Bromocriptine: old drug, new formulation and new indication

Bromocriptine is an ergot alkaloid dopamine D(2) receptor agonist that has been used extensively in the past to treat hyperprolactinaemia, galactorrhoea and Parkinsonism. It is known that hypothalamic hypodopaminergic states and disturbed circadian rhythm are associated with the development of insulin resistance, obesity and diabetes in animals and humans. When administered in the early morning at the start of the light phase, a new quick release (QR) formulation of bromocriptine appears to act centrally to reset circadian rhythms of hypothalamic dopamine and serotonin and improve insulin resistance and other metabolic abnormalities. Phase II and III clinical studies show that QR-bromocriptine lowers glycated haemoglobin by 0.6-1.2% (7-13 mmol/mol) either as monotherapy or in combination with other antidiabetes medications. Apart from nausea, the drug is well tolerated. The doses used to treat diabetes (up to 4.8 mg daily) are much lower than those used to treat Parkinson's disease and have not been associated with retroperitoneal fibrosis or heart valve abnormalities. QR-bromocriptine (Cycloset™) has recently been approved in the USA for the treatment of type 2 diabetes mellitus (T2DM). Thus, a QR formulation of bromocriptine timed for peak delivery in the early morning may provide a novel neurally mediated approach to the control of hyperglycaemia in T2DM.

Key considerations around the risks and consequences of hypoglycaemia in people with type 2 diabetes

Hypoglycaemia and its consequences represent a significant risk for many people who have type 2 diabetes, and hypoglycaemia is currently under-recognised and commonly avoidable. Current clinical guidelines recommend the targeting of tight glycaemic control and this strategy may also be associated with an increased risk of hypoglycaemia. Hypoglycaemia impacts on morbidity, mortality and quality of life of people with type 2 diabetes, and improved recognition of the symptoms of hypoglycaemia will allow effective treatment and reduce the risk of progression to more severe episodes. A common cause of hypoglycaemia in people with type 2 diabetes is glucose-lowering medication, in particular, those which raise insulin independently of ambient glucose concentration such as sulphonylureas and exogenous insulin. The recently published National Institute for Health and Clinical Excellence guideline recommends the use of Dipeptidyl peptidase-4 inhibitors or thiazolidinediones (glitazones) as alternative second-line therapy instead of a sulphonylurea in those patients who are at significant risk of hypoglycaemia and its consequences.

Is the ADA/EASD algorithm for the management of type 2 diabetes (January 2009) based on evidence or opinion? A critical analysis

The ADA and the EASD recently published a consensus statement for the medical management of hyperglycaemia in patients with type 2 diabetes. The authors advocate initial treatment with metformin monotherapy and lifestyle modification, followed by addition of basal insulin or a sulfonylurea if glycaemic goals are not met (tier 1 recommendations). All other glucose-lowering therapies are relegated to a secondary (tier 2) status and only recommended for selected clinical settings. In our view, this algorithm does not offer physicians and patients the appropriate selection of options to individualise and optimise care with a view to sustained control of blood glucose and reduction both of diabetes complications and cardiovascular risk. This paper critically assesses the basis of the ADA/EASD algorithm and the resulting tiers of treatment options.

Exenatide compared with long-acting insulin to achieve glycaemic control with minimal weight gain in patients with type 2 diabetes: results of the Helping Evaluate Exenatide in patients with diabetes compared with Long-Acting insulin (HEELA) study

AIM

The Helping Evaluate Exenatide in overweight patients with diabetes compared with Long-Acting insulin (HEELA) study was designed to examine whether the glucagon-like peptide-1 (GLP-1) receptor agonist, exenatide, could improve HbA1c (< or =7.4%) with minimal weight gain (< or =1 kg) compared with insulin glargine.

METHODS

Patients [body mass index (BMI) >27 kg/m(2)] with elevated cardiovascular risk and type 2 diabetes inadequately controlled on two or three oral antidiabetes drugs (OADs) were randomized to add-on exenatide 5-10 microg b.i.d. (n = 118) or insulin glargine o.d. (titrated to target fasting plasma glucose < or =5.6 mmol/l; n = 117) for 26 weeks.

