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Mulla K, Farag S, Moore B, Matharu S, Young K, Larkin J, Popat S, Morganstein DL. Hyperglycaemia following immune checkpoint inhibitor therapy-Incidence, aetiology and assessment. Diabet Med 2023; 40:e15053. [PMID: 36696014 DOI: 10.1111/dme.15053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Revised: 12/11/2022] [Accepted: 01/23/2023] [Indexed: 01/26/2023]
Abstract
AIMS We systematically studied the presence of hyperglycaemia during treatment with Immune Checkpoint Inhibitors (ICPI) for cancer, in those with and without diabetes at baseline, and determined the cause of new-onset hyperglycaemia, METHODS: Retrospective review of electronic records of those receiving an ICPI for melanoma, lung or renal cancer. RESULTS Overall, 959 participants were included. In this study, 103 had diabetes at baseline (10.7%). Those with lung cancer had the highest frequency of diabetes; 131 people had hyperglycaemia (defined as at least one glucose ≥11.1 mmol/L) in the year after starting an ICPI. The incidence was 55% in those with diabetes at baseline, and 8.6% in those without baseline diabetes. Among 74 with new-onset hyperglycaemia (without pre-existing diabetes) 76% was attributable to steroid induced diabetes, with 9.5% due to ICPI Induced diabetes resembling type 1 diabetes. CONCLUSIONS Hyperglycaemia is common in persons receiving an ICPI for cancer, including 8.6% of those without known diabetes. While much of this is due to glucocorticoid use, care is needed to avoid missing those with ICPI-induced diabetes who are at risk of diabetic ketoacidosis, which is a medical emergency.
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Affiliation(s)
- Kaenat Mulla
- Beta Cell Diabetes Unit, Chelsea and Westminster Hospital, London, UK
| | | | - Benedict Moore
- Beta Cell Diabetes Unit, Chelsea and Westminster Hospital, London, UK
| | | | - Kate Young
- Skin Unit, Royal Marsden Hospital, London, UK
| | | | | | - Daniel Laurence Morganstein
- Beta Cell Diabetes Unit, Chelsea and Westminster Hospital, London, UK
- Lung Unit, Royal Marsden Hospital, London, UK
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2
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Sinclair AJ, Bellary S, Dashora U, Abdelhafiz AH, Rowles S, Reedman L, Turner B, Green M, Forbes A, Middleton A. Enhancing diabetes care for the most vulnerable in the 21st century: Interim findings of the National Advisory Panel on Care Home Diabetes (NAPCHD). Diabet Med 2023:e15088. [PMID: 36929728 DOI: 10.1111/dme.15088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Revised: 03/08/2023] [Accepted: 03/11/2023] [Indexed: 03/18/2023]
Abstract
Older adults with diabetes may carry a substantial health burden in Western ageing societies, occupy more than one in four beds in care homes, and are a highly vulnerable group who often require complex nursing and medical care. The global pandemic (COVID-19) had its epicentre in care homes and revealed many shortfalls in diabetes care resulting in hospital admissions and considerable mortality and comorbid illness. The purpose of this work was to develop a national Strategic Document of Diabetes Care for Care Homes which would bring about worthwhile, sustainable and effective quality diabetes care improvements, and address the shortfalls in care provided. A large diverse and multidisciplinary group of stakeholders (NAPCHD) defined 11 areas of interest where recommendations were needed and using a subgroup allocation approach were set tasks to produce a set of primary recommendations. Each subgroup was given 5 starter questions to begin their work and a format to provide responses. During the initial phase, 16 key findings were identified. Overall, after a period of 18 months, 49 primary recommendations were made, and 7 major conclusions were drawn from these. A model of community and integrated diabetes care for care home residents with diabetes was proposed, and a series of 5 'quick-wins' were created to begin implementation of some of the recommendations that would not require significant funding. The work of the NAPCHD is ongoing but we hope that this current resource will help leaders to make these required changes happen.
