Rapid Improvement In Glycemic Control Research Articles

Effects of Close Monitoring with Telemedicine on Glycemic Control in an Immunocompromised Patient with Type 1 Diabetes.

Background: Hypoglycaemia is a condition that can have a severely negative impact on the life of a person with diabetes, making blood sugar control difficult. Closed loop hybrid insulin pump therapy has been shown to be highly effective in managing this condition, resulting in rapid improvement in glycaemic control and a reduction in the frequency and severity of hypoglycaemic attacks. This article presents a case study in which a type 1 diabetic achieved significant improvement in glycaemic control after switching to a closed-loop hybrid insulin pump system and receiving remote monitoring. Case presentation: A 57-year-old female with type 1 diabetic who had all micro and macro vascular complications. Her blood glucose control was achieved rapidly after switching to insulin pump and her daily life was became more active and normalised. Conclusion: This study highlights rapid achievement of glycemic control, minimization of hypoglycemic episodes, and remote monitoring of the person with type 1 diabetes using a closed circuit insulin pump system. The study's evaluation is objective and based on clear evidence.

Advanced Hybrid Closed-Loop System Achieves and Maintains Recommended Time in Range Levels for Up To 2 Years: Predictors of Best Efficacy.

Aim: To evaluate the long-term efficacy, up to 2 years, of an advanced hybrid closed-loop (AHCL) system and to assess predictors of best results of the therapy. Methods: We retrospectively evaluated 296 adults with type 1 diabetes mellitus [mean age 42.8 ± 16.5 years, men 42.9%, duration of diabetes 22.5 ± 12.8 years, body mass index 24.9 ± 4.7 kg/m2, baseline glycated hemoglobin (HbA1c) 63.4 ± 12.2 mmol/mol (8.0 ± 1.1%) ] who used the MiniMed™ 780G system. Demographic and clinical data were recorded. Continuous glucose monitoring (CGM)-derived metrics and insulin requirement were analyzed from the 4 weeks before and from every quarter after the switch to the AHCL system. Results: In the first quarter of AHCL treatment, all CGM metrics improved. Time in range (TIR) increased from 58.1 ± 17.5% to 70.3 ± 9.5% (P < 0.0001). The improvement lasted for up to 2 years of observation regardless of previous insulin therapies. Throughout the period of observation, 53.4% of participants achieved mean TIR >70%, 92.6% mean time below range <4%, and 46% mean glucose management indicator <53 mmol/mol (7.0%). At univariable logistic regression older age, lower baseline HbA1c and insulin requirement were associated with mean TIR >70%. At multivariable analysis, lower HbA1c remained independently associated with a better glycemic control. However, mean TIR increased more in participants with a higher baseline HbA1c. Conclusions: Switching to an AHCL leads to a rapid improvement in glycemic control lasting for up to 24 months along with a low risk for hypoglycemia, confirming the safety of the system. Lower baseline HbA1c was the main predictor of better efficacy of therapy, although higher baseline HbA1c was associated with the greatest improvement in mean TIR.

Diabete mellito dopo trattamento con ocrelizumab per sclerosi multipla primariamente progressiva

Objectives: immune reconstitution therapies, which include antibody-based cell-depleting therapies targeting CD20+ (ocrelizumab, ofatumumab) or CD52+ (alemtuzumab) leukocytes, are approved for the treatment of multiple sclerosis. Autoimmune thyroid disease is the most common adverse effect of treatment with alemtuzumab, but some cases of autoimmune diabetes have been reported. To date, diabetes mellitus has not been reported after CD20-targeting monoclonal antibodies therapy. Case Report: a 41-year-old man with primary progressive multiple sclerosis was diagnosed with diabetes mellitus six months following the first ocrelizumab infusion. He experienced polyuria and polydipsia, but not other symptoms as visual loss or weight loss. We started a basal-bolus insulin therapy, with progressive and relatively rapid improvement of glycemic control. To note, C-peptide resulted indicative of a preserved beta-cell activity and autoantibodies were negative. To present date, the patient reached an excellent control with metformin. Conclusions: this is the first case of diabetes mellitus reported after ocrelizumab administration. The timing of onset and course are similar to alemtuzumab-induced autoimmune diseases, usually interpreted as an “immune reconstitution syndrome”; however, ocrelizumab cell count depletion appears inferior in duration and cell population affected. This case suggests the need for screening and follow-up of glycemic status in patients treated with ocrelizumab. As a novel therapeutic antibody, further investigation is required to elucidate the correlation between hyperglycemia and ocrelizumab.

