Glucose Control In Type Research Articles

Sodium–Glucose Co-transporter 2 Inhibition – A Novel Strategy for Glucose Control in Type 2 Diabetes

In addition to its central role in the development of microvascular complications, hyperglycaemia plays an important role in the pathogenesis of type 2 diabetes, i.e. glucotoxicity. Thus, effective glycaemic control not only reduces the incidence of microvascular complications, but also corrects the metabolic abnormalities that contribute to the progression of the disease. Progressive beta-cell failure and side effects associated with therapy, such as hypoglycaemia and weight gain, present obstacles to the achievement of optimal durable glycaemic control in subjects with type 2 diabetes. Most recently, inhibitors of the renal sodium glucose co-transporter have been developed to produce glucosuria and reduce the plasma glucose concentration. Because the mechanism of action of these oral antidiabetic agents is independent of beta-cell and tissue sensitivity to insulin, they improve glycaemic control while avoiding hypoglycaemia and promoting weight loss. In this article, we will summarise the available data concerning the mechanism of action, efficacy and safety of this novel antidiabetic therapeutic approach.

Effects of Qigong on Glucose Control in Type 2 Diabetes

Qigong is a traditional Chinese energy medicine practice combining breathing, movement, and meditation. Although previous studies suggest that Qigong may be a beneficial adjunct treatment for individuals with type 2 diabetes (1–3), few randomized controlled trials of Qigong in patients with type 2 diabetes have been performed. The purpose of the present study was to investigate the effects of Qigong relative to physical exercise or standard care on glucose control in adults with type 2 diabetes. Two hundred fifty-one potential subjects were phone screened, 46 individuals were further evaluated at Bastyr University, and 32 eligible participants enrolled in the study. Age- and sex-matched participants were randomly assigned to one of three groups: group 1 ( n = 11) received the Qigong intervention, group 2 ( n = 10) …

Impact of untreated obstructive sleep apnea on glucose control in type 2 diabetes.

Obstructive sleep apnea (OSA), a treatable sleep disorder that is associated with alterations in glucose metabolism in individuals without diabetes, is a highly prevalent comorbidity of type 2 diabetes. However, it is not known whether the severity of OSA is a predictor of glycemic control in patients with diabetes. To determine the impact of OSA on hemoglobin A1c (HbA1c), the major clinical indicator of glycemic control, in patients with type 2 diabetes. We performed polysomnography studies and measured HbA1c in 60 consecutive patients with diabetes recruited from outpatient clinics between February 2007 and August 2009. A total of 77% of patients with diabetes had OSA (apnea-hypopnea index [AHI] > or =5). Increasing OSA severity was associated with poorer glucose control, after controlling for age, sex, race, body mass index, number of diabetes medications, level of exercise, years of diabetes and total sleep time. Compared with patients without OSA, the adjusted mean HbA1c was increased by 1.49% (P = 0.0028) in patients with mild OSA, 1.93% (P = 0.0033) in patients with moderate OSA, and 3.69% (P < 0.0001) in patients with severe OSA (P < 0.0001 for linear trend). Measures of OSA severity, including total AHI (P = 0.004), rapid eye movement AHI (P = 0.005), and the oxygen desaturation index during total and rapid eye movement sleep (P = 0.005 and P = 0.008, respectively) were positively correlated with increasing HbA1c levels. In patients with type 2 diabetes, increasing severity of OSA is associated with poorer glucose control, independent of adiposity and other confounders, with effect sizes comparable to those of widely used hypoglycemic drugs.

Glucose Control in Type 2 Diabetes: Review of Cardiovascular Outcomes

Because recent reports have raised questions about the benefits and risks of intensive control of glucose in patients with type 2 diabetes (JW Gen Med

Cardiovascular disease and intensive glucose control in type 2 diabetes mellitus: moving practice toward evidence-based strategies