RESULTS

The study population had baseline mean (s.d.) age of 56.5 (9.1) years and BMI of 34.1 (5.3) kg/m(2), and 58.5% of patients were taking two OADs. Mean baseline HbA1c was 8.65 (0.68)% in the exenatide group and 8.48 (0.66)% in the insulin glargine group. The proportions of patients achieving the composite endpoint of HbA1c < or =7.4% with weight gain < or =1 kg were 53.4% for the exenatide group and 19.8% for the insulin glargine group (p < 0.001 for exenatide vs. insulin glargine). Exenatide and insulin glargine did not demonstrate a significant difference in HbA1c improvements [least square (LS) mean [s.e.m.]: -1.25 [0.09]% and -1.26 [0.09]% respectively; p = 0.924], but had divergent effects on body weight (-2.73 [0.31] vs. +2.98 [0.31] kg respectively, p < 0.001) after 26 weeks. There were more treatment-related adverse events with exenatide but a lower incidence of nocturnal hypoglycaemia, with no differences in overall or severe hypoglycaemia.

CONCLUSIONS

Additional treatment with exenatide resulted in significantly more overweight and obese patients with an elevated cardiovascular risk and type 2 diabetes achieving better glycaemic control with minimal weight gain compared with insulin glargine.

Translating science into clinical practice: focus on vildagliptin in combination with metformin

Vildagliptin is a potent and selective oral dipeptidyl peptidase-4 inhibitor that improves glycaemic control in patients with type 2 diabetes mellitus (T2DM) by increasing both alpha- and beta-cell responsiveness to glucose. The efficacy, tolerability and safety of the combination of vildagliptin and metformin in the treatment of T2DM have been established in numerous trials in the extensive vildagliptin clinical programme. As add-on therapy in patients with inadequate glycaemic control on metformin, vildagliptin produces clinically significant reductions in glycated haemoglobin (HbA1c) and fasting plasma glucose, is well tolerated, and is associated with absence of weight gain and minimal risk of hypoglycaemia. Compared with thiazolidinedione add-on treatment, vildagliptin is associated with similar significant reductions in HbA1c without the weight gain seen with the former. Compared with sulfonylurea add-on treatment, vildagliptin is associated with similar efficacy in controlling glycaemia but absence of weight gain and a markedly lower risk of hypoglycaemia. In drug-naive patients, single-tablet combinations of vildagliptin/metformin 50/500 and 50/1000 mg bid produced significantly greater reductions in HbA1c than monotherapy with either agent and were well tolerated, with no weight gain and minimal risk of hypoglycaemia. The combination of vildagliptin and metformin poses numerous advantages in the treatment of T2DM.

Individual patient data meta-analysis of trials of self-monitoring of blood glucose in non-insulin treated type 2 diabetes: protocol for a systematic review

BACKGROUND AND AIM OF THE STUDY

Recent trials have provided differing estimates of the benefits of self-monitoring of blood glucose (SMBG) for non-insulin treated patients with type 2 diabetes. Designing and conducting randomised trials to demonstrate the efficacy of complex interventions is challenging. Variations in the components of the intervention delivered, target population selected, and reporting methods used have limited the conclusions drawn in recent systematic reviews. We will systematically examine these factors within the trials of SMBG to enable further investigation of the data through an individual patient data analysis (IPD).

METHODS/DESIGN

The IPD analysis will include data from randomised trials comparing blood glucose self-monitoring and decisions about self-management versus a control group with standardised or routine care. The data requested for each trial will include outcomes (HbA1c, blood glucose and quality of life), potential moderators of effect (e.g. demographic variables, clinical data and psychosocial factors) and intervention descriptors. The primary outcome of interest will be HbA1c. Secondary outcomes include alternative measures of glycaemia, cardiovascular risk factors, persistence with monitoring, and measures of health status, quality of life and psychosocial factors. Analysis of patient sub-groups defined by age at randomisation, gender, prior use of monitoring and health status will be carried out. An intention to treat analysis will be performed and assessed for clinical and statistical heterogeneity.

DISCUSSION

With current uncertainty about the extent of benefit from SMBG for non-insulin treated patients with type 2 diabetes, this study will provide the best estimates to date of overall effectiveness, effectiveness within potential target populations, and optimal components of the intervention.