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Affiliation(s)
- A J Sinclair
- Foundation for Diabetes Research in Older People and King's College, London, UK
| | - S Bellary
- University of Aston and University Hospitals Birmingham Foundation Trust, Birmingham, UK
| | - U Dashora
- East Sussex Healthcare NHS Trust and Joint British Diabetes Societies-IP Care JBDS-IP and Association of British Clinical Diabetologists (ABCD), Malmesbury, UK
| | - A H Abdelhafiz
- Rotherham NHS Foundation Trust and Older Peoples Diabetes Network (OPDN), Rotherham, UK
| | - S Rowles
- Pennine Acute Hospitals NHS Trust and ABCD, Manchester, UK
| | | | | | | | | | - A Middleton
- Person Living with Diabetes (PLWD) and Diabetes, UK Diabetes Research Steering Group, London, UK
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3
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Dickson R, Bell J, Dar A, Downey L, Moore V, Quigley M. #WeAreNotWaiting DIY artificial pancreas systems and challenges for the law. Diabet Med 2022; 39:e14715. [PMID: 34637553 DOI: 10.1111/dme.14715] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Accepted: 10/11/2021] [Indexed: 10/20/2022]
Abstract
Commercial hybrid closed-loop systems are becoming more readily available, yet the number of DIY artificial pancreas system (DIY APS) users continues to rise. These DIY systems have not gone through the usual regulatory approvals processes, and, thus, present a number of legal difficulties for a number of actors, including clinicians, parents who build DIY APS for their children, and users themselves. These issues have so far received insufficient attention. Due to the complex constellation of actors involved in both development of DIY APSs and in its deployment, it is not currently clear who, and to what extent, different parties might (successfully) be held liable if something goes wrong. Despite this uncertainty, unless and until clearer guidance is issued by relevant bodies, or a case appears before the courts which clarifies the situation, existing legal principles apply. In this article, we examine some of these to shed light on how the law would likely be applied if harm were to result from the use of a DIY APS.
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Affiliation(s)
| | | | - Amber Dar
- University of Birmingham Law School, Birmingham, UK
| | - Laura Downey
- University of Birmingham Law School, Birmingham, UK
| | - Victoria Moore
- The University of Manchester School of Social Sciences, Manchester, UK
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Yakou F, Saburi M, Hirose A, Akaoka H, Hirota Y, Kobayashi T, Awane N, Asahi N, Amagawa T, Ozawa S, Ohno A, Matsushita T. A Case Series of Ketoacidosis After Coronavirus Disease 2019 Vaccination in Patients With Type 1 Diabetes. Front Endocrinol (Lausanne) 2022; 13:840580. [PMID: 35370952 PMCID: PMC8971718 DOI: 10.3389/fendo.2022.840580] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Accepted: 01/10/2022] [Indexed: 12/26/2022] Open
Abstract
Introduction We report a case series of severe ketoacidosis after COVID-19 vaccination in a type 1 diabetes patients treated with insulin and an SGLT-2 inhibitor. Case Report We present two cases of type 1 diabetes mellitus. One patient was treated with insulin therapy and an SGLT-2 inhibitor, and the other patient was treated with insulin therapy alone. Both patients became ill after coronavirus disease-2019 vaccination, making it difficult to continue their diet or insulin injections. On admission, they developed severe diabetic ketoacidosis. This is the first report of ketoacidosis after coronavirus disease-2019 vaccination. Conclusion The vaccine should be carefully administered to type 1 diabetes patients receiving intensive insulin therapy and a sodium-glucose transporter due to the high risk ketoacidosis. It is important to instruct patients to drink sufficient fluids and to continue insulin injections when they become sick.
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Affiliation(s)
- Fumiyoshi Yakou
- Department of Diabetology, Endocrinology and Metabolism, Tokyo Medical University Hachioji Medical Center, Hachioji, Japan
| | - Masuo Saburi
- Department of Diabetology, Endocrinology and Metabolism, Tokyo Medical University Hachioji Medical Center, Hachioji, Japan
| | - Ai Hirose
- Department of Diabetology, Endocrinology and Metabolism, Tokyo Medical University Hachioji Medical Center, Hachioji, Japan
| | - Hiroaki Akaoka
- Department of Diabetology, Endocrinology and Metabolism, Tokyo Medical University Hachioji Medical Center, Hachioji, Japan
| | - Yusuke Hirota
- Department of Diabetology, Endocrinology and Metabolism, Tokyo Medical University Hachioji Medical Center, Hachioji, Japan
| | - Takaaki Kobayashi
- Department of Diabetology, Endocrinology and Metabolism, Tokyo Medical University Hachioji Medical Center, Hachioji, Japan
| | - Naoko Awane
- Department of Diabetology, Endocrinology and Metabolism, Tokyo Medical University Hachioji Medical Center, Hachioji, Japan
| | - Nobuteru Asahi
- Department of Diabetology, Endocrinology and Metabolism, Tokyo Medical University Hachioji Medical Center, Hachioji, Japan
| | - Toshihiro Amagawa
- Department of Diabetology, Endocrinology and Metabolism, Tokyo Medical University Hachioji Medical Center, Hachioji, Japan
| | | | - Atsushi Ohno
