Glycaemic control in patients with type 2 diabetes switching from premixed insulin to long‐acting basal insulin analogue plus oral antidiabetic drugs: an observational study

Aim: To evaluate whether administration of long‐acting basal insulin analogue plus oral antidiabetic drugs (OADs) improves glycaemic control in type 2 diabetic patients with glycosylated haemoglobin (HbA1c) > 7% (53 mmol/mol) under premixed insulin therapy. Methods: This is a multicentre, observational, retrospective study performed in type 2 diabetic patients switching from premixed insulin to long‐acting basal insulin analogue plus OADs. Data on patients’ medical history and assessments were retrieved from patients’ medical charts prior to switching the treatment and 6 months thereafter. Results: A total of 131 evaluable patients were enrolled (mean age, 68.2 ± 9.4 years; female, 65.6%; mean diabetes duration, 12.7 ± 6.9 years; mean time on insulin therapy, 53.2 ± 41.9 months). Patients were receiving premixed insulin (once‐daily, 4.7%; twice‐daily, 85.0%; thrice‐daily, 10.2%), 82.4% of whom in combination with OADs (metformin, 79.4%). After the treatment was switched, only 14.5% required intensification of treatment with additional preprandial insulin. HbA1c decreased ?1.4% [mean ± SD, 8.4 ± 1.0% (68.7 ± 11.4 mmol/mol) vs. 7.0 ± 1.0% (53.6 ± 10.9 mmol/mol), p < 0.001] and the proportion of patients achieving HbA1c < 7% (53 mmol/mol) increased to 52.7% (p < 0.001). The percentage of patients with hypoglycaemia decreased (19.2% vs. 10.8%, p < 0.05; symptomatic, 17.6% vs. 4.6%, p < 0.01) and body weight diminished by ?1.9 kg (mean ± SD, 78.5 ± 14.7 kg vs. 76.6 ± 13.9 kg, p < 0.05). Basal insulin plus OADs was considered more convenient and flexibly adapted to patients’ life in 98.4% and 99.2% of patients, respectively. Additionally, 96.9% of patients reported being more satisfied and 96.9% would recommend it. Conclusions: Switching the treatment from premixed insulin to long‐acting basal insulin analogue plus OADs is a feasible and convenient approach to improve glycaemic control of type 2 diabetic patients poorly controlled with premixed insulin under routine clinical practice conditions.     

HbAlc in an unselected population of 4438 people with type 2 diabetes in a Danish county

OBJECTIVE: To describe the use and level of HbA1c in a large unselected Type 2 diabetic population in Denmark. In addition, to describe the characteristics of the patients and the general practitioners in relation to the monitoring of HbA1c. DESIGN: Data were collected from public data files for the period January 1993 to December 1997. SETTING: The County of Vejle with a background population of 342,597 citizens, 303,250 of whom were listed with participating general practitioners. PATIENTS: The Type 2 diabetic population alive and resident in the county on 1 January 1997. RESULTS: In a population of 4438 Type 2 diabetics, 73% had a minimum of one annual HbA1c measurement in 1997. No HbA1c measurement was associated with a long history of diabetes, diet treatment or old age. Poor glycaemic regulation was found in 65% of the Type 2 diabetics in 1997. Poor glycaemic regulation was associated with tablet or insulin treatment, age under 70 years and long history of diabetes. The interpractice variation was huge. CONCLUSION: The quality of HbA1c monitoring of Type 2 diabetics needs to be improved. Possibilities for improvement seem to be present.     

Drug utilization of oral hypoglycemic agents in a university teaching hospital in India

