Glycaemic management in diabetes: old and new approaches

Ceriello, A. et al | 2021 | Glycaemic management in diabetes: old and new approaches | The Lancet Diabetes & Endocrinology | DOI:https://doi.org/10.1016/S2213-8587(21)00245-X

Summary

HbA1c is the most used parameter to assess glycaemic control. However, evidence suggests that the concept of hyperglycaemia has profoundly changed and that different facets of hyperglycaemia must be considered. A modern approach to glycaemic control should focus not only on reaching and maintaining optimal HbA1c concentrations as early as possible, but to also do so by reducing postprandial hyperglycaemia, glycaemic variability, and to extend as much as possible the time in range in near-normoglycaemia. These goals should be achieved while avoiding hypoglycaemia, which, should it occur, should be reverted to normoglycaemia. Modern technology, such as intermittently scanned glucose monitoring and continuous glucose monitoring, together with new drug therapies (eg, ultra-fast insulins, SGLT2 inhibitors, and GLP-1 receptor agonists), could help to change the landscape of glycaemia management based on HbA1c in favour of a more holistic approach that considers all the different aspects of this commonly oversimplified pathophysiological feature of diabetes.

Glycaemic management in diabetes: old and new approaches [abstract only]

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Adult-Onset Type 1 Diabetes: Current Understanding and Challenges

Adult-Onset Type 1 Diabetes: Current Understanding and Challenges David Leslie, R. et al | 2021 | Diabetes Care | 44| 11| P. 2449-2456 |  DOI: 10.2337/dc21-0770

Abstract

Recent epidemiological data have shown that more than half of all new cases of type 1 diabetes occur in adults. Key genetic, immune, and metabolic differences exist between adult- and childhood-onset type 1 diabetes, many of which are not well understood. A substantial risk of misclassification of diabetes type can result. Notably, some adults with type 1 diabetes may not require insulin at diagnosis, their clinical disease can masquerade as type 2 diabetes, and the consequent misclassification may result in inappropriate treatment. In response to this important issue, JDRF convened a workshop of international experts in November 2019. Here, we summarize the current understanding and unanswered questions in the field based on those discussions, highlighting epidemiology and immunogenetic and metabolic characteristics of adult-onset type 1 diabetes as well as disease-associated comorbidities and psychosocial challenges. In adult-onset, as compared with childhood-onset, type 1 diabetes, HLA-associated risk is lower, with more protective genotypes and lower genetic risk scores; multiple diabetes-associated autoantibodies are decreased, though GADA remains dominant. Before diagnosis, those with autoantibodies progress more slowly, and at diagnosis, serum C-peptide is higher in adults than children, with ketoacidosis being less frequent. Tools to distinguish types of diabetes are discussed, including body phenotype, clinical course, family history, autoantibodies, comorbidities, and C-peptide. By providing this perspective, we aim to improve the management of adults presenting with type 1 diabetes.

This Perspective piece published in the journal Diabetes Care , based on that workshop, the participants outline the evidence for a new viewpoint, suggesting future directions of research and ways to alter disease management to help adults living with type 1 diabetes. They also outline a roadmap for addressing these deficiencies (Fig. 1). A cornerstone of this roadmap is a renewed emphasis on the careful consideration of the underlying etiology of diabetes in every adult presenting with diabetes.

Image source: David Leslie et al, 2021. Image shows the roadmap to better understand, diagnose and care for adults with T1D.


The full article is available from Diabetes Care [paper]

Habit and diabetes self-management in adolescents with type 1 diabetes

Cummings, C. et al | 2021| Habit and diabetes self-management in adolescents with type 1 diabetes| Health Psychology | .https://doi.org/10.1037/hea0001097

Objective The development of habit (i.e., behavioral automaticity, the extent to which a behavior is performed with decreased thresholds for time, attention [effort], conscious awareness, and goal dependence), for goal-directed health behaviors facilitates health behavior engagement in daily life. However, there is a paucity of research examining automaticity for Type 1 diabetes self-management in adolescence. This study examined if greater perceived automaticity for diabetes self-management was associated with increased daily self-management, decreased daily self-regulation failures in glucose checking, and more optimal daily glycemic levels in adolescents with Type 1 diabetes.

Method: Adolescents aged 13–17 and diagnosed with Type 1 diabetes (n equal to 79) completed the Self-Report Behavioral Automaticity Index, a measure of automaticity of diabetes self-management (i.e., automaticity of glucose checking, carbohydrate counting, and insulin dosing), and a measure of perceived self-management at baseline. One to 3 months later, a subsample of teens (n equal to 42) also completed a daily diary for a 7-day period including perceptions of daily self-management, daily self-regulation failures in glucose checking, and daily glucose levels.