- Department of Diabetology, Endocrinology and Metabolism, Tokyo Medical University Hachioji Medical Center, Hachioji, Japan
| | - Takaya Matsushita
- Department of Diabetology, Endocrinology and Metabolism, Tokyo Medical University Hachioji Medical Center, Hachioji, Japan
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Stimson RH, Dover AR, Forbes S, Strachan MWJ, McKnight JA, Gibb FW. HbA1c Is Disproportionately Higher in Women and Older People With Type 1 Diabetes Compared With Flash Glucose Monitoring Metrics of Glycemic Control. J Diabetes Sci Technol 2022; 16:446-453. [PMID: 33100062 PMCID: PMC8861792 DOI: 10.1177/1932296820967335] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
AIMS Discrepancy between HbA1c and glucose exposure may have significant clinical implications. We sought to assess predictors of disparity between HbA1c and flash monitoring metrics and how these relate to microvascular complications. METHODS We conducted a cross-sectional study of adults with type 1 diabetes (n = 518). We assessed the relationship between clinic HbA1c and flash monitoring metrics, predictors of discrepancy between these measurements, and whether discrepancy was associated with microvascular complications. RESULTS Actual HbA1c and estimated HbA1c were strongly correlated (r = .779, P < .001). The likelihood of having a higher actual HbA1c than estimated HbA1c was greater with increasing age (OR = 1.055 per year, P < .001) and lower in men (OR = .208, P < .001). HbA1c was significantly lower in men (58 mmol/mol [51-67]) (7.5% [6.8-8.3]) compared to women (61 mmol/mol [54-70], P = .021) (7.7% [7.1-8.6]), despite no significant differences in any flash monitoring metrics. Whereas HbA1c was not different between younger (≤39 years) and older individuals (>39 years) despite significantly higher glucose exposure, in younger people, based on multiple flash monitoring metrics. Having a lower estimated than actual HbA1c was independently associated with a lower prevalence of retinopathy (OR = .55, P = .004). CONCLUSIONS HbA1c appears to overestimate glucose exposure in women and older people with type 1 diabetes. This has potentially important clinical implications, as is hinted at by the independent relationship with retinopathy prevalence. It may also be of relevance when considering the use of HbA1c for the diagnosis of diabetes.
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Affiliation(s)
- Roland H. Stimson
- Edinburgh Centre for Endocrinology &
Diabetes, Royal Infirmary of Edinburgh, Edinburgh, UK
- Centre for Cardiovascular Science,
University of Edinburgh, Edinburgh, UK
| | - Anna R. Dover
- Edinburgh Centre for Endocrinology &
Diabetes, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Shareen Forbes
- Edinburgh Centre for Endocrinology &
Diabetes, Royal Infirmary of Edinburgh, Edinburgh, UK
- Centre for Cardiovascular Science,
University of Edinburgh, Edinburgh, UK
| | - Mark W. J. Strachan
- Edinburgh Centre for Endocrinology &
Diabetes, Western General Hospital, Edinburgh, UK
| | - John A. McKnight
- Edinburgh Centre for Endocrinology &
Diabetes, Western General Hospital, Edinburgh, UK
| | - Fraser W. Gibb
- Edinburgh Centre for Endocrinology &
Diabetes, Royal Infirmary of Edinburgh, Edinburgh, UK
- Centre for Cardiovascular Science,
University of Edinburgh, Edinburgh, UK
- Fraser W. Gibb, FRCP PhD, Edinburgh Centre
for Endocrinology & Diabetes, Royal Infirmary of Edinburgh, Little France
Crescent, Edinburgh, EH16 4SA, UK.
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Pikkemaat M, Larsson Lönn S, Bennet L. Insulin action and secretion independent of traditional risk factors predict new-onset type 2 diabetes in Iraqi and Swedish born citizens - The MEDIM cohort study. Diabetes Metab Res Rev 2022; 38:e3509. [PMID: 34704668 DOI: 10.1002/dmrr.3509] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Revised: 10/20/2021] [Accepted: 10/21/2021] [Indexed: 11/06/2022]
Abstract
AIMS Our aim was to study the incidence of type 2 diabetes in a population-based cohort of Swedish and Iraqi born individuals, focussing on traditional risk factors, insulin action, insulin secretion and ethnicity. MATERIALS AND METHODS The cohort consisted of 1164 Iraqi and 693 Swedish-born citizens. We investigated the association between new-onset type 2 diabetes and the predictors including lifestyle factors, metabolic risk markers, country of birth, insulin sensitivity and secretion assessed by Matsuda index with Cox regression. RESULTS Eighty-nine individuals were diagnosed with type 2 diabetes with a mean follow-up of 7.5 years. Both lower insulin sensitivity (ISI, HR 0.02 [0.01-0.08]) as well as insulin secretion (CIR, HR 0.13 [0.07-0.24]) at baseline predicted type 2 diabetes onset, independent of traditional risk factors. Our results were not modified by country of birth. Regarding traditional risk factors, WHR (1.05 [1.00-1.09]), blood glucose (3.27 [2.35-4.55]), LDL/HDL (1.46 [1.20-1.78]) and diastolic blood pressure (1.04 [1.00-1.07]) predicted diabetes incidence in the full model. CONCLUSIONS Both impaired insulin sensitivity index and corrected insulin response predicted type 2 diabetes onset, independent of traditional risk factors. We conclude that insulin secretion and action might be useful additional predictors for type 2 diabetes in populations of European and Middle Eastern ethnicities.
