Dm Research Studies In Focus Jul 09

Diabetes Care Journal: RESEARCH STUDIES in FOCUS By Liz Ho 21 Jul 09 Assessing Glycemic Control in Maintenance Hemodialysis Patients With Type 2 Diabetes Kazempour-Ardebili, Sara et al. (UK) Diabetes Care. 32(7):1137-1142, July 2009. OBJECTIVE: The study hypothesizes that 1) 48-h continuous glucose monitoring (CGM) provides additional, clinically relevant, information to that provided by the A1C measurement and 2) glycemic profiles differ significantly between day on and day off dialysis. RESEARCH DESIGN AND METHODS: With the use of GlucoDay S, 48-h CGM was performed in 19 type 2 diabetic subjects undergoing hemodialysis to capture consecutive 24-h periods on and off dialysis. Energy intake was calculated using food diaries. A1C was assayed by a high-performance liquid chromatography method. RESULTS: 17 subjects (13 male) with a mean (range) age of 61.5 years (42-79 years) and diabetes duration of 18.8 years (4-30 years) were analysed. Dialysis Non-Dialysis Day Day Mean 24 hours 9.8 12.6 P=0.013 glucose (+/-3.8) (+/- 5.6) 6hr Nocturnal 9.5 12.9 P<0.05 Glucose (+/-4.4) (+/-7.0) • 10 out of 17 had their lowest reading within 12 hours of starting dialysis • 3 out of 17 subjects had <2.5mmol/L for 30 minutes. • Lowest reading captured is 1.38mmol/L. • Yet no patients reported symptoms of hypoglycemia. CONCLUSIONS: Glucose values are significantly lower on dialysis days than on nondialysis days despite similar energy intake. The risk of asymptomatic hypoglycemia was highest within 24 h of dialysis. Physicians caring for patients undergoing hemodialysis need to be aware of this phenomenon and consider enhanced glycemic monitoring after a hemodialysis session. CGM provides glycemic information in addition to A1C, which is potentially relevant to clinical management. Hypoglycemia and Clinical Outcomes in Patients With Diabetes Hospitalized in the General Ward. Turchin, Alexander et al. (US) Diabetes Care. 32(7):1153-1157, July 2009. OBJECTIVE: Study aimed to determine whether hypoglycemic episodes are associated with higher mortality in diabetic patients hospitalized in the general ward. RESEARCH DESIGN AND METHODS: -- Retrospective cohort study analyzed 4,368 admissions of 2,582 patients with diabetes hospitalized in the general ward of a teaching hospital. -- Explore associations between the number and severity of hypoglycemic (<=3.0mmol/L) episodes and inpatient mortality, length of stay (LOS), and mortality within 1 year after discharge. RESULTS: • 7.7% of admissions had hypoglycemia • Each additional day with hypo was associated with 85.3% increase in the odds of inpatient death (P = 0.009) Odds of death within 1 year of discharge, is increased by 65.8% (P = 0.0003). • Odds of inpatient death rose threefold for every decrease 0.5mmol/L in the lowest blood glucose during hospitalization (P = 0.0058). • LOS increased by 2.5 days for each day with hypoglycemia (P < 0.0001). CONCLUSIONS: Patients with hypoglycemia have increased LOS and higher mortality both during and after admission. Measures should be undertaken to decrease the frequency of hypoglycemia in this high-risk patient population.

Hypoglycemia Unawareness Is Associated With Reduced Adherence to Therapeutic Decisions in Patients With Type 1 Diabetes: Evidence from a clinical audit. Smith, Charlotte B. et al. (UK) Diabetes Care. 32(7):1196-1198, July 2009. OBJECTIVE: Study compared adherence to treatment changes by hypoglycemia awareness status. RESEARCH DESIGN AND METHODS: Case notes of 90 type 1 diabetic patients were analyzed retrospectively, identifying awareness status and insulin regimens over four visits. The proportion of patients adhering to advice and percent advice taken were calculated. RESULTS: • 31 patients with hypo awareness and 19 patients with hypo unawareness were identified. • 74.2% in hypo awareness group and 68.4% of hypo unawareness group had insulin regimens • Patients with hypo unawareness were older (P = 0.001) • Unaware group had longer diabetes duration (P = 0.002) • Unaware group had lower A1C (P = 0.007). • They also reported severe hypoglycemia (P = 0.002) • 87% of Aware group is adherent and only 53.8% in the Unaware group (P = 0.046)) • Aware group adherence score is 75.3 compared to 42.5 in Unaware group (P = 0.001). CONCLUSIONS: Reduced adherence to changes in insulin regimen in hypoglycemia unawareness is compatible with habituation to hypoglycemic stress. Therapies aimed at reversing repetitive harmful behaviors may be useful to restore hypoglycemia awareness and protection from severe hypoglycemia.