Results: Greater overall automaticity of diabetes self-management was associated with greater baseline and daily self-management, fewer daily self-regulation failures in glucose checking, and lower average daily mean blood glucose levels but not more optimal daily variations in blood glucose levels.

Conclusions: Greater automaticity for diabetes self-management may support more optimal daily diabetes self-management in adolescence. Further research is needed to clarify the benefits and mechanisms of automaticity and explore possible interventions. (PsycInfo Database Record (c) 2021 APA, all rights reserved)

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NHS England: More people with diabetes set to benefit from blood sugar monitors as NHS roll-out succeeds

NHS England | November 2021 | More people with diabetes set to benefit from blood sugar monitors as NHS roll-out succeeds

Half of NHS Type 1 diabetes patients in England are now benefiting from the use of “life-changing” flash monitors that allow them to check their glucose levels more easily and regularly, paving the way for more people to benefit.

Health service chief executive Amanda Pritchard, patient groups and senior clinicians have welcomed the milestone, showing that the NHS is ahead of target to roll-out the monitors, as the independent health advisory NICE, confirmed it was beginning to consult on expanding access to the convenient and effective kit.

The most recent figures show that around 125,000, or half, of patients living with Type 1 diabetes are now using these monitors to help control their condition.

The insight from the successful roll-out by NHS England has helped to inform the case for potential wider use of these technologies to benefit patients living with Type 1 diabetes, and potentially those living with Type 2 diabetes, as the health service continues to improve care for people with both forms of the condition.

The NHS Long Term Plan included a target to ensure 20 per cent of people with Type 1 diabetes were benefiting from flash monitors by March 2021.

Data for March shows the NHS significantly exceeded that goal, with the actual percentage of those benefiting hitting more than 45 per cent – double the target, with uptake by July hitting half of eligible people.

Eligible patients are currently able to access the monitors on prescription from their local GP or diabetes team, helping them to better manage their blood sugar levels.

The wearable gadgets have a sensor that easily attaches to the back of the arm, allowing patients to check their glucose quickly and easily with a simple one-second scan.

The monitors link to an easy-to-use app on your phone, where patients can access the data gathered by the device.

Unlike conventional blood glucose monitors they allow you to view patterns over time, not only showing current and previous levels but also where they’re headed (Source: NHS England).

More people with diabetes set to benefit from blood sugar monitors as NHS roll-out succeeds

Diabetes Distress Is About the Person Not Just the Numbers

McCall, B. | 17 November 2021 | Diabetes Distress Is About the Person Not Just the Numbers via MedScape

This article from Medscape summarises two presentations that were given at the recent Diabetes Professional Care (DPC) conference on 11 November 2021.

Dr Anne Kilvert, consultant physician, Northamptonshire Community Diabetes Team, presented a workshop at the 2021 Diabetes Professional Care (DPC) conference, on addressing mental health and well-being during the consultation with people with diabetes.

“It’s about not just focusing on the numbers around diabetes – they do have to be addressed, but it’s about talking to the person and finding out how their diabetes is affecting them and their life more broadly,” she said. “People with diabetes ask, ‘look at me as a person – not at the numbers’,” she told Medscape UK.

Professor Barnard-Kelly spoke at the session Suicide, Self-Injury and Diabetes – a multi-pronged approach by the FDA RESCUE Collaborative Community. Dr Barnard-Kelly said: “Rates of suicide are reportedly twice as prevalent amongst people with diabetes as the general population, however it is likely this figure is an under-estimation due to problems with identification and reporting. Many HCPs underestimated the prevalence of suicidal ideation and suicide attempts, however this likely reflects challenges with disclosure.”

More information about each of the sessions is available from MedScape

Blood pressure lowering and risk of new-onset type 2 diabetes: an individual participant data meta-analysis

Nazarzadeh, M., Bidel, Z., Canoy, D., Copland, E., Wamil, M., Majert, J., … & Trialists’Collaboration, B. P. L. T. | 2021 | Blood pressure lowering and risk of new-onset type 2 diabetes: an individual participant data meta-analysis | The Lancet398 | 10313 | P. 1803-1810.

This meta-analysis used large-scale individual participant data from randomised controlled trials to investigate the effect of blood pressure lowering and the differential effects of five major classes of antihypertensives on risk of new-onset type 2 diabetes. A fixed level of 5 mm Hg reduction in systolic blood pressure reduced the risk of diabetes by 11 per cent. This treatment effect constituted quantitatively and qualitatively diverging effects of major antihypertensive drug classes. In analysis of specific drug classes versus placebo, angiotensin-converting enzyme inhibitors and angiotensin II receptor blockers had the strongest protective effect on the risk of diabetes. For calcium channel blockers no material effect was found, while β blockers and thiazide diuretics increased the risk.