Background: India has witnessed a rapidly exploding epidemic of diabetes in recent years and currently leads the world with the largest number of diabetic subjects in a single country. World Health Organization estimates that in 2000, 31·7 million individuals were affected by diabetes in India and these numbers will rise to 79·4 millions by the year 2030. In view of the above situation, drug utilization review of antidiabetic medicines in Indian healthcare settings has a valid significance to promote rational drug use in diabetics. Objective: The present study is aimed to determine the drug utilization patterns in type 2 diabetic patients on oral hypoglycemic agents in the Medicine Outpatient Department (OPD) and Inpatient Department (IPD) of Majeedia Hospital, a teaching hospital of Hamdard University, New Delhi. Methods: Patients with established type 2 diabetes (n = 218) visiting the OPD and IPD were interviewed using a structured questionnaire during the period January–May 2006. Results:  A majority of the type 2 diabetic patients in this setting were treated with multiple antidiabetic drug therapy. The most commonly prescribed antidiabetic drug class was biguanides (metformin) followed by sulphonylureas (glimepiride), thiazolidinediones (pioglitazone), insulin and alpha‐glucosidase inhibitors (miglitol). As monotherapy insulin was the most common choice followed by metformin. The most prevalent multiple therapy was a three‐drug combination of glimepiride + metformin + pioglitazone. More than half of the type 2 diabetic patients showed poor adherence (compliance) to the prescribed therapy. Conclusion: This study strongly highlights the need for patient education or counselling on use of antidiabetic and concomitant drugs, monitoring of blood glucose and glycosylated haemoglobin (HbA1c) levels, diet control, and correction of diabetic complications. Metabolic control was poor and HbA1c monitoring was underutilized. Clinical monitoring of patients’ adherence to prescribed treatments is recommended and measures should be taken to improve it.     

Diabetes care in rural area: clinical and metabolic evaluation

To evaluate the efficacy of conventional diabetes care in a rural area, metabolic control and the presence of late complications were studied in 622 diabetic patients treated by general practitioners beyond the reach of diabetic centers. Seventy-three (12%) of the patients were classified as type I diabetics (age, 38.0 +/- 16.1 yr; duration of diabetes, 12.8 +/- 9.3 yr) and 549 as type II diabetics (age, 67.0 +/- 10.8 yr; duration of diabetes, 7.3 +/- 5.8 yr). Fifty-eight percent of type I diabetic patients administered insulin once daily and 42% twice daily, whereas most (83%) type II diabetics on insulin received only one insulin injection per day. Treatment of type II diabetic patients consisted of sulfonylureas (58%), diet alone (22%), insulin (18%), and biguanides or a combination of sulfonylurea with biguanides (2%). Poor therapeutic efficacy was observed in all patients, and postprandial hyperglycemia (blood glucose greater than 160 mg/dl) was predominant both in type I diabetics (86%) and in type II diabetics on insulin (80%) as well as off insulin (55%). HbA1c above normal (greater than 5.8%) was seen in 96% of type I and in 90 and 73% of type II diabetics with or without insulin therapy, respectively. Accompanying glucosuria was present in type I (73%) and in type II diabetics (on insulin, 71%; off insulin, 33%). Mean prevalence of late diabetic complications was greatest for insulin-treated patients (type I, type II with, and type II without insulin treatment: retinopathy, 41, 56, 22%; proteinuria, 13, 14, 3%; peripheral neuropathy, 21, 51, 12%), whereas macroangiopathy (16, 53, 31%) predominated in type II diabetic patients.(ABSTRACT TRUNCATED AT 250 WORDS)     

Evaluation of drug therapy and risk factors in diabetic hypertensives: a study of the quality of care provided in diabetic clinics in Bahrain

OBJECTIVE: To evaluate control of blood pressure (BP) and diabetes and the associated risk factors in diabetic hypertensives treated by diabetic clinic primary care physicians. METHODS: A retrospective analysis of the medical records of diabetic hypertensives from six primary care diabetic clinics in Bahrain. RESULTS: The recommended BP target <130/<85 mmHg and of glycosylated haemoglobin (HbA1C) <7% were achieved in 7.5% and 14.5%, respectively. Most of the patients with uncontrolled BP and HbA(1C) were at high cardiovascular risk. More patients were on antihypertensive monotherapy than on combination therapy (60.6% vs. 36.7%; P<0.0001). The recommended two- and three-antihypertensive drug combinations were less often prescribed. In high-risk patients glycaemic control achieved was poor: antidiabetic combination therapy vs. monotherapy did not significantly differ. Inappropriate prescribing practices, such as the use of immediate-release nifedipine monotherapy, use of sulphonylurea instead of metformin in obese patients, and a trend towards prescribing of glyburide rather than a gliclazide in the elderly, were observed. Lipid-lowering (13.5%) and antiplatelet (12.8%) drugs were infrequently prescribed. CONCLUSIONS: Hypertension and diabetes in patients treated at the primary care diabetic clinics were inadequately controlled. In several instances, mono- and combination antihypertensives prescribed were irrational. Lipid-lowering and platelet aggregation inhibition strategies have received little attention. Intensive antihypertensive and antidiabetic complementary combination therapy should be encouraged. Continuous professional education of diabetic clinic physicians and expert-supervised diabetic clinics are desirable.     

