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Editorials

Does metformin lower CVD risk in type 2 diabetes?

28 Sep 2017Registered users

A recent meta-analysis to evaluate the impact of metformin on cardiovascular disease has been unable to demonstrate convincingly that it is associated with a reduction of risk. The investigators searched Medline, Embase and the Cochrane Library for relevant papers in all languages.  The final yield was ten articles, reporting 13 trials of metformin, virtually all carried out in Northern Europe or North America. In total, 2,079 patients with type 2 diabetes were allocated to metformin and a similar number to comparison groups. All the outcomes, with the exception of stroke, favoured metformin but none achieved statistical significance.

Cognitive deficits and awareness of hypoglycaemia in type 1 diabetes

22 Jun 2017Registered users

A study of patients with type 1 diabetes has shown an association between impaired awareness of hypoglycaemia and cognitive deficits such as diminished learning, memory and pattern separation. This study compared cognitive function in type 1 diabetes patients who had normal awareness of hypoglycaemia with patients who had impaired awareness of hypoglycaemia. The study authors state: ‘It is possible that people with impaired awareness of hypoglycaemia have a diminished ability to distinguish cues that are specifically associated with hypoglycaemia and hence are unable to take appropriate action to avoid severe hypoglycaemia.'

Practice nurses can improve insulin uptake in type 2 diabetes

24 Apr 2017Registered users

Achieving and maintaining glycaemic targets early on in type 2 diabetes has been shown to improve long-term outcomes. Delay in stepping up treatment, especially initiating insulin therapy is known to be a problem in primary care. A primary care study from Australia, in which practice nurses were trained to have an enhanced role, has shown improved rates of safe and effective insulin initiation compared with usual care.

Obesity, metformin and prostate cancer risk

15 Dec 2014Registered users

A total of 104 global studies were reviewed, examining nearly 10 million (9,855,000) men and 191,000 cases of prostate cancer. The analysis concluded that being overweight or obese significantly increases the risk of advanced prostate cancer. The link between obesity and advanced prostate cancer is important for primary care. In order to maximise the benefit from PSA testing of asymptomatic men, we should be trying to target higher-risk men and should now think of adding obesity to that list. [With external links to the evidence base]

Women with diabetes at greater risk of CHD than men

23 Jun 2014Registered users

A recent large meta-analysis has confirmed that women with diabetes have more than a 40% higher risk of incident coronary heart disease (CHD) than men. For GPs this is a timely reminder to consider CHD as a high risk in women with diabetes, and to treat risk factors vigorously. This is especially important because routine screening in the healthy population accustoms us to women being generally at lower risk than men using the current CHD risk tools.

 

Major articles on diabetes

Improving pain control in diabetic neuropathy

22 Mar 2017Paid-up subscribers

Diabetic neuropathy is thought to affect 1.9% of the world’s population and 50% of patients with a diagnosis of diabetes mellitus which would equate to 2.25 million people in the UK. The term diabetic neuropathy includes multiple distinct clinical entities that have been classified under the broad headings of focal and multifocal neuropathies and symmetrical neuropathies. Peripheral diabetic neuropathy, a chronic distal symmetrical predominantly sensory neuropathy, is the most common form of diabetic neuropathy. The common presentation is of painful symptoms originating in the feet, that then spread to the knees before involving the distal portion of the upper limbs in a ‘glove and stocking’ distribution.

Frailty predicts adverse outcomes in older people with diabetes

23 Jan 2017Registered users

In older people living with diabetes, geriatric syndromes, which indicate frailty, are emerging as a third category of complications in addition to the traditional microvascular and macrovascular sequelae. Frailty is defined by the presence of three or more phenotypes (weight loss, weakness, decreased physical activity, exhaustion and slow gait speed). Patients may progress from a non-frail to pre-frail or frail state. With timely intervention, there is a greater chance for an individual to recover from pre-frail to non-frail than to deteriorate into frailty.

Set individualised targets for patients with type 2 diabetes

23 Sep 2016

In type 2 diabetes regular physical activity totalling 30 minutes most days of the week improves muscle insulin sensitivity, lipid profile and blood pressure although a total of 60-75 minutes a day is required for weight reduction and better metabolic profiles. NICE guidelines acknowledge the need for individualised treatment targets. Lowering HbA1c is beneficial in reducing microvascular complications and may have macrovascular benefits in the long term. However, intensive glycaemic control in the elderly with more advanced disease may not have similar benefits and poses a risk due to hypoglycaemia.

Improving the detection and management of type 1 diabetes

25 Jan 2016Registered users

Type 1 diabetes affects around 370,000 adults in the UK, about 10% of all those diagnosed with diabetes. In type 1 diabetes there is a lack of beta cell insulin secretion as a result of autoimmune destruction of the beta cells. However, patients are not affected by insulin resistance, and so do not routinely experience the features of metabolic syndrome that occur in type 2 diabetes. It is therefore important to classify the type of diabetes correctly and to recognise that type 1 diabetes is a condition with its own management requirements. Structured education is the cornerstone of care providing tools to allow effective self-management.