Mechanism of metabolic surgery for the treatment of Type 2 Diabetes Mellitus (T2DM)

After metabolic surgery, patients with type 2 diabetes (T2DM) typically experience a rapid improvement in glycemic control before any significant weight loss occurs. Furthermore, a significant proportion of patients are able to achieve long-term T2DM remission and improvement in β-cell function. While historically believed to be related to weight loss and caloric restriction, multiple weight loss independent mechanisms have been identified to contribute to the long-term glycemic effects induced by metabolic surgery. There are changes in bile acid metabolism, the gut microbiome, incretins, and other gut hormones after surgery that are implicated. It is also becoming increasingly evident that adipose tissue, specifically visceral adipose tissue, is implicated in the pathogenesis of insulin resistance (IR) and T2DM through inflammatory changes involving the host immune system. Therefore, metabolic surgery may exert its effects by reducing the inflammatory response through reduction of adipose. While these mechanisms may seem discrete, there is a significant cross-talk between all these factors that contributes to the regulation of glucose homeostasis. Together, this leads to reduced gluconeogenesis, improved glucose tissue uptake, reduced IR, and improved β-cell function after metabolic surgery.

Abstract #1394296: The First Reported Case of Lorlatinib-Associated Diabetic Ketoacidosis

Lorlatinib is a third-generation tyrosine kinase inhibitor that inhibits anaplastic lymphoma kinase (ALK) and c-ros oncogene 1 (ROS1). Although 2-10% of patients with non-small cell lung cancer developed hyperglycemia in phase 2 and 3 studies of lorlatinib, only one case has subsequently reported hyperglycemia >500 mg/dL, and no cases of diabetic ketoacidosis (DKA) have been previously reported. Phase 1 trials in neuroblastoma are ongoing. A 34-year-old woman with ALK-mutated paraspinal neuroblastoma presented with DKA 14 months after initiation of lorlatinib. Prior to starting lorlatinib, her hemoglobin A1c had been 5.0% (n: < 5.7%). After 12 months of therapy, her A1c increased to 7.8%, prompting the initiation of metformin 500 mg daily. However, two months later she was admitted for DKA with a blood glucose of 591 mg/dL (n: 65-99 mg/dL), CO2 17 mmol/L (n: 20-30 mmol/L), anion gap 18 (n: 8-12), moderate serum ketones, and 3+ ketonuria. Her A1c was 14.8%, C-peptide was 1.2 ng/mL (n: 1.1-4.3 ng/mL), and her glutamic acid decarboxylase-65 and islet antigen-2 autoantibodies were negative. She was also found to be incidentally positive for COVID-19 but was asymptomatic without any oxygen requirement. The patient’s DKA was successfully treated with IV insulin infusion, and she was discharged after 3 days with insulin glargine 27 units twice daily and insulin aspart 16 units with meals. One month later, her hemoglobin A1c had improved to 9.4%, and the patient’s oncologist discontinued lorlatinib due to sustained remission of her neuroblastoma and her complication of DKA. After stopping lorlatinib, her blood glucose rapidly improved, and she self-discontinued all her insulin in the following 3 weeks. One month later, she was seen in endocrine clinic only taking metformin 500 mg twice daily with fasting and post-prandial blood glucose ranging 86-107 mg/dL. This is the first reported case of DKA associated with lorlatinib. This case highlights the importance of close glucose monitoring and the risk of severe hyperglycemia and DKA while on lorlatinib therapy. Discontinuation of lorlatinib results in rapid improvement of glycemic control, and glucose-lowering treatments should be promptly deescalated to avoid hypoglycemia.