Insulin secretion and sensitivity as determinants of HbA1c in type 2 diabetes

BACKGROUND: Defects in insulin secretion and sensitivity, two major determinants of glycaemic control, can occur and progress or not in parallel. The present study was designed to compare the respective roles of both determinants on HbA1c, in type 2 diabetic patients, according to whether or not residual beta-cell function was stimulated with insulin secretagogues. MATERIALS AND METHODS: Insulin secretion and insulin sensitivity were both estimated using the homeostasis model assessment (HOMA). HbA1c, insulin sensitivity (HOMA2%S) and insulin secretion (HOMA2%B) were determined in 289 noninsulin-using type 2 diabetic patients who were further divided into two groups according to treatment: metformin alone (group I, n = 57) or metformin and glyburide (group II, n = 232). The patients of both groups were further divided into three subsets in order to test the dependence of HbA1c on HOMA2%B and HOMA2%S. RESULTS: In group I mean HbA1c were greater (8.4%) in patients with HOMA2%B < 50% than in the two subsets with HOMA2%B > or = 50%: 7.2 and 6.8% (P = 0.0013). In group II mean values of stimulated-insulin secretion (HOMA2%B) were lesser (40.7 and 30.1%) in the two subsets of patients with HbA1c > or = 8% than in patients with HbA1c < 8%: 55.1% (P < 0.0001). By contrast, we found no differences in both groups with HOMA2%S. A stepwise multiple regression showed that HOMA2%B contributed to HbA1c more than HOMA2%S both in groups I (33.5% vs. 23.4%) and II (22.7% vs. 8%). CONCLUSIONS: Although the role of insulin sensitivity is not negligible, insulin secretion appears to be the major determinant of diabetic control in overt type 2 diabetic patients who are treated with metformin alone or with a two-drug therapy combining metformin and glyburide.     

Antidiabetic prescriptions and glycemic control in German patients with type 2 diabetes mellitus: a retrospective database study

OBJECTIVES: This study examined patterns of antidiabetic treatment among individuals with type 2 diabetes in Germany and investigated potential differences in attainment of glycemic control associated with the use of specific antidiabetic regimens. METHODS: This was a retrospective database study. Data were obtained from the German IMS Disease Analyzer-MediPlus database. Patients aged >or=20 years who were identified as having type 2 diabetes and who underwent glycosylated hemoglobin (HbA(1c)) testing at least once between April 1, 2004, and December 31, 2004, were included in the analyses. Potential associations between age, sex, and diabetic complications and the use of specific antidiabetic medications were examined. Also examined were potential associations between attainment of the HbA(1c) target for glycemic control (56.5%), particular patient characteristics, and the use of specific antidiabetic medications. RESULTS: The study included data from 5135 patients with type 2 diabetes (mean age, 67 years; 2702 men, 2433 women; mean [SD] HbA(1c), 6.9% [1.2%]). The most commonly diagnosed comorbidities were hypertension (66.5%) and obesity (18.7%). There were no significant differences in mean age, sex, or comorbidities between patients categorized by HbA(1c) values 6.5%. The most commonly prescribed antidiabetic medications were metformin (20.4%), a sulfonylurea (11.7%), and oral combination therapy (10.9%). In the assessment of potential associations between selected patient characteristics and the receipt of specific antidiabetic medications, individuals were less likely to receive metformin monotherapy if they were aged >or=75 years (12.0%, compared with 21.4% of those aged 65-74 years and 24.7% of those aged <65 years; P < 0.001) or had a diagnosis of a diabetic complication (15.9%, compared with 21.2% in those without complications; P < 0.001). Among those who were more likely to receive insulin monotherapy were women (11.5%, compared with 9.6% of men; P = 0.025) and patients with diabetic complications (13.9%, compared with 9.8% of those without complications; P < 0.001). More than half (52.7%) of patients did not attain the HbA(1c) target. There were significant differences between patients attaining the HbA(1c) target and receipt of specific antidiabetic medications (P < 0.001). Patients treated with insulin monotherapy or oral plus insulin combination therapy were least likely to reach the HbA(1c) target (26.4% and 22.9%, respectively, attained glycemic control; both, P < 0.001). Only 179 (31.9%) of 562 patients treated with oral combination therapy achieved the HbA(1c) target (P < 0.001). CONCLUSIONS: Over half of these German patients with type 2 diabetes failed to attain the HbA(1c) target for glycemic control. Patients who were prescribed insulin monotherapy or combination therapy were least likely to achieve the target.     