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Affiliation(s)
- Miriam Pikkemaat
- Center for Primary Health Care Research, Department of Clinical Sciences Malmö, Lund University, Malmö, Sweden
| | - Sara Larsson Lönn
- Center for Primary Health Care Research, Department of Clinical Sciences Malmö, Lund University, Malmö, Sweden
| | - Louise Bennet
- Department of Family Medicine, Lund University, Malmö, Sweden
- Department of Clinical Sciences Malmö, Lund University, Malmö, Sweden
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7
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Edwards AE, Vathenen R, Henson SM, Finer S, Gunganah K. Acute hyperglycaemic crisis after vaccination against COVID-19: A case series. Diabet Med 2021; 38:e14631. [PMID: 34185927 PMCID: PMC8420566 DOI: 10.1111/dme.14631] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Accepted: 06/28/2021] [Indexed: 12/19/2022]
Affiliation(s)
- Amy E. Edwards
- Department of Diabetes and EndocrinologyNewham University HospitalBarts Health NHS TrustLondonUK
| | - Ramu Vathenen
- Department of Diabetes and EndocrinologyNewham University HospitalBarts Health NHS TrustLondonUK
| | - Sian M. Henson
- Centre for Translational Medicine and TherapeuticsWilliam Harvey Research Institute, Barts and the London School of Medicine and DentistryQueen Mary University of LondonLondonUK
| | - Sarah Finer
- Department of Diabetes and EndocrinologyNewham University HospitalBarts Health NHS TrustLondonUK
- Institute for Population Health Sciences, Barts and the London School of Medicine and DentistryQueen Mary University of LondonLondonUK
| | - Kirun Gunganah
- Department of Diabetes and EndocrinologyNewham University HospitalBarts Health NHS TrustLondonUK
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8
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Rotbain Curovic V, Magalhães P, He T, Hansen TW, Mischak H, Rossing P. Urinary peptidome and diabetic retinopathy in the DIRECT-Protect 1 and 2 trials. Diabet Med 2021; 38:e14634. [PMID: 34228837 DOI: 10.1111/dme.14634] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Accepted: 07/05/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Given the association of diabetic retinopathy (DR) and kidney disease, we investigated the urinary peptidome to presence and deterioration of DR in a post hoc analysis of trials investigating the effect of candesartan on progression of DR in type 1 and type 2 diabetes, respectively. METHODS Baseline urinary peptidomic analysis was performed on a random selection of 783 and 792 subjects in two randomized controlled trials, DIRECT-Protect 1 and 2, respectively. End points were two-step (RET2) and three-step (RET3) change in Early Treatment of Diabetic Retinopathy Study protocol (ETDRS) defined level. Peptide levels were correlated to baseline EDTRS level in a discovery set of 2/3 of the participants from DIRECT-Protect 1. The identified peptides were then validated cross-sectionally in the remaining 1/3 from DIRECT-Protect 1. Thereafter, peptides identified in the discovery set were assessed in the entire DIRECT-Protect 1 and 2 cohorts and significant peptides were tested longitudinally. RESULTS Follow-up ranged 4.0-4.7 years. 24 peptides were associated with baseline DR in the discovery set. COL3A1 (seq: NTG~) and COL4A1 (seq: DGA~) were associated with baseline DR in the validation set (Rho: -.223, p < 0.001 and Rho: -.141, p = 0.024). Neither was significantly associated with end points. Assessing the 24 identified peptides in the entire cohorts, several collagen peptides were associated with baseline DR and end points; however, there was no overlap across diabetes types. CONCLUSIONS We identified several urinary peptides (mainly collagen) associated with the presence of DR, however they could not be conclusively associated with worsening of DR.