Current and emerging medications for the management of obesity in adults.

Current and emerging medications for the management of obesity in adults.

Insulin edema after initiation of hybrid closed-loop insulin pump therapy with continuous glucose monitoring: a case report

BackgroundInsulin edema is a rare complication which can present after initiation or intensification of insulin therapy in people with diabetes. Initiation of closed-loop hybrid insulin pump therapy can result in rapid improvement in glycemic control for people with diabetes. We present a case in which transition to a closed-loop hybrid insulin pump system, followed by significant improvement in glycemic control, led to development of insulin edema in a person with type 1 diabetes.Case presentationWe present a 51-year-old woman with type 1 diabetes of 16 years duration, on insulin pump therapy for more than 10 years, who presented for follow-up 7 weeks after transitioning to a hybrid closed-loop insulin pump system with continuous glucose monitoring (CGM). She complained of weight gain and bilateral lower extremity edema which had started two weeks after the change in pump modality. Laboratory studies and echocardiogram did not reveal any etiology of the acute edema. HbA1c was 3.3% lower than the previous measurement 15 weeks earlier, and there was a significant increase in the daily total insulin dose. With exclusion of other causes of acute edema, the patient was diagnosed with insulin edema and started on hydrochlorothiazide. On follow up, her lower extremity edema significantly improved although her weight did not return to baseline.ConclusionTo our knowledge, this is the first case of insulin edema reported in a person with type 1 diabetes using CGM and a hybrid closed-loop insulin pump system. The increase in total daily insulin dose, rapid improvement of glycemic control, and lack of hypoglycemic episodes were important factors to consider in evaluation of this case. Use of hybrid closed-loop systems can help achieve rapid improvement in glycemic control in people with diabetes. This case suggests that consideration should be given to adjusting initial blood glucose targets when starting these remarkable new technologies in people with baseline poor glycemic control.

Early Worsening of Retinopathy in Type1 and Type2 Diabetes After Rapid Improvement in Glycaemic Control: A Systematic Review.

To systematically review the epidemiology of early worsening of diabetic retinopathy (EWDR) after substantial improvements in glycaemic control and evaluate characteristics including risk factors. This systematic review was registered with PROSPERO (CRD42020158252). An electronic literature search was performed according to PRISMA guidelines using MEDLINE, EMBASE, PubMed, Web of Science, Scopus and Cochrane databases and manual reference for the articles published until 2020. Published full-text English language articles that report data on diabetic retinopathy in people with diabetes experiencing a rapid, substantial decrease in HbA1c after going through intensive therapy were included. All articles were screened, data were extracted and methodological quality was evaluated by two independent reviewers using a priori criteria. A total of 346 articles were identified after the removal of duplicates. Data were extracted from 19 full-text articles with a total of 15,588 participants. Included studies varied considerably in terms of patient selection, timing and method of assessing the eye and retinopathy classification. EWDR was reported to occur in a wide range of prevalences; 3.3–47% of participants within 3–84 months after intensification of glycaemic control. Risk factors for EWDR included long duration of diabetes, long-term uncontrolled hyperglycemia, amplitude of and baseline retinopathy severity in both type 1 and type 2 diabetes. The occurrence of EWDR and progression of retinopathy were found to have an association with the amplitude of HbA1c reduction. EWDR has been described in a proportion of people with intensification of glycaemic control. However, the prevalence remains unclear because of methodological differences in the identified studies. Future interventional studies should report retinopathy and visual outcomes using standardized protocols.

The use of SGLT2 inhibitors in achieving glycaemic control in maturity-onset diabetes of the young type 3.