Differential expression of HLA-DQ alleles in peripheral blood mononuclear cells: alleles associated with susceptibility to and protection from autoimmune type 1 diabetes

Differential expression of human leucocyte antigen (HLA) class II genes has been postulated to influence the risk of developing autoimmune disease. In this study, we investigated the relationship between the level of mRNA expression of DQA1 and DQB1 alleles in peripheral blood mononuclear cells and the influence of the alleles on susceptibility to type 1 diabetes (T1D). Transcripts from pairs of DQA1 and DQB1 alleles were quantified in 59 DQ-heterozygous individuals (29 patients with T1D and 30 healthy control subjects). Luciferase reporter gene assays were used to investigate the relative promoter activities of the alleles associated with high and low risk of disease. DQA1*0301 and the DQB1*06 group of alleles (*0601, *0602, *0603 and *0604) were generally overexpressed in comparison to other alleles. In contrast, mRNA for DQB1*0201/*0202 was generally less abundant than other DQB1 transcripts. These data correlated well with the relative promoter activities observed for the diabetes-associated alleles; the strongest promoters were those derived from DQA1*0301 and DQB1*0602, while a 700-bp fragment derived from the DQB1*0201 promoter showed the lowest activity of the DQB1 constructs. There was no simple correlation between the level of expression of specific DQ alleles and their influence on the risk of diabetes. The functional relevance of our findings and their implications for the pathogenesis of autoimmunity remain to be determined.

Chronic kidney disease in long duration type 1 diabetes lasting more than 50 years

OBJECTIVE

There is evidence that microalbuminuria and overt nephropathy may progress more slowly in long duration (> 20 years) type 1 diabetes (T1DM). To explore this further, we examined the characteristics of chronic kidney disease (CKD) in a large cohort of long duration T1DM in the United Kingdom (UK).

RESEARCH DESIGN AND METHODS

We studied the UK 'Golden Years' cohort--a group of 400 patients from various parts of the UK with T1DM > 50 years duration. Demographic and clinical information were obtained. HbA(1c), lipids, creatinine and urinary albumin-creatinine ratio (ACR) were measured. Microalbuminuria was defined as 2.5-25.0 mg/mmol for males and 3.5-25.0 mg/mmol for females; macroalbuminuria was defined as an ACR > 25.0 mg/mmol for both sexes.

RESULTS

Mean age was 69 years and duration of diabetes 55 years. Nine percent had macroalbuminuria and 27% microalbuminuria. No patient had stage 5 CKD. Microalbuminuria was associated significantly with increased diabetes duration (p = 0.02), male sex (p = 0.02), smoking (p = 0.002), higher HbA(1c) (p < 0.0001), raised triglycerides (p = 0.04), and peripheral vascular disease (PVD) (p < 0.0001). Macroalbuminuria had significant associations with smoking (p = 0.02), raised triglycerides (p = 0.01), raised creatinine (p = 0.02), PVD (p = 0.01) and hypertension (p = 0.01).

CONCLUSIONS

We conclude that microalbuminuria and CKD are common, even at long duration (> 50 years) of T1DM, and have similar characteristics and associations as they do with shorter disease duration. There is a striking absence, however, of stage 5 CKD, but selection bias may be an important confounder since patients with advanced disease may have not survived.

Effects of menopausal status on circulating calcitonin gene-related peptide and adipokines: implications for insulin resistance and cardiovascular risks

OBJECTIVES

To determine, first, the effects of menopausal status on circulating calcitonin gene-related peptide (CGRP) levels and, second, the correlation between circulating CGRP levels and biomarkers for cardiovascular disease.

METHODS

Cross-sectional study of healthy premenopausal and postmenopausal women volunteers and women admitted for elective benign abdominal surgery in a district general hospital. All women were non-smokers, had no history of endocrinological problems and were not receiving any hormone therapy. Fasting blood samples (premenopausal (n = 45): follicle stimulating hormone (FSH) < 20 IU/l, estradiol (mean +/- SEM) 440.33 +/- 51.82 pmol/l; postmenopausal women (n = 28): FSH > 20 IU/l, estradiol 93.79 +/- 17.40 pmol/l) were analyzed for CGRP, resistin, leptin, adiponectin, insulin and lipids using ELISA and immunoassays.

