Here we go. As always, we start with our headlines and then we’ll share abstracts from medical journals, this month discussing Addition of biphasic, prandial, or basil insulin to oral therapy in type 2 diabetes, and Serum Lipids and Glucose Control.
Let’s start with two medications and their risk for cardiovascular events since this problem has made headlines and the nightly news. JAMA’s Sept 12, 2007 issue has an article titled Long-term Risk of Cardiovascular Events with Rosiglitazone by Sonal Singh, MD et al. This is a randomized controlled study lasting 4 years. The researchers found that in patients with impaired glucose tolerance or type 2 diabetes, Rosiglitazone used for at least 12 months is associated with a significantly increased risk of myocardial infarction and heart failure without a significantly increased risk of cardiovascular mortality.
The second study also in the Sept.12, 2007 JAMA is titled Pioglitazone and the Risk of Cardiovascular Events in Patients with Type 2 Diabetes Mellitus by A. Michael Lincoff, MD et al. The researchers looked at primary and secondary outcomes of using this medication. Primary outcomes included death, Myocardial infarction or stroke. Secondary outcome measures included serious heart failure. The researchers found that Pioglitazone is associated with a significantly lower risk of death, myocardial infarction and stroke among a diverse population of patients with diabetes. Serious heart failure is increased with its use, although it was not associated with increase in mortality.
The American Diabetes shared this past month that for type 2 diabetics using an insulin pen rather than syringes makes for fewer doctor and hospital visits and reduced use of health care resources, therefore translating directly to cost savings. A study cited in Clinical Therapeutics written by Dr. Rajesh Balkrishnan and associates examined information in the North Carolina Medicaid patient-claims database on patients with type 2 diabetes enrolled between 2001 and 2006. They found total annual healthcare costs, excluding prescriptions, to be roughly $14,000 per patient for the pen group as compared to $32,000, for syringe users.
I respect and truly like my primary care physician, however when she noted scratching marks on my back during an exam and I told her that diabetics are prone to skin conditions, she ran for her library. The phone call that followed is reason enough for all of us with diabetes to be the “expert" on the disease that we live with 24/7 and make sure that we can speak intelligently with our physicians. To further explain and up-date the article we have on the site about skin conditions, the August Diabetes Care has more information for you. Dr. Milos D. Pavlovic of the Military Academy of Belgrade, Serbia and his team compared the presence and frequency of skin manifestations in 212 young type 1 diabetic patients from age 2 to 22 compared to 196 controls. Overall, 67% of the diabetic patients had at least one skin disorder vs. 26% of the controls. The three most seen were Ichthyosis, dry patches of scaly skin, seen on 22% of diabetics, Rubeosis, abnormal growth of blood vessels causing red discoloration which occurred in 7.1% of diabetics, and fungal infections were observed in 4.7 % of diabetics. Now another word to the wise. Make sure you and your primary care physician know a very good dermatologist who knows about diabetes.
The Archives of Internal medicine, Sept.10th issue has an article which once again reiterates the association between being overweight and coronary disease. Researchers in the Netherlands looked at data from more than 302,000 people. They concluded that, “…even under the theoretical scenario that optimal treatment would be available against hypertension and hypercholesterolemia in overweight persons, they would still have an elevated risk of coronary disease."
The August, Diabetes Care has an interesting article about bone growth and type 1 children with diabetes by Dr. Susanne Bechtold and colleagues from the University Children’s Hospital, Munich, Germany. They studied the long-term effects of type 1 diabetes in bone development in 41 children for about 4 years. They found that at the first evaluation, the children were shorter than normal but that height normalized by the second evaluation. The researchers concluded that there exists no so-called “diabetic osteopathy" at least in children and adolescents. “There is only a temporary lower bone mass which normalizes with time since manifestation." “Additionally, there seems to be no higher fracture rate in children with type 1 diabetes’. Bechtold also noted that the study contained only a few patients with poorly controlled diabetes. "Therefore, we cannot exclude an affected bone development with poor metabolic control over a prolonged times", she said.
