LITTLE ROCK, AR. A total of 4636 subjects without prior diagnosis of diabetes had fasting plasma glucose, 2-hour OGTT and measurement of cardiovascular risk factors. It is published online June 16 in Cancer. Data on dipeptidyl peptidase 4 (DPP-4) inhibitors such as saxagliptin (Ongylza—AstraZeneca) and alogliptin (Nesina—Takeda) have shown that there may be an increased risk of CV events in patients given these agents. We analyzed the compliance to metabolic goals set by ADA and ISPAD and the differences between patients treated with continuous subcutaneous insulin infusion and multiple daily injections. The point most stressed by Inzucchi about the recent guidelines was the need for individualization in diabetes treatment, since the achievement of any degree of glucose control requires active patient participation and commitment. She was 68.
Approaches to reducing cardiovascular risk factors include smoking cessation, treating high blood pressure and managing cholesterol (using recommended therapies such as statins). Founded in 1940, the Association has an area office in every state and conducts programs in communities nationwide. The concordant normoglycaemic group was the youngest and had the lowest body-mass index (BMI), waist girth, waist-hip ratio (WHR), total cholesterol, and systolic and diastolic blood pressures. Giovannucci told Medscape Oncology that diabetics have a higher mortality from all causes, including cancer. In addition, no differences in the rate of hospitalizations for heart failure were observed between the sitagliptin and placebo groups (3.1% in each group). Either drug is an option in peripheral vascular disease (PVD).12 It will be interesting to see if the outcomes of the Study in Cardiovascular Events in Diabetes ASCEND trial,13 expected in 2017, will alter this advice. This scale should not be applied rigidly but rather used as a broad construct to help guide healthcare providers.
At diagnosis she began Metformin, and followed the advice to adopt the ADA diet of 65% carbohydrates. This explains why the majority of people with diabetes between the age of 40 and 59 are at particularly high risk. Retinopathy is also linked with duration of diabetes – those who have been diagnosed for five to 10 years are five times more likely to develop early retinal changes.15 This reinforces the evidence for annual retinal screening as primary and secondary prevention. Controlling blood glucose fluctuations and maintaining an HbA1c below 53mmol/mol reduces the incidence of retinopathy by 76%.16 Good glycaemic control has been consistently demonstrated to reduce the risk and incidence of retinal damage.17,18 Controlling blood pressure below 140/80mmHg sustained a 40% reduction in the progression of diabetic retinopathy in the landmark UK Prospective Diabetes Study, 1998.9 If retinopathy is already present, controlling blood pressure and glycaemia can facilitate regression from the initial asymptomatic stages back to the retinopathy-free stage. Dr. The first CV outcomes study for a glucagonlike peptide–1 (GLP-1) agonist, lixisenatide (Lyxumia—Sanofi), found no evidence of increased cardiac risk compared with placebo, according to results of the ELIXA (Evaluation of Cardiovascular Outcomes in Patients with Type 2 Diabetes After Acute Coronary Syndrome During Treatment with Lixisenatide) trial presented at ADA. Approximately one third of those with diabetic nephropathy will progress to end-stage renal disease (ESRD) requiring some form of renal replacement therapy.20 However, the risk of CVD in this population is elevated and greater than the risk of progression to ESRD.
Many patients will then also require insulin therapy, alone or in combination with other agents, to maintain glucose control. Admitted to the hospital in Kansas City, her blood sugar rocketed out of all control and she suddenly lost consciousness late in the evening, just fell into the diabetic shock. The higher the creatinine, the worse the kidney function. People with type 2 diabetes should be monitored routinely as part of their annual review from diagnosis. Sub-optimal glycaemic control often goes undetected, so an early morning ACR and concurrent serum creatinine should be checked. Blood pressure should be measured regularly in everyone with type 2 diabetes and nephropathy, aiming for less than 130/80mmHg.3,21 It should be recognised, though, that targets should be individualised. Not everyone can achieve the set targets without adverse effects on their health – for example, postural hypotension may be induced in older adults, increasing their risk of falls and fractures22 so targets should be adapted as appropriate.
Good blood glucose control, aiming for an HbA1c target of 48mmol/mol, has been shown to reduce diabetic nephropathy.3 However, this needs to be balanced with the individual’s risk of hypoglycaemia, especially in older people.22 Additionally, if a person is taking metformin,3 specialist advice from a nephrologist and/or diabetologist is required if their renal function is deteriorating. Diabetes is the leading cause of peripheral neuropathy worldwide.23 Diabetic neuropathy has varied clinical manifestations and may involve every system in the body.24 This means diabetic neuropathies can result in considerable morbidity, disability and reduction in quality of life with increased mortality. But it’s not inevitable if we can educate people on the power of low-carb living for treating diabetes with little to no need for medications or insulin (despite the fact doctors are still encouraging carb consumption even when low-carb controls the diabetes). Another considerable problem is peripheral neuropathic pain, which affects 15-26% of people with diabetes25 and can lead to considerable disability. under-acknowledged in evidence and practice. Often help can be easily found. A simple way to broach the subject is to ask: “Some people with diabetes have problems with their sex lives; have you ever had a problem like that?”29 This can help to open the dialogue.
Gastroparesis occurs with vagus nerve damage, which stops the muscles of the stomach and intestines working normally and alters digestion.24 The effects include failure of stomach emptying (which can cause discomfort, vomiting and problems with glycaemic control) and bowel problems such as constipation, diarrhoea and occasionally incontinence. Less often, the bladder is affected, causing urinary retention and overflow incontinence. Practitioners should enquire during review about bowel and bladder function. Can you imagine if you show them pictures of what you eat like bacon, butter, eggs, steak, full-fat cheese, etc. Specialist referral is required for management of these conditions. Clear communication about individual risks is key to helping people understand their goals of care and getting them engaged with their care decisions.30 NICE NG283 promotes individualised care approaches. This can be supported by tools such as Diabetes UK Information Prescriptions31 on EMIS and Systemone to help them set goals they feel able to achieve.
NICE NG2183 and the ADA and EASD4 guidance are built around the approach of helping people to understand about their diabetes, to set goals they will be able to achieve and to know when it is important to seek help. The practitioner-patient partnership has never been more pivotal in preventing the complications of diabetes. 4. Inzucchi S, Bergenstal R, Buse J et al. She developed pneumonia and an infection at the surgery site. Diabetes Care 2015;35:1364-1379. 16.
Diabetes Control & Complications Trial. The effect of the intensive treatment of diabetes on the development & progression of long-term complications in insulin dependent diabetes mellitus. New England Journal of Medicine, 2014 nejm.org/doi/pdf/10.1056/NEJM199309303291401 (accessed 4 May 2016). 24. Tesfaye S. I am estimating that her carb intake while in hospital was ~350 g per day!!!! Springer Science, 2013.