RESULTS

Mean circulating CGRP levels were higher in the postmenopausal women compared with premenopausal women (pre: 41.79 +/- 9.01 pg/ml, post: 138.14 +/- 45.75 pg/ml; p = 0.047). Among women who were experiencing hot flushes, the postmenopausal women had significantly higher CGRP levels than the premenopausal women (pre: 21.98 +/- 4.95 pg/ml, post: 171.08 +/- 61.80 pg/ml; p = 0.028). Serum CGRP levels positively correlated with serum insulin levels (r = 0.652, p = 0.016) and HOMA index (r = 0.54, p < 0.001).

CONCLUSION

These data show that circulating CGRP levels are influenced by menopausal status and suggest additional mechanisms through which increased risk of hyperinsulinemia and cardiovascular disease may arise in postmenopausal women.

The efficacy of self-monitoring of blood glucose in the management of patients with type 2 diabetes treated with a gliclazide modified release-based regimen. A multicentre, randomized, parallel-group, 6-month evaluation (DINAMIC 1 study)

AIM

To determine if therapeutic management programmes for type 2 diabetes that include self-monitoring of blood glucose (SMBG) result in greater reductions in glycated haemoglobin (HbA1c) compared with programmes without SMBG in non-insulin requiring patients.

METHODS

Multicentre, randomized, parallel-group trial. A total of 610 patients were randomized to SMBG or non-SMBG groups. Patients in both groups received the same oral antidiabetic therapy using a gliclazide modified release (MR)-based regimen for 27 weeks. The primary efficacy end-point was the difference between groups in HbA1c at the end of observation.

RESULTS

A total of 610 patients were randomized: 311 to the SMBG group and 299 to the non-SMBG group. HbA1c decreased from 8.12 to 6.95% in the SMBG group and from 8.12 to 7.20% in the non-SMBG group; between-group difference was 0.25% (95% CI: 0.06, 1.03; p = 0.0097). Symptoms suggestive of mild to moderate hypoglycaemia was the most commonly reported adverse event, reported by 27 (8.7%) and 21 (7.0%) patients in the SMBG and non-SMBG groups, respectively; the incidence of symptomatic hypoglycaemia was lower in the SMBG group.

CONCLUSION

In patients with type 2 diabetes, the application of SMBG as an adjunct to oral antidiabetic agent therapy results in further reductions in HbA1c.

Hypertriglyceridaemia is associated with an increased likelihood of albuminuria in extreme duration (> 50 years) Type 1 diabetes

AIMS

To explore the association between dyslipidaemia and albuminuria at the extreme of diabetes duration.

METHODS

Data and samples were collected from 400 patients with extreme duration (> 50 years) of Type 1 diabetes in the UK (Golden Years Cohort). Urinary albumin-creatinine ratio (ACR), glycated haemoglobin (HbA(1c)), creatinine, non-fasting triglycerides, total cholesterol, high-density lipoprotein- and low-density lipoprotein-cholesterol were analysed in all patients.

RESULTS

Thirty-six percent of patients had albuminuria (micro- or macroalbuminuria). After adjusting for age, gender, HbA(1c), disease duration and presence of macrovascular disease, hypertriglyceridaemia was more likely to be associated with the presence of albuminuria.

CONCLUSIONS

High triglycerides may be a potential risk factor for progression of diabetic nephropathy at the extreme of diabetes duration, but the benefit of targeting this aggressively remains to be evaluated further.

Detection of impaired glucose tolerance and undiagnosed type 2 diabetes in UK South Asians: an effective screening strategy

AIM

We tested a stepwise, community-based screening strategy for glucose intolerance in South Asians using a health questionnaire in conjunction with body mass index (BMI). Anthropometric measurements (waist and hip circumference, sagittal diameter and percentage body fat) were then conducted in a hospital setting followed by an oral glucose tolerance test (OGTT) to identify subjects at the highest risk and analyse the factors predicting that risk.

METHODS

A health questionnaire was administered to 435 subjects in a community setting and BMI was measured. Subjects were graded by a risk score based on the health questionnaire as high, medium and low. Subjects with high and medium risk scores and a representative sample of those with low scores had anthropometric measurements in hospital followed by an OGTT. In total, 205 (47%) of the subjects had an OGTT performed.