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Affiliation(s)
| | | | - Tianlin He
- Mosaiques Diagnostics, Hannover, Germany
- Institute for Molecular Cardiovascular Research, University of Aachen, Aachen, Germany
| | | | | | - Peter Rossing
- Steno Diabetes Center Copenhagen, Gentofte, Denmark
- University of Copenhagen, Copenhagen, Denmark
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9
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Jalving AC, Gant CM, Binnenmars SH, Soedamah‐Muthu SS, Bakker SJL, Navis G, Laverman GD. Glycaemic control in the diabetes and Lifestyle Cohort Twente: A cross-sectional assessment of lifestyle and pharmacological management on Hba1c target achievement. Diabetes Obes Metab 2018; 20:2494-2499. [PMID: 29862616 PMCID: PMC6175458 DOI: 10.1111/dom.13399] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2018] [Revised: 05/18/2018] [Accepted: 05/25/2018] [Indexed: 12/18/2022]
Abstract
The majority of patients with type 2 diabetes do not reach target levels of glycated haemoglobin (HbA1c < 7%). We investigated the prevalence of HbA1c-target achievement and opportunities afforded by lifestyle and pharmacological treatment to increase target achievement. We performed cross-sectional analyses of baseline data from the Diabetes and Lifestyle Cohort Twente-1 (DIALECT-1). Patients were divided according to (1) HbA1c <53 and ≥53 mmol/mol (<7%) and (2) non-insulin treatment and tertiles of daily insulin use. We found that 161 (36%) patients achieved the target HbA1c level. Patients with HbA1c ≥53 mmol/mol had a longer duration of diabetes (13 [8-20] vs 9 [4-14] years; P < .001) and more frequently were insulin-users (76% vs 41%, P < .001). Patients in the highest tertile of insulin use had a higher body mass index than those in the lowest tertile (35.8 ± 5.5 vs 29.8 ± 5.5 kg/m2 ; P < .001). Achievement of target HbA1c is low in this type 2 diabetes population. High resistance to pharmacological treatment, paralleled with high body mass index, illustrates that increasing insulin sensitivity through lifestyle intervention is the best opportunity to improve HbA1c target achievement in this real-life population.
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Affiliation(s)
- Annis C. Jalving
- Department of Internal Medicine/NephrologyZGT HospitalAlmelo and HengeloThe Netherlands
| | - Christina M. Gant
- Department of Internal Medicine/NephrologyZGT HospitalAlmelo and HengeloThe Netherlands
- Department of Internal Medicine, Division of NephrologyUniversity of Groningen, University Medical Centre GroningenGroningenThe Netherlands
| | - S. Heleen Binnenmars
- Department of Internal Medicine, Division of NephrologyUniversity of Groningen, University Medical Centre GroningenGroningenThe Netherlands
| | - Sabita S. Soedamah‐Muthu
- Center of Research on Psychology in Somatic Diseases (CORPS), Department of Medical and Clinical PsychologyTilburg UniversityTilburgThe Netherlands
- Institute for Food, Nutrition and HealthUniversity of ReadingReadingUK
| | - Stephan J. L. Bakker
- Department of Internal Medicine, Division of NephrologyUniversity of Groningen, University Medical Centre GroningenGroningenThe Netherlands
| | - Gerjan Navis
- Department of Internal Medicine, Division of NephrologyUniversity of Groningen, University Medical Centre GroningenGroningenThe Netherlands
| | - Gozewijn D. Laverman
- Department of Internal Medicine/NephrologyZGT HospitalAlmelo and HengeloThe Netherlands
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10
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Stidsen JV, Henriksen JE, Olsen MH, Thomsen RW, Nielsen JS, Rungby J, Ulrichsen SP, Berencsi K, Kahlert JA, Friborg SG, Brandslund I, Nielsen AA, Christiansen JS, Sørensen HT, Olesen TB, Beck-Nielsen H. Pathophysiology-based phenotyping in type 2 diabetes: A clinical classification tool. Diabetes Metab Res Rev 2018; 34:e3005. [PMID: 29697198 DOI: 10.1002/dmrr.3005] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2017] [Revised: 02/10/2018] [Accepted: 03/14/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND Type 2 diabetes may be a more heterogeneous disease than previously thought. Better understanding of pathophysiological subphenotypes could lead to more individualized diabetes treatment. We examined the characteristics of different phenotypes among 5813 Danish patients with new clinically diagnosed type 2 diabetes. METHODS We first identified all patients with rare subtypes of diabetes, latent autoimmune diabetes of adults (LADA), secondary diabetes, or glucocorticoid-associated diabetes. We then used the homeostatic assessment model to subphenotype all remaining patients into insulinopenic (high insulin sensitivity and low beta cell function), classical (low insulin sensitivity and low beta cell function), or hyperinsulinemic (low insulin sensitivity and high beta cell function) type 2 diabetes. RESULTS Among 5813 patients diagnosed with incident type 2 diabetes in the community clinical setting, 0.4% had rare subtypes of diabetes, 2.8% had LADA, 0.7% had secondary diabetes, 2.4% had glucocorticoid-associated diabetes, and 93.7% had WHO-defined type 2 diabetes. In the latter group, 9.7% had insulinopenic, 63.1% had classical, and 27.2% had hyperinsulinemic type 2 diabetes. Classical patients were obese (median waist 105 cm), and 20.5% had cardiovascular disease (CVD) at diagnosis, while insulinopenic patients were fairly lean (waist 92 cm) and 17.5% had CVD (P = 0.14 vs classical diabetes). Hyperinsulinemic patients were severely obese (waist 112 cm), and 25.5% had CVD (P < 0.0001 vs classical diabetes). CONCLUSIONS Patients clinically diagnosed with type 2 diabetes are a heterogeneous group. In the future, targeted treatment based on pathophysiological characteristics rather than the current "one size fits all" approach may improve patient prognosis.