Longitudinal Analysis of Depressive Symptoms and Glycemic Control in Type 2 Diabetes. Aikens, James E. et al. (US) Diabetes Care. 32(7):1177-1181, July 2009. OBJECTIVE: Compare depressive symptoms relation to subsequent or prior glycemic control in type 2 diabetes and to test whether patient characteristics modify these longitudinal associations. RESEARCH DESIGN AND METHODS: -- On two occasions separated by 6 months, depressive symptoms and glycemic control were assessed in 253 adults with type 2 diabetes. 1) Examined depressive symptoms as both a predictor and outcome of glycemic control and 2) Explore whether medication regimen (e.g., insulin versus oral drugs) RESULTS and CONCLUSIONS: • Depressive symptoms do not necessarily lead to worsened glycemic control. • In contrast, insulin-treated patients in poor glycemic control are at moderate risk for worsening of depressive symptoms. • These patients should be carefully monitored to determine whether depression treatment should be initiated or intensified.

Insulin Analogs Versus Human Insulin in the Treatment of Patients With Diabetic Ketoacidosis: A randomized controlled trial Umpierrez, Guillermo E. et al. (US) Diabetes Care. 32(7):1164-1169, July 2009. OBJECTIVE: Compare safety and efficacy of insulin analogs and human insulins both during acute intravenous treatment and during the transition to subcutaneous insulin in patients with diabetic ketoacidosis (DKA). RESEARCH DESIGN AND METHODS: Patients with DKA were randomly assigned to receive intravenous treatment with regular or glulisine insulin until resolution of DKA. After resolution of DKA, (1) patients treated with intravenous regular insulin were transitioned to subcutaneous NPH and regular insulin twice daily (n = 34). (2) Patients treated with intravenous glulisine insulin were transitioned to subcutaneous glargine once daily and glulisine before meals (n = 34). RESULTS: • No differences in mean duration of treatment or amount of insulin infusion until resolution of DKA. • After transition to subcutaneous insulin, no differences in mean daily blood glucose levels • Patients treated with NPH and regular insulin had a higher rate of hypoglycemia (blood glucose <3.9mmol/L). Fourteen patients (41%) treated with NPH and regular insulin had 26 episodes of hypoglycemia and 5 patients (15%) in the glargine and glulisine group had 8 episodes of hypoglycemia (P = 0.03). CONCLUSIONS: Regular and glulisine insulin are equally effective during the acute treatment of DKA. A transition to subcutaneous glargine and glulisine after resolution of DKA resulted in similar glycemic control but in a lower rate of hypoglycemia than with NPH and regular insulin. IV regular insulin is still preferred as the cost is relatively cheaper than insulin analogs. The Second-Meal Phenomenon in Type 2 Diabetes. Jovanovic, Ana et al. (UK) Diabetes Care. 32(7):1199-1201, July 2009. OBJECTIVE: In health, the rise in glucose after lunch is less if breakfast is eaten. Study evaluated the second-meal effect in type 2 diabetes. RESEARCH DESIGN AND METHODS: Metabolic changes after lunch in eight obese type 2 diabetic subjects were compared on 3 days: breakfast eaten, no breakfast, and no breakfast but intravenous arginine 1 h before lunch. RESULTS: Comparable insulin levels was observed. Rise in plasma glucose after lunch was considerably less if breakfast had been eaten Breakfast eaten: No Breakfast: and No Breadfast + IV Arginine 1hr: 7.88 (+/ Breakfast No Breakfast No Breakfast + 1hr Arginine B4 Lunch Rise in Plasma 0.68 (+/12.32 (+/7.88 (+/- 1.03) (P<0.0001 Glucose 1.49). 1.73) ) (mmol/L) Plasma free fatty acid concentration at lunchtime moderately related to plasma glucose rise after lunch (r = 0.67, P = 0.0005).