Patients with type 2 diabetes inadequately controlled on premixed insulin: effect of initiating insulin glargine plus oral antidiabetic agents on glycaemic control in daily practice

AIM: Premixed insulin regimens are commonly used for type 2 diabetes mellitus (T2DM) patients. However, there is limited information regarding next-step therapy options in cases where premixed insulin does not provide adequate glycaemic control. This 12-week observational study of everyday clinical practice evaluated the efficacy and safety of insulin glargine (glargine) plus oral antidiabetic drugs (OADs) in T2DM patients previously treated with premixed insulin. METHODS: Type 2 diabetes mellitus patients taking premixed insulin were identified from German clinics and were eligible to switch to glargine plus OADs at the physicians' and patients' discretion, as part of routine clinical practice. The study design and conduct was in accordance with German regulations. Fasting blood glucose (FBG), 2-h postprandial blood glucose (PPBG) and glycosylated haemoglobin (HbA(1c)) were measured at the start and after a 12-week observation period. RESULTS: A total of 5045 patients were followed-up and received glargine plus OADs. FBG [start to end-point: 9.9 +/- 2.7 to 6.9 +/- 1.5 mmol/l (178 +/- 48 to 124 +/- 26 mg/dl); p < or = 0.001], 2-h PPBG [10.8 +/- 2.8 to 7.8 +/- 1.5 mmol/l (195 +/- 50 to 140 +/- 27 mg/dl)] and HbA(1c) (8.3 +/- 1.2 to 7.2 +/- 0.8%; p < or = 0.001) improved significantly from start to end-point, respectively. A total of 48.9%, 38.4% and 73.9% of patients had FBG < 6.7 mmol/l (< 120 mg/dl), 2-h PPBG < 7.2 mmol/l (< 130 mg/dl) or HbA(1c) < 7.5%, respectively, after 12 weeks. Significant reductions in body weight were observed between the start and end of the observation period. A total of 71 adverse events were reported by 38 patients. Hypoglycaemia was the most common event (n = 16). CONCLUSIONS: This observational study shows that, in T2DM patients inadequately controlled with premixed insulin, switching therapy to glargine plus OADs is associated with significant improvements in FBG and HbA(1c), and is well tolerated in everyday clinical practice. Further intensification of insulin therapy, perhaps by adding one or more injections of prandial insulin, would help provide further improvements in glycaemic control in these patients.     

Microalbuminuria in diabetic patients: relationship to lipid, glyco-metabolic, coagulation and fibrinolysis parameters