The Sept. 18th issue of the Annals of Internal Medicine reiterates what we have been telling you about the benefits of exercise for many years, and if you want more of a pep talk, just read the book review after the abstracts which will be coming up right after this headline. This research done by Ronald J. Sigal. MD, MPH et al looks the Effects of Aerobic Training, Resistance Training, or Both on Glycemic Control in Type 2 Diabetes. The researchers looked at 251 adults ages 39 to 70 years with type 2 diabetes. They used the hemoglobin A1c test as a measure for outcome. The interventions were aerobic training, resistance training, or both types of exercise (combined exercise training). A secondary control group was also included. Exercise training was performed 3 times weekly for 22 weeks. Adjusted absolute HbA1c levels fell significantly with the aerobic training and resistance training. The combination-exercise group saw additional reductions. Changes in blood pressure and lipids did not differ among the groups. The authors cite research showing a 15% to 20% reduction in major cardiovascular events with a 1-percentage point reduction in HbA1c. So there you go—we have given you even one more reason to include exercise in you daily routine. Remember to check out with your physician before you run out and start to exercise and please read our Exercise articles for more information.
Let’s look at our abstracts. This article has been widely reported because many type 2 diabetics do have to supplement oral agents with insulin. The results have made the newspapers so we thought we’d give you information right form the authors. The New England Journal of medicine Sept 21, 2007 issue has an article titled Addition of Biphasic, Prandial, or Basal Insulin to Oral Therapy in Type 2 diabetes by Rury R. Holman, M.B., Ch.B. F., F.R.C.P. et al. The authors knowing that evidence supporting specific insulin regimes is limited carried out this open-label, controlled, multicenter trial where 708 patients with a suboptimal glycated hemoglobin level (7.0 to 10.0%) who were receiving maximally tolerated doses of metformin and sulfonylurea were place into one of the three insulin groups: 1. biphasic insulin aspart twice daily, 2. prandial insulin aspart three times daily, or 3. basal insulin detemir once daily (twice if necessary). Outcome measures at 1 year were mean glycated hemoglobin level, the proportion of patients with a glycated hemoglobin level of 6.5% or less, the rate of hypoglycemia, and weight gain. At 1 year, mean glycated hemoglobin levels were similar in the biphasic group and the prandial group but higher in the basal group. The respective proportions of patients with a glycated hemoglobin level of 6.5% or less were 17.0%, 23.9%, and 8.1%; respective mean weight gains were 4.7 kg, 5.7 kg. and 1.9 kg. Rates of adverse events were similar among the three groups. They concluded that a single analogue-insulin formulation added to metformin and sulfonylurea resulted in a glycated hemoglobin level of 6.5% or less in a minority of patients at 1 year. The addition of biphasic or prandial insulin aspart reduced levels more than the addition of basal detemir but was associated with greater risk of hypoglycemia and weight gain.
We were fascinated by an article in the Archives of Pediatrics and Adolescent Medicine 20007;161:159-165 titled Serum Lipids and Glucose Control, The SEARCH for Diabetes in Youth Study, by Diana B. Petitti, MD, MPH et al. The objective of the study is to assess the relationship of serum lipid concentrations with glucose control in youth with diabetes. The design is a cross-sectional analysis of data from the SEARCH for Diabetes in Youth Study and is a multicenter study of youth with diabetes onset younger than 20 years of age. 1973 SEARCH participants aged 10 years or older with hemoglobin A1c and fasting total cholesterol (TC), low-density lipoprotein cholesterol (LDL-C), high-density lipoprotein cholesterol (HDL-C), and triglyceride measured at the SEARCH study examination. The researchers found that there were significant trends of higher levels of TC, LDL-C, triglyceride, and non-HDL-C (but not HDL-C) with higher hemoglobin A1c concentrations for both diabetes types. The slopes of TC increase were 7.8 mg/dl per unit increase in hemoglobin A1c for type 1 and 8, 1 mg/dl for type 2. Levels of TC, LDL-C, triglyceride, and non-HDL-C were significantly higher in type 2 diabetes than in type 1 diabetes. Among those with type 1 diabetes in poor glycemic control, 35%, 12% and 12% had high concentrations of TC, LDL-C, and triglyceride. In youth with type 2 diabetes in poor glycemic control, percentages with high levels of TC, LDL-C, and triglycerides were 65%, 43%, and 40% respectively. They concluded that glycemic control and lipid levels are independently associated in youth with both type 1 and type 2 diabetes.
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