SummaryMaturity-onset diabetes of the young type 3 (MODY3) accounts for approximately 50% of cases of MODY. First-line treatment with sulfonylureas has been well established for individuals with MODY3. In contrast, the use of sodium-glucose co-transporter 2 (SGLT2) inhibitors in the treatment of individuals with MODY3 remains unclear. This case illustrates the in vivo effect of an SGLT2 inhibitor in a 30-year-old woman with MODY3 with poor glycaemic control despite the treatment with supramaximal doses of sulfonylurea and metformin. The addition of a SGLT2 inhibitor resulted in a rapid improvement in glycaemic control without any hypoglycaemic episodes. This case suggests that SGLT2 inhibitors may be an effective and potent treatment option in addition to sulfonylureas for individuals with MODY3.Learning pointsMaturity-onset diabetes of the young type 3 (MODY3) arises from mutations in the hepatocyte nuclear factor-1alpha gene, which controls the expression of sodium-glucose co-transporter 2 (SGLT2) in the kidneys.Paradoxically, despite individuals with MODY3 having reduced expression of SGLT2, SGLT2 inhibitors induce higher glycosuria in individuals with MODY3 compared to individuals with type 2 diabetes mellitus.SGLT2 inhibitors may be an effective treatment for achieving glycaemic control in individuals with MODY3.

Non-glycemic Adverse Effects of Insulin.

Insulin is primarily considered for its glycemic effects in patients with diabetes. There are, however, non-glycemic adverse effects of insulin that may significantly impact patient health and interfere with glycemic control. Insulinogenic edema primarily occurs with rapid improvement in glycemic control either in patients with newly discovered diabetes or in patients with poorly-controlled diabetes. Insulin-induced sympathetic activation, vasodilation, changes in vascular permeability, and most importantly, sodium retention play significant etiologic roles in the development of edema. Clinically, it is usually self-limited, but significant complications can develop. Allergic reactions to all insulin preparations and various compounds used in insulin formulations with a wide range of severity have been reported. Frequently, changing the type of insulin or delivery method is sufficient, but more advanced treatments such as insulin desensitization and anti-IgE antibody treatment may be needed. Lipohypertrophy and lipoatrophy frequently develop with the overuse of injection sites. Lipohypertrophy can affect tissue insulin absorption and glycemic control.

755-P: Generalizability of Pediatric to Adult Transition Models: Preliminary Results from the Supporting Emerging Adults with Diabetes (SEAD) Program

Structured programs facilitating healthcare transition of young adults (YA) (18-30 yrs) have shown improved A1c and loss to follow-up. However, generalizability of these models is lacking. We previously published on a transition program (SEAD) based in an adult diabetes center in Philadelphia, PA that improved A1c, glucose monitoring adherence, and loss to follow-up. We have since moved SEAD to a new health system in the Bronx, NY, expanding care to economically vulnerable and minority YA. We were interested in examining whether the SEAD model was generalizable to a new health system and population. We prospectively followed YA with T1D in the first year of SEAD and collected standardized data on sociodemographic, visit attendance, and clinical factors for 1 year prior to and during care. The program involved an adult endocrinologist and nurse practitioner, and focused on topics including pediatric care coordination, self-management re-education, adult healthcare orientation, behavioral support, and engagement in care efforts. We used multilevel linear and logistic regression with repeated measures to examine visit attendance, A1c, and diabetes technology use. Of 79 YA with a scheduled SEAD visit (mean age at transition 23 yrs, 46% female, 93% Hispanic or Black, 89% Medicaid), 30% (n=24) never attended SEAD or re-established care. Of the 55 YA who attended SEAD, 74% (n=41) returned for at least 1 follow-up within 3 months. Mean A1c improved by 0.97% from 9.81% to 8.84% (n=41, p&amp;lt;0.05). For diabetes technology use, 29% (n=14) were initiated while 66% (n=27) continued use (p&amp;lt;0.05). SEAD preliminary results from a new health system and population demonstrate retention of YA after initial establishment of care, rapid improvement in glycemic control, and robust technology use. More efforts to promote establishing care are needed. The SEAD program is promising as a generalizable model for healthcare transition of YA with T1D. Disclosure C. Lopez-Prieto: None. A. Jang: None. M. Greenberg: None. S. Agarwal: None. Funding National Institute of Diabetes and Digestive and Kidney Diseases (K23DK115896)

Immediate and long-term effects of a very-low-calorie diet on diabetes remission and glycemic control in obese Thai patients with type 2 diabetes mellitus.