Type 2 diabetes mellitus (T2DM) is associated with a high risk of complications, essentially macrovascular events. Surprisingly, the effect of improved glucose control on coronary and cerebrovascular complications and the target level of glycated hemoglobin (HbA(1c)) in this population remains questionable. We here report the results of 4 recently published randomized controlled trials (ACCORD, ADVANCE, VADT, UKPDS post-trial), which did not demonstrate a significant reduction of cardiovascular events in the intensive group compared to the standard group. On the contrary, in ACCORD, the study with the most ambitious goal (HbA(1c) < 6%), the overall and cardiovascular mortality was greater in the intensive group, although the risk of microangiopathic complications, especially nephropathy, was significantly decreased. VADT suggests that one possibility for the lack of observed effect of intensive therapy could be that the cardiovascular benefit is delayed. This contrasts strongly with the long-term postintervention outcomes of UKPDS, which show a persistent benefit of glycemic control during 10 years of post-trial follow-up ('legacy effect'). Therefore, the best way to protect patients with T2DM against coronary and cerebrovascular disease is to target all cardiovascular risk factors as early as possible by an individualized approach.

Modeling the Value for Money of Changing Clinical Practice Change

Decision making about resource allocation for guideline implementation to change clinical practice is inevitably undertaken in a context of uncertainty surrounding the cost-effectiveness of both clinical guidelines and implementation strategies. Adopting a total net benefit approach, a model was recently developed to overcome problems with the use of combined ratio statistics when analyzing decision uncertainty. To demonstrate the stochastic application of the model for informing decision making about the adoption of an audit and feedback strategy for implementing a guideline recommending intensive blood glucose control in type 2 diabetes in primary care in the Netherlands. An integrated Bayesian approach to decision modeling and evidence synthesis is adopted, using Markov Chain Monte Carlo simulation in WinBUGs. Data on model parameters is gathered from various sources, with effectiveness of implementation being estimated using pooled, random-effects meta-analysis. Decision uncertainty is illustrated using cost-effectiveness acceptability curves and frontier. Decisions about whether to adopt intensified glycemic control and whether to adopt audit and feedback alter for the maximum values that decision makers are willing to pay for health gain. Through simultaneously incorporating uncertain economic evidence on both guidance and implementation strategy, the cost-effectiveness acceptability curves and cost-effectiveness acceptability frontier show an increase in decision uncertainty concerning guideline implementation. The stochastic application in diabetes care demonstrates that the model provides a simple and useful tool for quantifying and exploring the (combined) uncertainty associated with decision making about adopting guidelines and implementation strategies and, therefore, for informing decisions about efficient resource allocation to change clinical practice.

Is the evidence from clinical trials for cardiovascular risk or harm for glitazones convincing?

Thiazolidinediones (TZDs), agonists of the nuclear receptor peroxisome proliferator-activated receptor-gamma, induce the expression of many genes, including several enzymes and transporters involved in glucose and lipid metabolism. Although the efficacy of TZDs on blood glucose control in type 2 diabetes is not questionable, their cardiovascular effects have been debated, with beneficial or harmful actions suggested by different authors. This article reviews the available clinical evidence on the cardiovascular effects of TZDs, discussing possible mechanisms underlying the observed effects and suggesting some directions for future research.

Effects of a Plant-Based High-Carbohydrate/High-Fiber Diet Versus High–Monounsaturated Fat/Low-Carbohydrate Diet on Postprandial Lipids in Type 2 Diabetic Patients

OBJECTIVETo search for a better dietary approach to treat postprandial lipid abnormalities and improve glucose control in type 2 diabetic patients.RESEARCH DESIGN AND METHODSAccording to a randomized crossover design, 18 type 2 diabetic patients (aged 59 ± 5 years; BMI 27 ± 3 kg/m2) (means ± SD) in satisfactory blood glucose control on diet or diet plus metformin followed a diet relatively rich in carbohydrates (52% total energy), rich in fiber (28g/1,000 kcal), and with a low glycemic index (58%) (high-carbohydrate/high-fiber diet) or a diet relatively low in carbohydrate (45%) and rich in monounsaturated fat (23%) (low-carbohydrate/high–monounsaturated fat diet) for 4 weeks. Thereafter, they shifted to the other diet for 4 more weeks. At the end of each period, plasma glucose, insulin, lipids, and lipoprotein fractions (separated by discontinuous density gradient ultracentrifugation) were determined on blood samples taken at fasting and over 6 h after a test meal having a similar composition as the corresponding diet.RESULTSIn addition to a significant decrease in postprandial plasma glucose, insulin responses, and glycemic variability, the high-carbohydrate/high-fiber diet also significantly improved the primary end point, since it reduced the postprandial incremental areas under the curve (IAUCs) of triglyceride-rich lipoproteins, in particular, chylomicrons (cholesterol IAUC: 0.05 ± 0.01 vs. 0.08 ± 0.02 mmol/l per 6 h; triglycerides IAUC: 0.71 ± 0.35 vs. 1.03 ± 0.58 mmol/l per 6 h, P < 0.05).CONCLUSIONSA diet rich in carbohydrate and fiber, essentially based on legumes, vegetables, fruits, and whole cereals, may be particularly useful for treating diabetic patients because of its multiple effects on different cardiovascular risk factors, including postprandial lipids abnormalities.