RESULTS

In total, 48.7% of the subjects tested with an OGTT had evidence of glucose dysregulation: 20% had diabetes and 28.7% had impaired glucose tolerance (IGT). Logistic regression model explained 49.1% of the total variability. The significant predictors of diabetes and IGT were Blood Glucose Monitoring Strips (BMI), random blood glucose (BM), sibling with diabetes and presence of diagnosed hypertension or ischaemic disease. Most of these predictors along with other heredity diabetes factors create a composite score, with high predictability, as the receiver operating curve analysis shows.

CONCLUSION

We describe a simple, stepwise strategy in a community setting, based on a health questionnaire and anthropometric measurements, to explain about 50% of cases with IGT and diabetes and diagnose about 50% of cases from the population screened. We have also identified factors that predict the risk.

MRI total sagittal abdominal diameter as a predictor of metabolic syndrome compared to visceral fat at L4-L5 level

OBJECTIVE

To compare associations between anteroposterior (AP) diameter or sagittal abdominal diameter - a measure of total central fat, and visceral fat alone with the metabolic syndrome as defined by ATPIII criteria.

RESEARCH DESIGN AND METHODS

Twenty-four Caucasian male with type 2 diabetes and 24 non-diabetic Caucasian male subjects [body mass index (BMI) (+/-SD): 32.23 +/- 7.52 kg/m(2), age (+/-SD): 51.35 +/- 13.80 years] were studied by magnetic resonance imaging (MRI) scan to measure central fat at L4-L5 level. The visceral and total central adipose tissue was calculated in cm(2) and total sagittal MRI diameter and visceral sagittal MRI diameters in cm. Components of the ATPIII definition of the metabolic syndrome and circulating adipocytokine concentrations were also measured.

RESULTS

MRI total sagittal abdominal diameter was positively associated with waist circumference in controls (r=0.62, p=0.007) and in diabetic subjects (r=0.81, p<0.001). Binary logistic regression analysis showed that MRI-calculated total sagittal diameter (r=0.61, p=0.002) was a more significant predictor of the adverse metabolic profile of the metabolic syndrome than MRI-assessed visceral fat. Receiver operating characteristic curves revealed that MRI-calculated total sagittal diameter most effectively identified subjects with the metabolic syndrome.

CONCLUSIONS

MRI-calculated total sagittal abdominal diameter is a non-validated MRI method that predicts the adverse metabolic profile of the ATPIII definition of the metabolic syndrome. Antero-posterior fat is a dimension of central fat that seems to be more closely associated with cardiovascular risk compared to visceral fat.

Effect of the orlistat on serum endotoxin lipopolysaccharide and adipocytokines in South Asian individuals with impaired glucose tolerance

BACKGROUND

Orlistat has been shown to increase adiponectin and reduce progression to type 2 diabetes in obese Caucasians. Some effects of orlistat are thought to be independent of weight loss by altering gut flora and the production of endotoxin lipopolysaccharide (LPS). We studied the effect of dietary treatment with and without orlistat in South Asian individuals with impaired glucose tolerance (IGT) on adiponectin and inflammatory markers including LPS.

METHODS

South Asian individuals were randomised to either dietary treatment with orlistat or dietary treatment alone. At the end of 12 months, a comparison was made between the two groups for differences in anthropomorphic measurements and serum markers.

RESULTS

Three hundred and five individuals underwent oral glucose tolerance test of whom 40 had IGT. Complete baseline and 1-year data was available for 31 patients. After 1 year, patients in the orlistat group demonstrated a greater but insignificant decrease in weight (4.5 +/- 0.1 kg), and a significant increase in adiponectin (6.73 +/- 3.2 microg/ml) and decrease in LPS (4.55 +/- 1.98 EU/ml) compared with- the diet-alone group. In the orlistat group the reduction in LPS was correlated with the increase in adiponectin (p < 0.005).

CONCLUSION

The increase in adiponectin levels in the orlistat group would suggest that orlistat may reduce the progression to type 2 diabetes in South Asian individuals by raising serum adiponectin. The finding that LPS levels are also reduced by orlistat and that this reduction correlates with the increase in adiponectin raises the possibility that the increase in adiponectin may be mediated via an effect on LPS levels.