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Affiliation(s)
- Jacob V Stidsen
- Diabetes Research Centre, Department of Endocrinology, Centre for Individualized Medicine in Arterial Diseases, Odense University Hospital, Odense, Denmark
| | - Jan E Henriksen
- Diabetes Research Centre, Department of Endocrinology, Centre for Individualized Medicine in Arterial Diseases, Odense University Hospital, Odense, Denmark
| | - Michael H Olsen
- Department of Internal Medicine, Holbaek Hospital, and Centre for Individualized Medicine in Arterial Diseases (CIMA), Odense University Hospital, University of Southern Denmark, Denmark
| | - Reimar W Thomsen
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | - Jens S Nielsen
- Diabetes Research Centre, Department of Endocrinology, Centre for Individualized Medicine in Arterial Diseases, Odense University Hospital, Odense, Denmark
| | - Jørgen Rungby
- Department for Diabetes Research, Gentofte University Hospital, Gentofte, Denmark
- Department of Biomedicine, Aarhus University, Aarhus, Denmark
| | - Sinna P Ulrichsen
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | - Klara Berencsi
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | - Johnny A Kahlert
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | - Søren G Friborg
- Diabetes Research Centre, Department of Endocrinology, Centre for Individualized Medicine in Arterial Diseases, Odense University Hospital, Odense, Denmark
| | - Ivan Brandslund
- Department of Biochemistry, Center Hospital Lillebaelt, Vejle, Denmark
| | - Aneta A Nielsen
- Department of Biochemistry, Center Hospital Lillebaelt, Vejle, Denmark
| | - Jens S Christiansen
- Department of Internal Medicine and Endocrinology, Aarhus University Hospital, Aarhus, Denmark
| | - Henrik T Sørensen
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | - Thomas B Olesen
- Diabetes Research Centre, Department of Endocrinology, Centre for Individualized Medicine in Arterial Diseases, Odense University Hospital, Odense, Denmark
| | - Henning Beck-Nielsen
- Diabetes Research Centre, Department of Endocrinology, Centre for Individualized Medicine in Arterial Diseases, Odense University Hospital, Odense, Denmark
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11
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Stidsen JV, Nielsen JS, Henriksen JE, Friborg SG, Thomsen RW, Olesen TB, Olsen MH, Beck-Nielsen H. Protocol for the specialist supervised individualised multifactorial treatment of new clinically diagnosed type 2 diabetes in general practice (IDA): a prospective controlled multicentre open-label intervention study. BMJ Open 2017; 7:e017493. [PMID: 29229652 PMCID: PMC5778341 DOI: 10.1136/bmjopen-2017-017493] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
INTRODUCTION We present the protocol for a multifactorial intervention study designed to test whether individualised treatment, based on pathophysiological phenotyping and individualised treatment goals, improves type 2 diabetes (T2D) outcomes. METHODS AND ANALYSIS We will conduct a prospective controlled multicentre open-label intervention study, drawing on the longitudinal cohort of the Danish Centre for Strategic Research in Type 2 Diabetes (DD2). New clinically diagnosed patients with T2D in the intervention group will be assigned to receive individualised treatment by their general practitioner. Intervention patients will be compared with a matched control cohort of DD2 patients receiving routine clinical care. Among intervention patients, we will first do pathophysiological phenotyping to classify patients into WHO-defined T2D or other specific types of diabetes (monogenic diabetes, secondary diabetes etc). Patients with WHO-defined T2D will then be further subcharacterised by their beta-cell function (BCF) and insulin sensitivity (IS), using the revised homeostatic assessment model, as having either insulinopaenic T2D (high IS and low BCF), classical T2D (low IS and low BCF) or hyperinsulinaemic T2D (low IS and high BCF). For each subtype, a specific treatment algorithm will target the primary pathophysiological defect. Similarly, antihypertensive treatment will be targeted at the specific underlying pathophysiology, characterised by impedance cardiography (relative importance of vascular resistance, intravascular volume and cardiac inotropy). All treatment goals will be based on individual patient assessment of expected positive versus adverse effects. Web-based and face-to-face individualised lifestyle intervention will also be implemented to empower patients to make a sustainable improvement in daily physical activity and to change to a low-carbohydrate diet. ETHICS AND DISSEMINATION The study will use well-known pharmacological agents according to their labels; patient safety is therefore considered high. Study results will be published in international peer-reviewed journals. TRIAL REGISTRATION NUMBER NCT02015130; Pre-results.