One hundred and sixteen insulin treated diabetic patients were evaluated for the relationship between the presence of microalbuminuria and several lipid, glyco-metabolic, coagulation and fibrinolysis factors. A significant correlation existed only between microalbuminuria and HbA1c (r = 0.23, p = 0.008) and D-dimer (r = 0.28, p = 0.002). After the subdivision of the patients in a group without (n = 85) and a group with microalbuminuria (n = 31) significant differences were found between these two groups for the HDL-cholesterol content (p less than 0.05), the HbA1c level (p less than 0.01) and for the D-dimer concentration (p less than 0.01). Comparison of the patient groups without and with microalbuminuria separately with a healthy volunteers group without albuminuria resulted in significant differences for HDL-cholesterol, triacylglycerols, HbA1c, fructosamine, fibrin monomer and D-dimer, whereas fibrinogen also was significantly different between the diabetic group without microalbuminuria and the healthy volunteers group. Several factors predisposing for atherosclerosis (decrease of HDL-cholesterol, increase of triacylglycerols, coagulation activation with relatively insufficient fibrinolysis) were noticed in both diabetic groups without or with microalbuminuria, but more pronounced in the latter group. The appliance of a Receiver Operating Characteristic (ROC) curve for HbA1c against microalbuminuria (cut-off level 20 micrograms/min) reconfirmed the value of adequate glycaemic control in diabetics for the prevention of microalbuminuria. In conclusion the results of this study show a significantly poorer glycaemic control in insulin treated diabetics with microalbuminuria than in those without microalbuminuria. The presence of lower HDL-cholesterol, higher triacylglycerols and the elevation of fibrin monomers and D-dimers is more pronounced in the microalbuminuria group.(ABSTRACT TRUNCATED AT 250 WORDS)     

Postprandial impairment of resistance vessel function in insulin treated patients with diabetes mellitus type‐2

Reduced postischaemic reactive hyperaemia, is considered a marker of impaired resistance vessel function. Acute postprandial hyperlipidaemia has been shown to induce vascular dysfunction. In the present study, the impact of postprandial hyperglycaemia on resistance vessel reactivity was investigated in insulin treated type‐2 diabetic patients. The study was performed in 16 insulin treated type‐2 diabetics (eight male/eight female, age 47 ± 3 years, HbA1c 7·2 ± 0·2) and 16 controls. Reactive hyperaemia was measured in the forearm by venous occlusion plethysmography after 5 min of ischaemia in the fasting state and 90 min after a test meal. In diabetics, blood glucose increased from 8·7 ± 1·1 to 15·3 ± 1·0 mmol l^?1 (P<0·001) postprandially. This resulted in (i) a significant increase of resting blood flow (3·4 ± 0·3 to 4·8 ± 0·4 ml min^?1 100 ml^?1, P<0·01) and (ii) in a reduced peak reactive hyperaemia (52·3 ± 7·4 to 36·8 ± 4·3 ml min^?1 100 ml^?1, P<0·005). In controls, a similar effect of the meal on resting flow was observed but reactive hyperaemia was unaltered. In the absence of a test meal, basal flow as well as peak reactive hyperaemia remained unchanged in diabetic as well as in non‐diabetic subjects. Our data provide evidence that in the postprandial state resistance vessel reactivity becomes reduced in insulin treated type‐2 diabetic patients.     

Factors affecting the efficacy of starting insulin treatment in Type 2 diabetic patients. A retrospective evaluation

OBJECTIVE: To assess the efficacy and practices of insulin treatment in Type 2 diabetes mellitus in primary health care. SETTING: Primary health care in southwest Finland (population 250,000). DESIGN: Cases in the target area with insulin treatment initiated in 1991-1997 were identified and the patient records were analysed retrospectively for up to 5 years from treatment. PATIENTS: A total of 883 patients with Type 2 diabetes (aged 40-91 years) were identified. MAIN OUTCOME MEASURES: HbA1c and body weight. RESULTS: HbA1c declined by 2.0 percentage points from 10.0% to 8.0% (p < 0.001) at 12 months from the initiation of insulin, irrespective of age. The decrease was smaller in obese patients (BMI > 34 kg/m2). A slightly better glycaemic control was achieved when the treatment was initiated by a specialist rather than by a general practitioner. The improvement in HbA1c was essentially unchanged at 4 years. The decrease in HbA1c was largely independent of the type of the insulin regimen (insulin alone, combined insulin and oral therapy). The daily insulin dose increased markedly and the proportion of patients on combination therapy decreased from 57% to 38% at 4 years. The mean body weight of the patients increased (3.7 kg at 12 months, 5.7 kg at 4 years). The weight increase was highest in patients treated with insulin alone. CONCLUSIONS: Introducing insulin therapy in poorly controlled Type 2 diabetic patients results in a marked decrease in HbA1c. Insulin therapy can be initiated in all age groups with equal results. Insulin treatment can be initiated and improved metabolic control maintained in primary health care.     