The potential impact of periodontal disease on general health: a consensus view

BACKGROUND

Evidence for a link between periodontal disease and several systemic diseases is growing rapidly. The infectious and inflammatory burden of chronic periodontitis is thought to have an important systemic impact. Current evidence suggests that periodontitis is associated with an increased likelihood of coronary heart disease and may influence the severity of diabetes.

SCOPE

This paper represents a UK and Ireland cross-specialty consensus review, undertaken by a group of physicians and dentists. The consensus group reviewed published evidence (PubMed search for review and original articles), focusing on the past 5 years, on the contributory role of periodontal disease to overall health. In particular, evidence relating to a role for periodontal disease in cardiovascular disease and in diabetes was considered.

FINDINGS

Initial studies of large epidemiological data sets have sought to find links between periodontitis and systemic disease outcomes, but a causal relationship still needs to be demonstrated between periodontal disease, cardiovascular disease and diabetes through prospective studies. There is a need for prospective studies assessing the association between periodontal disease and patients at particular risk of cardiovascular events which will allow assessment of both cardiovascular disease clinical endpoints and surrogate markers of cardiovascular risk. Of note, periodontal disease is also often more severe in subjects with diabetes mellitus, a group at already increased risk for cardiovascular events.

CONCLUSIONS

While further research is needed to define the population-attributable risk of periodontal disease to both cardiovascular diseases and to diabetes control and progression, health education to encourage better oral health should be considered as part of current healthy lifestyle messages designed to reduce the increasing health burden of obesity, cardiovascular disease and diabetes.

Enhanced diabetes care to patients of south Asian ethnic origin (the United Kingdom Asian Diabetes Study): a cluster randomised controlled trial

BACKGROUND

Delivery of high-quality, evidence-based health care to deprived sectors of the community is a major goal for society. We investigated the effectiveness of a culturally sensitive, enhanced care package in UK general practices for improvement of cardiovascular risk factors in patients of south Asian origin with type 2 diabetes.

METHODS

In this cluster randomised controlled trial, 21 inner-city practices in the UK were assigned by simple randomisation to intervention (enhanced care including additional time with practice nurse and support from a link worker and diabetes-specialist nurse [nine practices; n=868]) or control (standard care [12 practices; n=618]) groups. All adult patients of south Asian origin with type 2 diabetes were eligible. Prescribing algorithms with clearly defined targets were provided for all practices. Primary outcomes were changes in blood pressure, total cholesterol, and glycaemic control (haemoglobin A1c) after 2 years. Analysis was by intention to treat. This trial is registered, number ISRCTN 38297969.

FINDINGS

We recorded significant differences between treatment groups in diastolic blood pressure (1.91 [95% CI -2.88 to -0.94] mm Hg, p=0.0001) and mean arterial pressure (1.36 [-2.49 to -0.23] mm Hg, p=0.0180), after adjustment for confounders and clustering. We noted no significant differences between groups for total cholesterol (0.03 [-0.04 to 0.11] mmol/L), systolic blood pressure (-0.33 [-2.41 to 1.75] mm Hg), or HbA1c (-0.15% [-0.33 to 0.03]). Economic analysis suggests that the nurse-led intervention was not cost effective (incremental cost-effectiveness ratio pound28 933 per QALY gained). Across the whole study population over the 2 years of the trial, systolic blood pressure, diastolic blood pressure, and cholesterol decreased significantly by 4.9 (95% CI 4.0-5.9) mm Hg, 3.8 (3.2-4.4) mm Hg, and 0.45 (0.40-0.51) mmol/L, respectively, and we recorded a small and non-significant increase for haemoglobin A1c (0.04% [-0.04 to 0.13]), p=0.290).

INTERPRETATION

We recorded additional, although small, benefits from our culturally tailored care package that were greater than the secular changes achieved in the UK in recent years. Stricter targets in general practice and further measures to motivate patients are needed to achieve best possible health-care outcomes in south Asian patients with diabetes.

Development of alternative methods of data collection in South Asians with Type 2 diabetes

AIMS

Previous research in the UK has established the difficulty of recruiting and collecting information from individuals whose main language is spoken and does not have an agreed written form. The aims of this study were (i) to develop culturally competent translations of two questionnaires measuring diabetes self-care in languages with no written form and to establish their face validity and (ii) to develop acceptable methods of delivery with the potential for providing valid and reliable data for use in research studies.