Improving outcomes in diabetes in pregnancy

21 May 2015Paid-up subscribers

One in 250 pregnancies in the UK involves diabetes. The majority of cases (87.5%) are gestational diabetes, 7.5% are type 1 and 5% are type 2 diabetes. Diabetes in pregnancy is associated with a five fold increase in risk of stillbirth and a two-fold increased risk of congenital defects compared with the general maternity population. Women with gestational diabetes have a significant lifetime risk of developing type 2 diabetes, hence diabetes screening must be undertaken on an annual basis in primary care.

Managing patients with type 2 diabetes and obesity

22 Jan 2015Paid-up subscribers

Diabetes risk increases exponentially with increasing BMI particularly if fat accumulates centrally and/or in the skeletal muscle, liver and other organs such as the pancreas. Those with diabetes and co-existing obesity, particularly if it is severe, are also at risk of other obesity-related conditions, such as cardiovascular disease, obstructive sleep apnoea, joint pain, many cancers and depression. Supporting patients to lose weight should be considered a key goal of diabetes care for all overweight and obese patients with type 2 diabetes.

Risk factor control is key in diabetic nephropathy

24 Feb 2014Paid-up subscribers

Prolonged duration of diabetes, poor glycaemic control and hypertension are major risk factors for both diabetic nephropathy and cardiovascular disease. Optimising blood sugar control together with excellent control of blood pressure can reduce the risk of developing diabetic nephropathy. Diabetic nephropathy should be considered in any patient with diabetes when persistent albuminuria develops.

Tailor treatment in the older patient with type 2 diabetes

24 Jan 2013Paid-up subscribers

In older people, diabetes is a disabling disease due to the associated vascular complications, multiple comorbidities and the increased prevalence of geriatric syndromes. Because of the complexity of diabetes in old age a comprehensive assessment is important at initial diagnosis, with the aim of preventing loss of autonomy and preserving independence. Cognitive and physical dysfunction are common in older people with diabetes which may affect health outcomes and quality of life. Individual therapeutic targets should take into consideration functional status, life expectancy and patient preferences.

Identifying patients at risk of type 2 diabetes

21 Aug 2012Paid-up subscribers

In July 2012, NICE published guidance on the identification and management of type 2 diabetes in adults who are at high risk. This new NICE guidance dovetails with the NHS Health Check programme. The guidance advises using a validated risk assessment tool to identify patients at risk of diabetes. NICE recommends that high-risk patients should be offered a programme encouraging them to undertake a minimum of 150 minutes of moderate intensity physical activity a week, gradually lose weight to reach and maintain a BMI within the healthy range, increase consumption of whole grains, vegetables, and other foods that are high in dietary fibre, reduce the total amount of fat in their diet and eat less saturated fat.

 

Clinical reviews of research - by GPwSI diabetes

Incretin-based diabetes therapy not associated with increased mortality

28 Jul 2017Registered users

A recent meta-analysis, published in the BMJ, has shown no increase in all cause mortality in patients with type 2 diabetes using incretin-based treatments i.e. GLP-1 agonists and DPP-4 inhibitors.

Insulin pumps vs multiple injections in adults with type 1 diabetes

23 May 2017Registered users

A randomised controlled trial comparing insulin pump use with multiple daily injections suggests that when patients are engaged with intensive self-management, insulin pump therapy may not add significant extra benefits in adults.

How accurate are screening tests for pre-diabetes?

22 Feb 2017Paid-up subscribers

A recent meta-analysis has confirmed that interventions in patients with pre-diabetes reduce the rate of progression to overt diabetes, but found that the screening tests used to identify pre-diabetes are inaccurate. The study was commissioned by policy makers in a London borough who wanted to identify an effective screen and treat policy in an area of high diabetes prevalence. The UK investigators trawled through Medline, PreMedline and Embase for eligible papers evaluating the accuracy of tests for pre-diabetes, and controlled studies of interventions (lifestyle changes or metformin) in pre-diabetes patients identified by screening. A total of 2,874 titles were scanned and 148 eligible papers reviewed. The final analysis included 49 studies of screening tests and 50 intervention trials.

Blood pressure and risk of cardiovascular events in type 2 diabetes

23 Jan 2017Registered users

A large cohort study has found that lower systolic blood pressure (BP) is associated with reduced cardiovascular risk in type 2 diabetes patients with no previous cardiovascular disease (CVD). However, there was evidence of a J-shaped relationship between systolic BP and heart failure, and also all cause mortality.

Is frequent self-monitoring and on-line reporting of blood glucose worthwhile?

23 Jan 2017Registered users

Frequent self-monitoring of blood glucose had a significant effect on HbA1c only when combined with frequent on-line reporting, in a study from Canada.

Diabetes therapy and bladder cancer risk

24 Oct 2016Registered users

A UK population-based cohort study concludes that pioglitazone is associated with an increased risk of bladder cancer in patients with type 2 diabetes.

Diabetes therapy and cardiovascular outcomes

23 Sep 2016Registered users

A large UK study  has shown clinically important differences in the risk of heart failure, cardiovascular disease (CVD), and all cause mortality in patients on different drugs, alone and in combination, for type 2 diabetes. Overall, use of gliptins or glitazones was associated with reduced risks of all three outcomes compared with non-use of these drugs.

 

Pre-set searches in diabetes