Intensive glucose control and macrovascular outcomes in type 2 diabetes

Improved glucose control in type 2 diabetes is known to reduce the risk of microvascular events. There is, however, continuing uncertainty about its impact on macrovascular disease. The aim of these analyses was to generate more precise estimates of the effects of more-intensive, compared with less-intensive, glucose control on the risk of major cardiovascular events amongst patients with type 2 diabetes. A prospectively planned group-level meta-analysis in which characteristics of trials to be included, outcomes of interest, analyses and subgroup definitions were all pre-specified. A total of 27,049 participants and 2,370 major vascular events contributed to the meta-analyses. Allocation to more-intensive, compared with less-intensive, glucose control reduced the risk of major cardiovascular events by 9% (HR 0.91, 95% CI 0.84-0.99), primarily because of a 15% reduced risk of myocardial infarction (HR 0.85, 95% CI 0.76-0.94). Mortality was not decreased, with non-significant HRs of 1.04 for all-cause mortality (95% CI 0.90-1.20) and 1.10 for cardiovascular death (95% CI 0.84-1.42). Intensively treated participants had significantly more major hypoglycaemic events (HR 2.48, 95% CI 1.91-3.21). Exploratory subgroup analyses suggested the possibility of a differential effect for major cardiovascular events in participants with and without macrovascular disease (HR 1.00, 95% CI 0.89-1.13, vs HR 0.84, 95% CI 0.74-0.94, respectively; interaction p = 0.04). Targeting more-intensive glucose lowering modestly reduced major macrovascular events and increased major hypoglycaemia over 4.4 years in persons with type 2 diabetes. The analyses suggest that glucose-lowering regimens should be tailored to the individual.

Efficacy of insulin glargine in perioperative glucose control in type 2 diabetic patients

Insulin glargine as a basal insulin exhibits constant absorption with no pronounced peaks in blood insulin levels and 24-h duration of action. We checked the effect of insulin glargine through the comparison of insulin glargine with glucose-insulin-potassium (GIK) on perioperative glucose control in insulin-treated type 2 diabetic patients. Thirty insulin-treated type 2 diabetic patients, 40-80 years of age, were subjected to femoral artery bypass or knee amputation under general anaesthesia. The insulin glargine group (n = 15) was treated with insulin glargine (two-thirds of the total daily insulin dose required) subcutaneous administration with 5% dextrose solution infusion. The GIK group (n = 15) was treated with GIK infusion (125 ml h). Blood glucose levels were checked every 30 min during anaesthesia and 1 h after extubation. Potassium was checked every 1 h during anaesthesia and 2-4 h after extubation. Statistical analysis was performed with unpaired t test. There were no significant differences in the time course of blood glucose levels during operation and postoperative period between the two groups (P < 0.05). There was no hypoglycaemic episode in the perioperative period and no significant differences in potassium levels between the two groups. Insulin glargine was as effective as GIK regimen for perioperative glycaemic control during major surgery in insulin-dependent type 2 diabetic patients.