METHODS

Adults with Type 2 diabetes from two minority ethnic groups whose main language is spoken (Sylheti and Mirpuri) were recruited via the Birmingham Heartlands hospital diabetes centre. Participants were invited to attend five focus groups to consider the content and method of delivery of two questionnaires measuring knowledge of diabetes and confidence in diabetes self-care. Delivery methods were (i) pen and paper self-completion in Bengali/Urdu, (ii) pen and paper assisted completion in spoken language, (iii) partially-assisted completion in spoken language, (iv) independent audio delivery in spoken language.

RESULTS

Culturally competent content was achieved for both questionnaires in both languages. The Mirpuri men and women's groups preferred assisted or partially assisted completion in spoken language. The Sylheti groups' preference was for independent audio delivery in spoken language.

CONCLUSIONS

The face validity of two questionnaires measuring diabetes self-care is established for Sylheti and Mirpuri, in four alternative delivery formats. The questionnaires are now ready for psychometric testing in minority ethnic populations and the methods available for use by researchers to establish within-study feasibility.

Long-term tolerability of inhaled human insulin (Exubera) in patients with poorly controlled type 2 diabetes

OBJECTIVE

Inhaled human insulin (Exubera; EXU) has shown encouraging tolerability in short-term trials. We evaluated the safety profile of EXU after long-term exposure.

DESIGN

In two, open-label, 2-year studies patients poorly controlled on a sulphonylurea were randomised to adjunctive EXU or metformin (study 1) and patients poorly controlled on metformin were randomised to adjunctive EXU or the sulphonylurea, glibenclamide (study 2).

PATIENTS

The studies included 446 (study 1) and 476 (study 2) patients with type 2 diabetes, no clinically significant respiratory disease and glycosylated haemoglobin (HbA(1c)) levels of 8-12%.

MEASUREMENTS

Main outcome measures were pulmonary function tests and insulin antibody assays.

RESULTS

A total of 109 patients (study 1) and 195 patients (study 2) completed 104 weeks treatment. In both studies, small treatment group differences in change from baseline forced expiratory volume in 1 s were greatest at 6 months (first time-point measured) and less at later visits, and reversed on treatment discontinuation. At 2 years, differences in mean changes were -0.10 and -0.01 l in studies 1 and 2, respectively, and -0.04 l for the pooled studies. There was no discernable effect of long-term EXU therapy on pulmonary gas exchange. Insulin antibody binding reached a plateau at 6 months and did not correlate with HbA(1c) or lung function changes. Glycaemic control was maintained over 2 years.

CONCLUSIONS

Exubera was well tolerated during long-term use. Pulmonary function changes compared with comparator groups were small, non-progressive and reversed upon treatment discontinuation. Importantly, rates of lung function change were indistinguishable between EXU and comparator after 6 months of therapy.

Dydrogesterone and norethisterone regulate expression of lipoprotein lipase and hormone-sensitive lipase in human subcutaneous abdominal adipocytes

AIM

In premenopausal women, hyperandrogenicity is associated with central obesity and an increased cardiovascular risk. The aim of this study was to investigate the effects of dydrogesterone (DYD) (a non-androgenic progestogen) and norethisterone (NET) (an androgenic progestogen) on lipoprotein lipase (LPL), hormone-sensitive lipase (HSL) and glycerol release in adipocytes isolated from subcutaneous abdominal adipose tissue.

METHODS

Adipose tissue was obtained from 12 non-diabetic women, mean age 51 years (range 37-78) and mean body mass index 25.4 kg/m(2) (range 20.3-26.4). Adipocytes were treated with increasing doses of DYD and NET for 48 h prior to protein extraction. Effects on lipogenesis and lipolysis were assessed using western blotting to determine the expression of key enzymes, LPL (56 kDa) and HSL (84 kDa) respectively. Measurement of glycerol release into the medium provided an assessment of lipolytic activity.