Improving glycaemic control of insulin-treated diabetic patients--a structured audit of specialist nurse intervention

Insulin-treated diabetic patients with poor glycaemic control are frequently referred to diabetes specialist nurses, but little data exist as to the effectiveness of this practice. We therefore analysed the progress of 43 prospectively referred insulin-treated patients with glycosylated haemoglobin (HbA1c) levels > 7.5%. Diabetes nurse intervention involved re-education, dietary advice and insulin dose adjustment. Improvement in control was defined as a final HbA1c < 7.0% or a fall of HbA1c of > 1.0% at 6 months post-intervention. Almost two-thirds (63%) of patients achieved improvement status, with no increase in body weight or hypoglycaemic episodes. Disappointingly, however, the 'non-improver' group (37%) showed a mean deterioration in HbA1c. In conclusion, diabetes nurse intervention for poorly controlled insulin-treated diabetic patients is generally effective, but intervention may be best targeted to responsive patients. The factors which influence diabetic patients' 'responsiveness to change' require further investigation.     

Vildagliptin: clinical trials programme in monotherapy and combination therapy for type 2 diabetes

As part of an extensive clinical development programme in patients with type 2 diabetes (T2DM), vildagliptin 50 mg once daily and twice daily, and 100 mg once daily have been assessed in placebo-controlled and, more importantly, in head-to-head active-comparator monotherapy trials over a wide range of baseline HbA1c levels and in a large number of elderly patients. Notable findings in individual trials included: comparable HbA1c lowering over 24 weeks with 100 mg once daily or 50 mg twice daily; efficacy comparable to rosiglitazone with reduced risk of weight gain and oedema over 24 weeks; and durable glycaemic control for up to 2 years with a reduced frequency of gastrointestinal adverse events compared with metformin. Pooled monotherapy data indicate that vildagliptin 100 mg daily produces consistent and clinically meaningful reductions in HbA1c across a range of initial HbA1c levels, in patients with lower and greater body mass index, and in younger and older patients. To date, the safety/tolerability profile seems comparable to placebo with neutral effects on body weight and lipid profiles, and minimal risk of hypoglycaemia. A preliminary study in subjects with impaired glucose tolerance showed that vildagliptin 50 mg once daily enhanced islet cell function, reduced glycaemic excursions and was very well tolerated, paving the way for a future trial in diabetes prevention. Vildagliptin has also been extensively studied in multiple clinical scenarios as add-on combination therapy in patients with inadequate glycaemic control on metformin, thiazolidinedione, sulfonylurea and insulin treatment, and has consistently been shown to improve glycaemic control with good tolerability and low risk for hypoglycaemia. In a trial in patients receiving metformin, the addition of vildagliptin 50 mg twice daily resulted in a 1.1% reduction in HbA1c at 24 weeks. Compared with add-on pioglitazone 30 mg daily in patients inadequately controlled with ongoing metformin therapy, vildagliptin 50 mg twice daily reduced HbA1c by 0.9% vs. 1.0% and was not associated with weight gain (+0.3 kg vs. +1.9 kg) over 24 weeks. Most notably, vildagliptin plus pioglitazone as initial combination therapy in drug-naive patients resulted in robust HbA1c reductions of 1.9% from baseline. In patients receiving stable insulin therapy, vildagliptin 50 mg twice daily improved glycaemic control and was associated with a significant reduction in hypoglycaemic episodes over 24 weeks. Vildagliptin shows considerable promise as a partner for metformin and other commonly used oral antidiabetic agents, and may well play an important role in combination with insulin therapy to further improve glycaemic control.     