The experts behind this study suggest that their findings indicate that blood pressure lowering can help prevent diabetes in addition to its well established beneficial effects in reducing cardiovascular events. The relative magnitude of reduction per 5 mm Hg systolic blood pressure lowering was similar to those reported for prevention of major cardiovascular events, which will strengthen the case for blood pressure reduction through lifestyle interventions known to reduce blood pressure, and blood pressure lowering treatments with drugs, and possibly device therapies (Source: Nazarzadeh et al, 2021).

Summary

Background

Blood pressure lowering is an established strategy for preventing microvascular and macrovascular complications of diabetes, but its role in the prevention of diabetes itself is unclear. We aimed to examine this question using individual participant data from major randomised controlled trials.

Methods

We performed a one-stage individual participant data meta-analysis, in which data were pooled to investigate the effect of blood pressure lowering per se on the risk of new-onset type 2 diabetes. An individual participant data network meta-analysis was used to investigate the differential effects of five major classes of antihypertensive drugs on the risk of new-onset type 2 diabetes. Overall, data from 22 studies conducted between 1973 and 2008, were obtained by the Blood Pressure Lowering Treatment Trialists’ Collaboration (Oxford University, Oxford, UK). We included all primary and secondary prevention trials that used a specific class or classes of antihypertensive drugs versus placebo or other classes of blood pressure lowering medications that had at least 1000 persons-years of follow-up in each randomly allocated arm. Participants with a known diagnosis of diabetes at baseline and trials conducted in patients with prevalent diabetes were excluded. For the one-stage individual participant data meta-analysis we used stratified Cox proportional hazards model and for the individual participant data network meta-analysis we used logistic regression models to calculate the relative risk (RR) for drug class comparisons.

Findings

145 939 participants (88 500 [60·6%] men and 57 429 [39·4%] women) from 19 randomised controlled trials were included in the one-stage individual participant data meta-analysis. 22 trials were included in the individual participant data network meta-analysis. After a median follow-up of 4·5 years (IQR 2·0), 9883 participants were diagnosed with new-onset type 2 diabetes. Systolic blood pressure reduction by 5 mm Hg reduced the risk of type 2 diabetes across all trials by 11% (hazard ratio 0·89 [95% CI 0·84–0·95]). Investigation of the effects of five major classes of antihypertensive drugs showed that in comparison to placebo, angiotensin-converting enzyme inhibitors (RR 0·84 [95% 0·76–0·93]) and angiotensin II receptor blockers (RR 0·84 [0·76–0·92]) reduced the risk of new-onset type 2 diabetes; however, the use of β blockers (RR 1·48 [1·27–1·72]) and thiazide diuretics (RR 1·20 [1·07–1·35]) increased this risk, and no material effect was found for calcium channel blockers (RR 1·02 [0·92–1·13]).

Interpretation

Blood pressure lowering is an effective strategy for the prevention of new-onset type 2 diabetes. Established pharmacological interventions, however, have qualitatively and quantitively different effects on diabetes, likely due to their differing off-target effects, with angiotensin-converting enzyme inhibitors and angiotensin II receptor blockers having the most favourable outcomes. This evidence supports the indication for selected classes of antihypertensive drugs for the prevention of diabetes, which could further refine the selection of drug choice according to an individual’s clinical risk of diabetes.

Funding

British Heart Foundation, National Institute for Health Research, and Oxford Martin School.

The Lancet Blood pressure lowering and risk of new-onset type 2 diabetes: an individual participant data meta-analysis [paper]

Dexamethasone Increases Diabetes Complications but Still Saves Lives

via MedScape | 12 November 2021 | Dexamethasone Increases Diabetes Complications but Still Saves Lives

Research presented earlier this month at The Society for Endocrinology’s annual conference, SfE BES 2021, suggests that  when dexamethasone is prescribed to hospitalised COVID-19 patients with diabetes may increase their risk of developing steroid-induced dysglycaemia but it does not prevent them from experiencing the life-saving benefits of the drug, suggests a real-world UK analysis.

Data on more than 2250 patients treated in the first and second waves of the pandemic showed that, in patients with diabetes, dexamethasone increased the risk of dysglycaemia more than 20-fold.

However, patients with dexamethasone-associated complications did not have an increased risk of death, and overall the drug was shown to reduce the risk of admission to intensive care or death within 30 days of admission by 56 per cent (Source: MedScape).

The full news story is available from MedScape

Diabetes NHS Long Term Plan Commitments ‘Met and Exceeded’

McCall, B. | 11 November 2021 | MedScape

Outcomes in diabetes are something to be proud of, said England’s National Specialty Advisor for Diabetes, addressing the opening session of the Diabetes Professional Conference 2021.

