; at 6 months, HbA1c was 7.9% in the usual care group and 8.1% in the GW2B group. A decrease in HbA1c of =0.5% was achieved in 21% of the usual care group and 28% of the GW2B group. Severe hypoglycemia events occurred in 7% of the GW2B group and in 2% of the usual care group. IN the GW2B group, sensor use declined throughout the study from a mean value of 2.1 times/week in the first month to 1.5 times/week in the sixth month. Reasons given for declining use included skin irritation (76%), frequent skips (56%), excessive alarms (47%), and inaccurate readings (33%). The researchers concluded that use of the GW2B in addition to standard monitoring did not improve glycemic control or reduce the frequency of severe hypoglycemia. Skin reaction and other problems led to decreasing sensor use over time.
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