RESULTS

Expression of LPL was increased by DYD and NET (mean protein expression relative to control +/- s.e.), with greatest effect at 10(-8) M for DYD: 2.32 +/- 0.51 (p < 0.01) and 10(-8) M for NET: 2.06 +/- 0.19 (p < 0.01). In contrast, HSL expression was reduced by all concentrations of DYD, with maximal effect at 10(-9) M : 0.49 +/- 0.02 (p < 0.001). NET reduced HSL expression at all concentrations from 10(-9) M : 0.62 +/- 0.06 (p < 0.001) to 10(-7) M : 0.69 +/- 0.08 (p < 0.001). Glycerol measurements supported the HSL expression studies although they were not statistically significant (p > 0.05).

CONCLUSIONS

DYD and NET significantly increased LPL expression relative to control, while significantly reducing HSL expression. At the concentrations studied, similar effects were observed with the androgenic NET and the non-androgenic DYD despite differing effects on the lipid profile when taken orally in combination with oestrogen. Further work examining the effects of different progestogens on body fat distribution may enable progestogen use to be tailored to maximize benefits and minimize potential harm.

Minimising metabolic and cardiovascular risk in schizophrenia: diabetes, obesity and dyslipidaemia

People with schizophrenia are at greater risk of obesity, Type 2 diabetes, dyslipidaemia and hypertension than the general population. This results in an increased incidence of cardiovascular disease (CVD) and reduced life expectancy, over and above that imposed by their mental illness through suicide. Several levels of evidence from data linkage analyses to clinical trials demonstrate that treatment-related metabolic disturbances are commonplace in this patient group, and that the use of certain second-generation antipsychotics may compound the risk of developing the metabolic syndrome and CVD. In addition, smoking, poor diet, reduced physical activity and alcohol or drug abuse are prevalent in people with schizophrenia and contribute to the overall CVD risk. Management and minimization of metabolic risk factors are pertinent when providing optimal care to patients with schizophrenia. This review recommends a framework for the assessment, monitoring and management of patients with schizophrenia in the UK clinical setting.

Ethnicity and cardiovascular disease prevention in the United Kingdom: a practical approach to management

The United Kingdom is a diverse society with 7.9% of the population from black and minority ethnic groups (BMEGs). The causes of the excess cardiovascular disease (CVD) and stroke morbidity and mortality in BMEGs are incompletely understood though socio-economic factors are important. However, the role of classical cardiovascular (CV) risk factors is clearly important despite the patterns of these risk factors varying significantly by ethnic group. Despite the major burden of CVD and stroke among BMEGs in the UK, the majority of the evidence on the management of such conditions has been based on predominantly white European populations. Moreover, the CV epidemiology of African Americans does not represent well the morbidity and mortality experience seen in black Africans and black Caribbeans, both in Britain and in their native African countries. In particular, atherosclerotic disease and coronary heart disease are still relatively rare in the latter groups. This is unlike the South Asian diaspora, who have prevalence rates of CVD in epidemic proportions both in the diaspora and on the subcontinent. As the BMEGs have been under-represented in research, a multitude of guidelines exists for the 'general population.' However, specific reference and recommendation on primary and secondary prevention guidelines in relation to ethnic groups is extremely limited. This document provides an overview of ethnicity and CVD in the United Kingdom, with management recommendations based on a roundtable discussion of a multidisciplinary ethnicity and CVD consensus group, all of whom have an academic interest and clinical practice in a multiethnic community.

Type 2 diabetes and cardiovascular risk in the UK south Asian community

A popular hypothesis for the greater prevalence of type 2 diabetes and cardiovascular disease in UK south Asians is that they have an increased susceptibility of developing insulin resistance in response to certain environmental factors, including obesity and adoption of a sedentary lifestyle. Insulin resistance is postulated as a central feature of the metabolic syndrome, culminating in type 2 diabetes, atherosclerotic vascular disease and CHD; a pathway potentially accelerated by migration/urbanisation. We describe and compare the prevalence of type 2 diabetes, cardiovascular disease and their associated risk factors in UK south Asian and white Caucasian populations to determine possible reasons for the increased preponderance of these diseases in south Asians, and highlight key evidence for optimal risk factor management. Finally, we describe a UK community-based programme that attempts to reduce the morbidity and mortality from type 2 diabetes and cardiovascular disease in south Asians through a new approach to management.