He added that the last decade had seen rates of amputations, cardiovascular disease, and hospital admissions all drop significantly, and much of this had been led by primary care as well as specialty services.

Professor Partha Kar, national specialty advisor for diabetes, together with Professor Jonathan Valabhji, national clinical director for diabetes and obesity, presented the annual update on the NHS England Diabetes and Obesity Programmes at the meeting, held in-person in London.

The update was dominated by the effect of the pandemic on delivery of care from the perspective of both clinicians and patients. Prof Valabhji pointed out that faced with the onslaught of COVID and the desperate need for a solution, the emphasis was on disentangling the unknowns at that time. “In severe outcomes there was a clear association between COVID and HbA1c, and BMI in the obese range. Our rich NHS datasets have provided info that other countries’ can’t do.” (Source: MedScape).

Read the full article from MedScape

Annual diabetes care processes and mortality using data from the National Diabetes Audit

Holman, N. et al | 2021 | Completion of annual diabetes care processes and mortality: A cohort study using the National Diabetes Audit for England and Wales | Diabetes Obesity & Metabolism | https://doi.org/10.1111/dom.14528

In England and Wales, the National Diabetes Audit (NDA) collects patient-level data on people with diagnosed diabetes. The present study assesses whether recorded care processes completion was associated with mortality over the subsequent decade after adjustment for the risk factors that the care processes uncover, individual demographic characteristics and comorbidities. This resulting paper, published in the journal Diabetes, Obesity & Metabolism highlights that individuals with diabetes who have fewer routine care processes have higher mortality.

Abstract

Aim

To conduct an analysis to assess whether the completion of recommended diabetes care processes (glycated haemoglobin [HbA1c], creatinine, cholesterol, blood pressure, body mass index [BMI], smoking habit, urinary albumin, retinal and foot examinations) at least annually is associated with mortality.

Materials and methods

A cohort from the National Diabetes Audit of England and Wales comprising 179 105 people with type 1 and 1 397 790 people with type 2 diabetes, aged 17 to 99 years on January 1, 2009, diagnosed before January 1, 2009 and alive on April 1, 2013 was followed to December 31, 2019. Cox proportional hazards models adjusting for demographic characteristics, smoking, HbA1c, blood pressure, serum cholesterol, BMI, duration of diagnosis, estimated glomerular filtration rate, prior myocardial infarction, stroke, heart failure, respiratory disease and cancer, were used to investigate whether care processes recorded January 1, 2009 to March 31, 2010 were associated with subsequent mortality.

Results

Over a mean follow-up of 7.5 and 7.0 years there were 26 915 and 388 093 deaths in people with type 1 and type 2 diabetes, respectively. Completion of five or fewer, compared to eight, care processes (retinal screening not included as data were not reliable) had a mortality hazard ratio (HR) of 1.37 (95 Over a mean follow-up of 7.5 and 7.0 years there were 26 915 and 388 093 deaths in people with type 1 and type 2 diabetes, respectively. Completion of five or fewer, compared to eight, care processes (retinal screening not included as data were not reliable) had a mortality hazard ratio (HR) of 1.37 (95 per cent confidence interval [CI] 1.28-1.46) in people with type 1 and 1.32 (95 per cent CI 1.30-1.35) in people with type 2 diabetes. The HR was higher for respiratory disease deaths and lower in South Asian ethnic groups. confidence interval [CI] 1.28-1.46) in people with type 1 and 1.32 (95 per cent CI 1.30-1.35) in people with type 2 diabetes. The HR was higher for respiratory disease deaths and lower in South Asian ethnic groups.

Conclusions

People with diabetes who have fewer routine care processes have higher mortality. Further research is required into whether different approaches to care might improve outcomes for this high-risk group.

Completion of annual diabetes care processes and mortality: A cohort study using the National Diabetes Audit for England and Wales [paper]

Scotland to rollout diabetes test for Type 1 patients

via BBC News | 31 October 2021 | Scotland to rollout diabetes test for Type 1 patients

Misdiagnosed Type 1 diabetes patients could be freed from the need to take insulin after a new test is rolled out.

Scotland will become the first country to offer the C-peptide blood test to all patients who have had a Type 1 diagnosis for at least three years.

The test shows how much insulin a patient’s body is producing itself. A pilot by NHS Lothian allowed some people who had been taking insulin to stop or reduce the treatment. The test will be available from 1 November.

C-peptide testing, which has been used as part of diagnosis for some patients for many years, can help distinguish whether a patient has Type 1 or Type 2 diabetes.

BBC News Scotland to rollout diabetes test for Type 1 patients