The prevalence of vitamin D abnormalities in South Asians with type 2 diabetes mellitus in the UK

Background: The high prevalence of both hypovitaminosis D and type 2 diabetes (T2DM) in the Asian community is well recognised, but the impact of diabetes on vitamin D status and vice versa, has not been well reported. Aims: To determine the prevalence of hypovitaminosis D in Asian patients with T2DM and its impact on glycaemic control. Methods: A cross‐sectional study was conducted in a tertiary referral centre in the UK. Two hundred and ten Asian patients aged more than 40 years were included (170 with and 40 without T2DM). Each had a standard bone profile (serum calcium, phosphate and alkaline phosphatase), serum parathyroid hormone and 25‐hydroxycholecalciferol. Results: The prevalence of low serum 25‐hydroxyvitamin D (< 50 nmol/l) was high in the group as a whole (> 80%) and more common in diabetics compared with controls (83% vs. 70%; p = 0.07). This was particularly so in men (82.5% vs. 57.9%; p = 0.02). HbA1c was higher in women with vitamin D deficiency (< 12.5 nmol/l) (8.11 ± 1.11% vs. 7.33 ± 1.32%, p = 0.046). In logistic regression analysis, T2DM was an independent predictor of hypovitaminosis D. In linear regression analysis, vitamin D deficiency was independently related to HbA1c in women with T2DM. Conclusions: Hypovitaminosis D remains a major public health issue in the Asian population and is exaggerated in patients with T2DM. The fact that vitamin D deficient women had higher HbA1c levels raises the possibility that vitamin D replacement may improve glycaemic control.     

Partial Remission of Diabetes Mellitus After Oral Antidiabetic Therapy

The course of diabetes after withdrawal of antidiabetic therapy was studied in diabetics with maturity-onset disease who had been unsuccessfully treated with diet alone. Therapy with oral antidiabetic drugs was given for 21 to 45 months. All patients were followed at regular intervals until diabetic relapse. The average time of relapse ranged from 3.8 months to 15.6 months.     

Serum leptin levels in type 1 diabetic and obese children: relation to insulin levels

OBJECTIVES: To compare serum leptin levels in type 1 diabetic and obese children. DESIGN AND METHODS: We studied serum leptin levels in 35 type 1 diabetic, 32 obese, and 35 healthy children. Seven of 35 were new-onset diabetics with ketoacidosis. C-peptide (CPE) levels were used for estimating insulin secretion. RESULTS: Serum leptin levels were lower in diabetics than in controls (p<0.001). Obese children had higher leptin and CPE levels than diabetics and controls. In new-onset diabetics, 1 month insulin treatment did not cause any change in leptin levels (p>0.05). Leptin was correlated positively with body mass index and CPE (p<0.001) and inversely with glucose (p = 0.001) and HbA1c (p<0.05) in the combined group. HbA1c and gender were the independent predictors of leptin in diabetic children (p<0.01). CONCLUSIONS: Low serum leptin levels in type 1 diabetic children may be due to chronic insulin deficiency related with their metabolic control. Leptin and insulin may have complementary roles in maintaining a stable body weight.     

Pattern of treatment among diabetic patients in France

Both the treatment pattern and the degree of metabolic control were estimated from a sample of 1172 French diabetic patients. The subjects were recruited from 80 medical-analysis laboratories scattered throughout the country, where they came for biologic blood sample tests. Patients had to be diagnosed as having diabetes, give consent for additional blood sampling, and fill out a short self-questionnaire. Glycosylated hemoglobin A1c (HbA1c) was centrally determined by liquid chromatography (normal range 3.5-6.3%). We found 135 patients (11.5%) who were not drug treated or treated with diet alone, 862 (73.5%) treated with oral agents, and 175 (15.0%) treated with insulin. Among the latter, 79 (6.7%) were defined as true insulin-dependent diabetes mellitus (IDDM) patients. Among patients receiving no drug or a slight dosage or oral agents, 47% were found to be in the normal range of HbA1c. On the other hand, among the patients intensively treated with oral agents or secondarily with insulin, less than half were under fair control (HbA1c less than 7.5%). These results are in agreement with previous estimates of treatment distribution derived from national drug sales data. They provide evidence regarding the particular features of diabetes in France, i.e., low prevalence of IDDM, low consumption of insulin, high consumption of oral agents. The finding of a large proportion of normal HbA1c values in non-insulin-dependent diabetic patients suggests a state of overdiagnosis linked to the use of nonspecific criteria of diagnosis in large-scale screening.     