AimA very‐low‐calorie diet (VLCD) can reverse the underlying defects of type 2 diabetes mellitus (DM) in obese subjects. We determined the efficacy, safety, and durability of VLCD in Thai patients with DM and obesity.MethodsTwenty Thai patients with DM and obesity were enrolled. After a 2‐week trial, VLCD (600 kcal/day) was continued for 8 weeks, followed by a 4‐week transition period. Data on diabetes remission (fasting plasma glucose level <126 mg/dl and HbA1c <6.5% without the use of glucose‐lowering medications), glycemic control, metabolic parameters, and quality of life (QOL) were collected along with indices of insulin resistance (IR) and beta cell function. Glycemic control 12 months after discontinuation of VLCD was also examined.ResultsAmong 19 patients (age 48 ± 2 years, BMI 27.7 kg/m2) who completed the study, rapid improvement in glycemic control was observed in the first 2 weeks of VLCD. At both 8 and 12 weeks, diabetes remission was achieved in 79%. Significant weight loss was accompanied by a significant reduction in IR and an increase in beta cell function, starting at 4 weeks of VLCD. QOL also significantly increased. At 12 months after VLCD, however, DM remission was achieved in approximately 30%.ConclusionVery‐low‐calorie diet was effective and safe in inducing short‐term diabetes remission in Thai subjects by ameliorating beta cell function and IR. Optimal long‐term glycemic control was potentially durable as one‐third of subjects remained without diabetes medication 12 months after VLCD.

An Unusual Cause of Generalized Insulin Edema and Truncal Neuropathy

Insulin edema and acute neuropathy are rare side effects of insulin initiation or rapid improvement in glycemic control. Both conditions occurring simultaneously are very rare and there are no previous data on truncal neuropathy as a dominant feature. A 35-year-old lady, who presented with an infected, necrotic fourth finger and was admitted for debridement and antibiotics, developed diabetic ketoacidosis. Past medical history included latent autoimmune disease of adults. She was non-compliant with medication and had experienced significant weight loss (37 kg; body mass index (BMI) 15.1 kg/m 2 ). She was glutamic acid decarboxylase antibody positive, with poor glycemic control (HbA1c 133 mmol/mol (14.3%)). She was treated with intravenous and then subcutaneous insulin. From day 3, she developed significant pitting edema to her umbilicus. She was treated with furosemide 40 mg once daily and fluid restriction. Other causes of edema were excluded. Peak weight gain was 5 kg and edema resolved 2 weeks later. She also developed a painful sensory neuropathy over dermatomes T12-L2 on day 5, which persisted for several months before resolution. Magnetic resonance imaging was normal and nerve conduction studies showed generalized diabetic sensorimotor neuropathy. This is the first report of edema and truncal neuropathy developing secondary to insulin initiation and a rapid improvement in glycemic control. Our case was particularly susceptible due to poor glycemic control, low bodyweight, hepatic dysfunction and low serum albumin. This case highlights the importance of being aware of the rare complications of insulin therapy, particularly in susceptible patients. J Med Cases. 2015;6(12):563-565 doi: http://dx.doi.org/10.14740/jmc2345w

A Case of Diabetic Chorea after the Relatively Rapid Improvement of Glycemic Control by Insulin Injection, and the Long-term Follow-up of the Patient&apos;s Condition

A Case of Diabetic Chorea after the Relatively Rapid Improvement of Glycemic Control by Insulin Injection, and the Long-term Follow-up of the Patient&apos;s Condition

The effect of the endoscopic duodenal-jejunal bypass liner on obesity and type 2 diabetes mellitus, a multicenter randomized controlled trial.