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Affiliation(s)
- Jacob Volmer Stidsen
- Department of Endocrinology, Diabetes Research Centre, Centre for Individualized Medicine in Arterial Diseases, Odense University Hospital, Odense, Denmark
| | - Jens Steen Nielsen
- Department of Endocrinology, Diabetes Research Centre, Centre for Individualized Medicine in Arterial Diseases, Odense University Hospital, Odense, Denmark
| | - Jan Erik Henriksen
- Department of Endocrinology, Diabetes Research Centre, Centre for Individualized Medicine in Arterial Diseases, Odense University Hospital, Odense, Denmark
| | - Søren Gunnar Friborg
- Department of Endocrinology, Diabetes Research Centre, Centre for Individualized Medicine in Arterial Diseases, Odense University Hospital, Odense, Denmark
| | | | - Thomas Bastholm Olesen
- Department of Endocrinology, Diabetes Research Centre, Centre for Individualized Medicine in Arterial Diseases, Odense University Hospital, Odense, Denmark
| | - Michael Hecht Olsen
- Department of Endocrinology, Diabetes Research Centre, Centre for Individualized Medicine in Arterial Diseases, Odense University Hospital, Odense, Denmark
| | - Henning Beck-Nielsen
- Department of Endocrinology, Diabetes Research Centre, Centre for Individualized Medicine in Arterial Diseases, Odense University Hospital, Odense, Denmark
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Buckingham B, Cheng P, Beck RW, Kollman C, Ruedy KJ, Weinzimer SA, Slover R, Bremer AA, Fuqua J, Tamborlane W. CGM-measured glucose values have a strong correlation with C-peptide, HbA1c and IDAAC, but do poorly in predicting C-peptide levels in the two years following onset of diabetes. Diabetologia 2015; 58:1167-74. [PMID: 25773405 PMCID: PMC4416994 DOI: 10.1007/s00125-015-3559-y] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2014] [Accepted: 02/27/2015] [Indexed: 10/23/2022]
Abstract
AIMS/HYPOTHESIS The aim of this work was to assess the association between continuous glucose monitoring (CGM) data, HbA1c, insulin-dose-adjusted HbA1c (IDAA1c) and C-peptide responses during the first 2 years following diagnosis of type 1 diabetes. METHODS A secondary analysis was conducted of data collected from a randomised trial assessing the effect of intensive management initiated within 1 week of diagnosis of type 1 diabetes, in which mixed-meal tolerance tests were performed at baseline and at eight additional time points through 24 months. CGM data were collected at each visit. RESULTS Among 67 study participants (mean age [± SD] 13.3 ± 5.7 years), HbA1c was inversely correlated with C-peptide at each time point (p < 0.001), as were changes in each measure between time points (p < 0.001). However, C-peptide at one visit did not predict the change in HbA1c at the next visit and vice versa. Higher C-peptide levels correlated with increased proportion of CGM glucose values between 3.9 and 7.8 mmol/l and lower CV (p = 0.001 and p = 0.02, respectively) but not with CGM glucose levels <3.9 mmol/l. Virtually all participants with IDAA1c < 9 retained substantial insulin secretion but when evaluated together with CGM, time in the range of 3.9-7.8 mmol/l and CV did not provide additional value in predicting C-peptide levels. CONCLUSIONS/INTERPRETATION In the first 2 years after diagnosis of type 1 diabetes, higher C-peptide levels are associated with increased sensor glucose levels in the target range and with lower glucose variability but not hypoglycaemia. CGM metrics do not provide added value over the IDAA1c in predicting C-peptide levels.