GLP-1 receptor agonists for type 2 diabetes

Type 2 diabetes is reaching epidemic proportions. Therapeutic maintenance of strict glycaemic control limits the risk of microvascular (retinopathy, nephropathy, and neuropathy) and macrovascular complications, 1 Holman RR Paul SK Bethel MA Matthews DR Neil HA 10-year follow-up of intensive glucose control in type 2 diabetes. N Engl J Med. 2008; 359: 1577-1589 Crossref PubMed Scopus (5150) Google Scholar and treatment of diabetes also requires aggressive intervention against dyslipidaemia, hypertension, and excessive weight. 2 Gaede P Lund-Andersen H Parving HH Pedersen O Effect of a multifactorial intervention on mortality in type 2 diabetes. N Engl J Med. 2008; 358: 580-591 Crossref PubMed Scopus (2753) Google Scholar Yet only about 40% of type 2 diabetic patients reach target glycaemia with standard therapies (eg, metformin, sulphonylurea, and insulin). Moreover, many antihyperglycaemic drugs induce hypoglycaemia, weight gain, or both. Weight gain is undesirable because about 85% of type 2 diabetic patients are overweight or obese, which could worsen cardiovascular risk. 3 Van Gaal LF Mertens IL De Block CE Mechanisms linking obesity with cardiovascular disease. Nature. 2006; 444: 875-880 Crossref PubMed Scopus (1988) Google Scholar Therefore, efficacious new antidiabetic agents without serious side-effects are highly desirable. Liraglutide once a day versus exenatide twice a day for type 2 diabetes: a 26-week randomised, parallel-group, multinational, open-label trial (LEAD-6)Liraglutide once a day provided significantly greater improvements in glycaemic control than did exenatide twice a day, and was generally better tolerated. The results suggest that liraglutide might be a treatment option for type 2 diabetes, especially when weight loss and risk of hypoglycaemia are major considerations. Full-Text PDF

New treatment options for glucose control in type 2 diabetes: an opportunity for individualised therapy is now possible

New treatment options for glucose control in type 2 diabetes: an opportunity for individualised therapy is now possible

Prevention of insulin resistance by n-3 polyunsaturated fatty acids

Review results from recent human and animal studies regarding the effects of n-3 polyunsaturated fatty acid (PUFA) in the prevention of insulin resistance. Overall, results from animal studies indicate that fish oil and individual n-3 PUFA [alpha-linolenic acid (ALA), eicosapentaenoic acid (EPA), and docosahexaenoic acid (DHA)] prevented insulin resistance in animal models; results from two studies in mice showed that EPA increased insulin secretion. ALA, EPA, and DHA may act at different sites and involve different mechanisms. Fish oil or purified EPA reduced insulin resistance in some but not other human studies in normal weight and obese individuals. Discrepancies may be due to differences in health status of participants, macronutrient, fatty acid, and antioxidant nutrient composition of basal diet; amount, duration, and fatty acid composition of n-3 PUFA, and methods used to assess insulin resistance. Moderate amounts of n-3 PUFA did not improve or deteriorate glucose control in type 2 diabetics. n-3 PUFA supplementation has clinical significance in the prevention and reversal of insulin resistance. However, increased intake of n-3 PUFA should be part of an overall healthy lifestyle that includes weight control, exercise, and reduction in the intake of refined sugars, n-6, saturated, and trans fatty acids.

Mobile communication using a mobile phone with a glucometer for glucose control in Type 2 patients with diabetes: as effective as an Internet-based glucose monitoring system

A mobile phone with a glucometer integrated into the battery pack (the 'Diabetes Phone') was launched in Korea in 2003. We compared its effect on management of type 2 diabetes to the Internet-based glucose monitoring system (IBGMS), which had been studied previously. We conducted a randomized trial involving 69 patients for three months. Participants were assigned to an Internet group or a phone group. The phone group communicated with medical staff through the mobile phone only. Their glucose-monitoring data were automatically transferred to individual, web-based charts and they received medical recommendations by short message service. The Internet group used the IBGMS. There were no significant differences between the groups at baseline. After three months' intervention, HbA(1c) levels of both groups had decreased significantly, from 7.6% to 6.9% for the Internet group and from 8.3% to 7.1% for the phone group (P < 0.01). Levels of patient satisfaction and adherence to medical advice were similar. Mobile, bidirectional communication between doctors and patients using the diabetes phone was as effective for glucose control as the previously-studied Internet-based monitoring system and it was good for patient satisfaction and adherence.