Investigate the safety and efficacy of 6 months' duodenal-jejunal bypass liner (DJBL) treatment in comparison with dietary intervention for obesity and type 2 diabetes mellitus (T2DM). The DJBL is a bariatric procedure involving an impermeable sleeve that is delivered endoscopically in the proximal intestine. This procedure not only is less invasive than conventional surgical techniques but also has beneficial effects on obesity and T2DM. A multicenter randomized controlled trial was conducted. Seventy-seven patients with obesity and T2DM were included. Thirty-eight patients were randomized to 6 months' DJBL treatment in combination with dietary intervention (34 successfully implanted, 31 completed the study), 39 patients received only dietary intervention (controls, 35 completed the study). Total study duration for both groups was 12 months, including 6 months of post-DJBL removal follow-up. After 6 months, just before DJBL removal, the DJBL group had lost 32.0% [22.0%-46.7%] of their excess weight versus 16.4% [4.1%-34.6%] in the control group (P < 0.05). Glycated hemoglobin A1c levels improved to 7.0% [6.4%-7.5%] in the DJBL group and to 7.9% [6.6%-8.3%] in the control group (P < 0.05). In addition, 85.3% of DJBL patients showed decreased postprandial glucose excursions versus 48.7% of control patients (P < 0.05). At 12 months, excess weight loss of the DJBL group was 19.8% [10.6%-45.0%] versus 11.7% [1.4%-25.4%] in the control group (P < 0.05). HbA1c was 7.3% [6.6%-8.0%] versus 8.0% [6.8%-8.8%], DJBL versus control respectively (P = ns). The DJBL is a safe and effective alternative to invasive bariatric procedures. Six months of DJBL treatment combined with diet leads to superior weight loss and improvement of T2DM when compared with diet alone.

The impact of improved glycaemic control with GLP-1 receptor agonist therapy on diabetic retinopathy

Rapid improvement in glycaemic control with GLP-1 receptor agonist (RA) therapy has been reported to be associated with significant progression of diabetic retinopathy. This deterioration is transient, and continuing GLP-1 RA treatment is associated with reversal of this phenomenon. Pre-existent maculopathy, higher grade of retinopathy and longer duration of diabetes may be risk factors for persistent deterioration.

Insulin oedema and treatment‐induced neuropathy occurring in a 20‐year‐old patient with Type 1 diabetes commenced on an insulin pump

Oedema may occur following initiation or intensification of insulin therapy in patients with Type1 and Type2 diabetes. Mild oedema is thought to be not uncommon, but under-reported, whilst generalized oedema with involvement of serous cavities has rarely been described. Multiple pathogenic mechanisms have been proposed, including insulin-induced sodium and water retention. Patients at greater risk for insulin oedema include those with poor glycaemic control. Dramatic improvement in glycaemic control is also associated with sensory and autonomic neuropathy. We describe a case of generalized oedema occurring in a 20-year-old, low body weight patient with Type1 diabetes with poor glycaemic control 3days following commencement of an insulin pump; blood sugars had dramatically improved with this treatment. Alternative causes for oedema were excluded. Oedema slowly improved with insulin dose reduction with higher blood sugar targets plus frusemide treatment. Subsequent to oedema resolution, the patient unfortunately developed generalized neuropathic pain, thought to be another manifestation of rapid improvement in glycaemic control. Caution should be taken when a patient with diabetes that is poorly controlled has an escalation in therapy that may dramatically improve their blood sugar levels; this includes the initiation of an insulin pump. Clinicians and patients should be aware of the potential risk of insulin oedema, treatment-induced neuropathy and worsening of diabetic retinopathy in the setting of rapid improvement in glycaemic control.