甘精胰岛素替换预混胰岛素的临床疗效及长期可行性研究

目的探讨甘精胰岛素替换预混胰岛素方案的临床疗效及长期可行性。方法将43例入组患者的预混胰岛素替换为甘精胰岛素,并调整口服降糖药物(OAD)。分别于治疗的第2、4、8、16周对患者进行实验室检查,测量项目包括:血糖、血脂、体质量指数、糖化血红蛋白(HbA1c)、医疗费用及观察试验结束后患者继续使用甘精胰岛素的依从性。调查患者的生活质量。结果治疗16周后,患者的空腹血糖、餐后血糖、HbA1c分别下降了1.35mmol/L、1.91mmol/L、0.71%,胰岛素剂量减少11.33U/d,生活质量得到提高,OAD种类明显增加,医疗费用上涨235.6元/月(均P0.05)。研究结束后的第12周随访显示,仅28.2%的患者继续选择甘精胰岛素治疗。结论甘精胰岛素替换预混胰岛素能有效降低血糖并减少低血糖事件发生风险,但医疗费用较高。     

Metabolic control in diabetic subjects in three Swedish areas with high, medium, and low sales of antidiabetic drugs

OBJECTIVE: The relationship between use of antidiabetic drugs and metabolic control was studied in Swedish diabetic populations in areas with high (Gotland), medium (Tierp), and low (Skellefte?) sales of antidiabetic drugs. RESEARCH DESIGN AND METHODS: The study population consisted of 405 drug-treated diabetic subjects aged 50-74 yr. In all three areas, glyburide comprised approximately 75% of the oral treatment. RESULTS: In accordance with sales, Gotland was found to be a heavy-use area, characterized by a high prevalence of insulin treatment (43%), combination therapy with sulfonylureas and biguanide (28%), and high prescribed daily doses (PDDs) of glyburide (15.5 +/- 0.8 mg) compared with other areas. In Skellefte?, 38% were on insulin, 4% were on combination therapy, and the PDD of glyburide was 7.1 +/- 0.6 mg. In Tierp, 27% were on insulin, 26% were on combination therapy, and the PDD of glyburide was 11.4 +/- 0.7 mg. In Gotland, both men and women had significantly lower HbA1c levels, regardless of treatment mode, and a tendency to be more overweight compared with the area with the least pharmacological intensity (Skellefte?). CONCLUSIONS: In the three diabetic populations, good metabolic control, defined as an HbA1c level of less than 7% and acceptable weight control (body mass index less than 27 for men and less than 25 for women), was achieved among only 16% in Gotland, 17% in Skellefte?, and 12% in Tierp.     

Estimating kidney function and use of oral antidiabetic drugs in elderly

The prevalence of diabetes mellitus (DM) and renal impairment rises with age making regular estimation of glomerular filtration rate (eGFR) in older diabetics necessary. This study investigated the differences among available estimating equations in assessing eGFR in older diabetics and examined the use of oral antidiabetic drugs (OADs) in relation to renal function. Patients with DM were participants of the Berlin Initiative Study (BIS), a population‐based cohort study initiated in 2009 in Berlin, Germany, to evaluate kidney function in people ≥70 years. GFR was estimated with the creatinine‐based CKD‐EPI_CREA (Chronic Kidney Disease Epidemiology Collaboration), the MDRD (Modification of Diet in Renal Diseases) and the BIS1 equation and was directly measured (mGFR) with iohexol clearance as a gold standard in a subgroup (n = 137). Creatinine clearance was estimated with the Cockcroft–Gault equation (CrCl). DM prevalence was 26% (539 of 2070 overall participants). The antidiabetic drugs most commonly used among OAD patients were metformin (67%), glimepiride (27%) and glibenclamide (14%). Three of ten metformin patients had a CrCl <60 mL/min. Compared to mGFR, the mean differences of filtration rates calculated by MDRD, CKD‐EPI_CREA and BIS1 were +8.9, +6.7 and ?1.8 mL/min/1.73 m², respectively. Summing up, many patients with a CrCl <60 mL/min received metformin, although this represents a contraindication in Germany. Glibenclamide was commonly used despite its classification as potentially inappropriate medication in older adults. Finally, BIS1 performed better in estimating GFR in older diabetics than MDRD or CKD‐EPI_CREA.