The Effect of an Inhaled Corticosteroid on Glucose Control in Type 2 Diabetes

To determine the effect of inhaled corticosteroid (ICS) therapy on glucose control in adults with type 2 diabetes mellitus and coexisting asthma or chronic obstructive pulmonary disease (COPD). A prospective randomized, double-blind, double-dummy placebo-controlled, crossover investigation of inhaled steroids and oral leukotriene blockers. A United States Department of Veterans Affairs Health Care System outpatient setting. Adults with type 2 diabetes and asthma or COPD. Subjects (n=12) were randomized to receive either inhaled fluticasone propionate (440 microg twice daily) and oral placebo, or inhaled placebo and oral montelukast (10 mg/day). After 6 weeks, subjects were switched to the opposite therapy for 6 weeks. The primary outcome measure was the change in the percentage of glycosylated hemoglobin (%HbA1c) at 6 weeks relative to the baseline value. Ten patients completed the study. The difference between the mean within-subject changes in %HbA1c associated with 6-week periods of fluticasone and the mean changes associated with montelukast therapy was small but statistically significant (mean difference=0.25; P<0.025). Neither fluticasone nor oral montelukast therapy for 6 weeks led to a significantly different mean % HbA1c compared with the relevant baseline (mean differences=0.11 and -0.14, respectively). The absence of a clinically significant within-subject difference in the changes in %HbA1c associated with fluticasone versus oral montelukast therapy, or between either therapy or baseline does not warrant recommending changes in therapy for asthma or diabetes in patients with these co-morbid conditions. However, we suggest that clinicians carefully monitor blood glucose control when diabetic patients initiate ICS, especially with higher dosages.

Intensive insulin therapy reduced long-term risk for incident hypertension in type 1 diabetes

ACP Journal Club17 February 2009Intensive insulin therapy reduced long-term risk for incident hypertension in type 1 diabetesApostolos Tsapas, MD, PhDApostolos Tsapas, MD, PhDOxford Centre for Diabetes Endocrinology and Metabolism, Oxford, England, UK, Aristotle University Thessaloniki, Thessaloniki, Greece (A.T.)Search for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/0003-4819-150-4-200902170-02012 SectionsAboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Source Citationde Boer IH, Kestenbaum B, Rue TC, et al. Insulin therapy, hyperglycemia, and hypertension in type 1 diabetes mellitus. Arch Intern Med. 2008;168:1867-73. https://pubmed.ncbi.nlm.nih.gov/18809813Clinical Impact RatingsGIM/FP/GP: Endocrinology: References1 Writing Team for the DCCT/EDIC Research Group. Sustained effect of intensive treatment of type 1 diabetes mellitus on development and progression of diabetic nephropathy: the Epidemiology of Diabetes Interventions and Complications (EDIC) study. JAMA. 2003;290:2159-67. [PMID: 14570951] Google Scholar2 Holman RR, Paul SK, Bethel MA, Matthews DR, Neil HA. 10-year follow-up of intensive glucose control in type 2 diabetes. N Engl J Med. 2008;359:1577-89. [PMID: 18784090] Google Scholar Author, Article, and Disclosure InformationAuthors: Apostolos Tsapas, MD, PhDAffiliations: Oxford Centre for Diabetes Endocrinology and Metabolism, Oxford, England, UK, Aristotle University Thessaloniki, Thessaloniki, Greece (A.T.)This article was published at Annals.org on 3 February 2009. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetails Metrics 17 February 2009Volume 150, Issue 4Page: JC2-12KeywordsCohort studiesDrugsExcretionHazard ratioHyperglycemiaHypertensionInsulinRenal diseasesRetinopathyType 1 diabetes ePublished: 17 February 2009 Issue Published: 17 February 2009 Copyright & PermissionsCopyright © 2009 by American College of Physicians. All Rights Reserved.PDF downloadLoading ...