Endoscopic Duodenal–Jejunal Bypass Liner Rapidly Improves Type 2 Diabetes

Bariatric procedures excluding the proximal small intestine improve glycemic control in type 2 diabetes within days. To gain insight into the mediators involved, we investigated factors regulating glucose homeostasis in patients with type 2 diabetes treated with the novel endoscopic duodenal-jejunal bypass liner (DJBL). Seventeen obese patients (BMI 30-50kg/m(2)) with type 2 diabetes received the DJBL for 24weeks. Body weight and type 2 diabetes parameters, including HbA1c and plasma levels of glucose, insulin, glucagon-like peptide-1 (GLP-1), glucose-dependent insulinotropic polypeptide (GIP), and glucagon, were analyzed after a standard meal before, during, and 1week after DJBL treatment. At 24weeks after implantation, patients had lost 12.7 ± 1.3kg (p < 0.01), while HbA1c had improved from 8.4 ± 0.2 to 7.0 ± 0.2% (p < 0.01). Both fasting glucose levels and the postprandial glucose response were decreased at 1week after implantation and remained decreased at 24weeks (baseline vs. week 1 vs. week 24: 11.6 ± 0.5 vs. 9.0 ± 0.5 vs. 8.6 ± 0.5mmol/L and 1,999 ± 85 vs. 1,536 ± 51 vs. 1,538 ± 72mmol/L/min, both p < 0.01). In parallel, the glucagon response decreased (23,762 ± 4,732 vs. 15,989 ± 3,193 vs. 13,1207 ± 1,946pg/mL/min, p < 0.05) and the GLP-1 response increased (4,440 ± 249 vs. 6,407 ± 480 vs. 6,008 ± 429 pmol/L/min, p < 0.01). The GIP response was decreased at week 24 (baseline-115,272 ± 10,971 vs. week 24-88,499 ± 10,971pg/mL/min, p < 0.05). Insulin levels did not change significantly. Glycemic control was still improved 1week after explantation. The data indicate DJBL to be a promising treatment for obesity and type 2 diabetes, causing rapid improvement of glycemic control paralleled by changes in gut hormones.

GLP-1 agonist treatment: Implications for diabetic retinopathy screening

Rapid improvement in glycaemic control induced by GLP-1 agonist therapy could be yet another illustration of transient or permanent progression of diabetic retinopathy, similar to documented examples such as pregnancy and continuous subcutaneous insulin infusion. Specific guidelines would be needed to monitor this paradoxical phenomenon during treatment with GLP-1 agonists.

Rapid Improvement of Glycemic Control in Type 2 Diabetes Using Weekly Intensive Multifactorial Interventions: Structured Glucose Monitoring, Patient Education, and Adjustment of Therapy—A Randomized Controlled Trial

We evaluated intensive intervention in poorly controlled patients with type 2 diabetes mellitus involving weekly clinic visits and adjustment of therapy with analysis of three seven-point glucose profiles and intervention from an interdisciplinary staff. Sixty-three patients were randomized to an intensive treatment group that obtained self-monitoring of blood glucose (SMBG) profiles (six or seven values per day, 3 days/week) and were seen in the clinic at Weeks 1-6 and 12. SMBG results were downloaded, analyzed using Accu-Chek(®) 360° software (Roche Diagnostics, Indianapolis, IN), and used to adjust therapy. Control group subjects obtained glucose profiles and had clinic visits only at Weeks 0, 6, and 12. There were highly statistically significant improvements in the intensive treatment group compared with the control group between Weeks 0 and 6 with greater reductions in weekly mean glycemia (WMG) (-76.7±8.9 mg/dL vs. -20.5±8.1 mg/dL), glycemic variability (SD) (-16.3±3.1 mg/dL vs. -5.0±3.1 mg/dL), and glycated hemoglobin (-1.82±0.16% vs. -0.66±0.22%) without significant changes in frequency of hypoglycemia or weight. Improvements were sustained in the intensive treatment group through Week 12. A minimal but statistically significant degree of improvement was seen in the control group at Week 12. This short-term pilot study of an intensive monitoring, educational, and pharmacological interventions program resulted in dramatic improvement of glycemic control within 6 weeks, and these effects are sustained through Week 12. SMBG glucose profiles, calculation of WMG and SD, and graphical displays of glucose data can improve the effectiveness of adjustment of therapy at weekly clinic visits when combined with intensive support from a multidisciplinary team.