Dysglycemia and Cardiovascular Risk in the General Population

Diabetes is a metabolic disorder that is diagnosed when the fasting and/or postload glucose level rises above well-established thresholds. These thresholds were chosen because they identified people at particularly high risk for retinopathy based on epidemiological data. These data also have shown that people with diabetes and poorly controlled glucose levels have higher risks of retinopathy than people with diabetes and well-controlled glucose levels.1,2 Moreover, recent studies have shown that the relationship between chronically elevated glucose levels (as measured by A1c) and retinal disease is not confined to people with diabetes and is apparent (although less marked) in people with high glucose levels that are below the diabetes cutoffs such as those with impaired glucose tolerance and/or impaired fasting glucose.3–5 Thus, there is a progressive relationship between glycemia and retinopathy that extends below glucose thresholds for diabetes. Article p 812 Clearly, diabetes also is a risk factor for many other serious chronic diseases, including cardiovascular disease.6 Indeed, a recent meta-analysis of large prospective studies comprising 450 000 people showed that men and women with diabetes are 2 and 3 times more likely, respectively, to die of coronary heart disease than men and women without diabetes.7 Other studies have shown that the degree of glucose elevation measured by A1c, fasting glucose, or postload glucose is progressively related to the incidence of cardiovascular outcomes in people with established diabetes and in people without diabetes after adjustment for age and varying numbers of other risk factors.8–15 Moreover, several studies that recruited people from both ambulatory and hospitalized settings suggest that there may be a stronger relationship between glycemia and incident cardiovascular outcomes in people without diabetes than in people with diabetes.8,9,15–17 Such a discrepancy may occur because in people with established diabetes, markers of …

Drug evaluation: Vildagliptin-metformin single-tablet combination

The single-tablet combination of vildagliptin and metformin addresses key defects of type 2 diabetes for improved glycemic control. By inhibiting the dipeptidyl peptidase-4 (DPP-4) enzyme, vildagliptin raises the levels of the active incretin hormones, glucagon-like peptide 1 and glucose-dependent insulinotropic peptide. This leads to increased synthesis and release of insulin from the pancreatic beta cells and decreased release of glucagon from the pancreatic alpha cells. The combination tablet also contains metformin, which addresses insulin resistance. The complementary mechanisms of action of the two agents in combination have been shown to provide additive and sustained reductions in hemoglobin A(1c) compared with metformin monotherapy. In active-controlled trials, the vildagliptin-metformin combination has been shown to produce equivalent reductions in hemoglobin A(1c) to pioglitazone-metformin and glimepiride-metformin combinations, without significant risk of hypoglycemia and without causing weight gain. In clinical trials, the overall incidence of any adverse event was similar in patients randomized to vildagliptin plus metformin and placebo plus metformin. Available data support the use of vildagliptin in combination with metformin as a promising second-line treatment for the management of type 2 diabetes and this is reflected in the latest UK National Institute for Health and Clinical Excellence draft guideline for consultation on new agents for blood glucose control in type 2 diabetes.

Benefits of early intensive glucose control to prevent diabetes complications were sustained for up to 10 years

Source Citation Holman RR, Paul SK, Bethel MA, Matthews DR, Neil HA. 10-year follow-up of intensive glucose control in type 2 diabetes. N Engl J Med. 2008;359:1577-89. 18784090

Follow-up of Intensive Glucose Control in Type 2 Diabetes

To the Editor: The United Kingdom Prospective Diabetes Study (UKPDS) reported by Holman et al. (Oct. 9 issue)1 shows the legacy effect of intensive glucose control (in the metformin group as well as in the group that received either sulfonylurea or insulin) on clinical outcomes in patients with newly diagnosed type 2 diabetes mellitus. The UKPDS has influenced international treatment guidelines2 leading to the recommendation of metformin as the initial pharmacologic therapy in all patients with type 2 diabetes. The original UKPDS trial compared outcome data in patients who received metformin versus conventional therapy (dietary restriction) or intensive therapy (either sulfonylurea or insulin therapy).3 However, comparisons between the metformin group and the sulfonylurea or insulin group separately have not been reported. The recent 10-year follow-up of the UKPDS survivor cohort suggests that metformin, sulfonylurea, and insulin are potentially equivalent candidates for initial glucose-lowering therapy. To guide such treatment choices, we hope that the UKPDS will report separate between-group comparisons within the intensive-therapy group (i.e., metformin vs. sulfonylurea, metformin vs. insulin, and insulin vs. sulfonylurea) in the original 1997 study and the recent 2007 follow-up. Soren S. Lund, M.D. Peter Rossing, M.D., D.M.Sc. Allan A. Vaag, M.D., Ph.D.