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Affiliation(s)
- Bruce Buckingham
- Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA, USA
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Zhao W, Katzmarzyk PT, Horswell R, Wang Y, Johnson J, Hu G. Sex differences in the risk of stroke and HbA(1c) among diabetic patients. Diabetologia 2014; 57:918-26. [PMID: 24577725 PMCID: PMC4141535 DOI: 10.1007/s00125-014-3190-3] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2013] [Accepted: 01/23/2014] [Indexed: 01/14/2023]
Abstract
AIMS/HYPOTHESIS Sex differences in macrovascular disease, especially in stroke, are observed across studies of epidemiology. We studied a large sample of patients with type 2 diabetes to better understand the relationship between glycaemic control and stroke risk. METHODS We prospectively investigated the sex-specific association between different levels of HbA(1c) and incident stroke risk among 10,876 male and 19,278 female patients with type 2 diabetes. RESULTS During a mean follow-up of 6.7 years, 2,949 incident cases of stroke were identified. The multivariable-adjusted HRs of stroke associated with different levels of HbA(1c) at baseline (HbA(1c) <6.0% [<42 mmol/mol], 6.0-6.9% [42-52 mmol/mol] [reference group], 7.0-7.9% [53-63 mmol/mol], 8.0-8.9% [64-74 mmol/mol], 9.0-9.9% [75-85 mmol/mol] and ≥10.0% [≥86 mmol/mol]) were 0.96 (95% CI 0.80, 1.14), 1.00, 1.04 (0.85, 1.28), 1.11 (0.89, 1.39), 1.10 (0.86, 1.41) and 1.22 (0.92, 1.35) (p for trend = 0.66) for men, and 1.03 (0.90, 1.18), 1.00, 1.09 (0.94, 1.26), 1.19 (1.00, 1.42), 1.32 (1.09, 1.59) and 1.42 (1.23, 1.65) (p for trend <0.001) for women, respectively. The graded association between HbA(1c) during follow-up and stroke risk was observed among women (p for trend = 0.066). When stratified by race, whether with or without glucose-lowering agents, this graded association of HbA(1c) with stroke was still present among women. When stratified by age, the adjusted HRs were significantly higher in women older than 55 years compared with younger women. CONCLUSIONS/INTERPRETATION The current study suggests a graded association between HbA1c and the risk of stroke among women with type 2 diabetes. Poor control of blood sugar has a stronger effect in diabetic women older than 55 years.
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Affiliation(s)
- Wenhui Zhao
- Chronic Disease Epidemiology Laboratory, Pennington Biomedical Research Center
| | - Peter T. Katzmarzyk
- Chronic Disease Epidemiology Laboratory, Pennington Biomedical Research Center
| | - Ronald Horswell
- Chronic Disease Epidemiology Laboratory, Pennington Biomedical Research Center
| | - Yujie Wang
- Chronic Disease Epidemiology Laboratory, Pennington Biomedical Research Center
| | | | - Gang Hu
- Chronic Disease Epidemiology Laboratory, Pennington Biomedical Research Center
- G Hu, Chronic Disease Epidemiology Laboratory, Pennington Biomedical Research Center, 6400 Perkins Road, Baton Rouge, LA 70808, USA, Tel: 225-763-3053, Fax: 225-763-3009,
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Abstract
OBJECTIVE We sought to develop a computerized clinical decision support for clinicians treating patients with type 2 diabetes mellitus (T2DM). METHODS We designed, developed, and tested a computer-assisted decision support (CADS) system using statistical analyses of self-monitoring of blood glucose data, laboratory data, medical and medication history, and individualized hemoglobin A1c goals. A rule-based expert system generated recommendations for changes in therapy and accompanying explanations. RESULTS A clinical decision support system (CADS) was developed that considers 9 classes of medications and 69 regimens with combinations of up to 4 therapeutic agents. The preferred sequences of regimens can be customized. The program is integrated with a "comprehensive diabetes management system," electronic medical record systems, and a method for uploading data from memory glucose meters via telephone without use of a computer or the Internet. The software provides a report to the clinician regarding the overall quality of glycemic control and identifies problems, e.g., hypoglycemia, hyperglycemia, glycemic variability, and insufficient data. The program can recommend continuation of current therapy, adjustment of dosages of current medications, or change of regimen and can provide explanations for its recommendations. If the user rejects the recommendations, the program will recommend alternative approaches. The CADS also provides access to Food and Drug Administration-approved prescribing information, guidelines from professional organizations, and selections from the general medical literature. The system has been extensively tested with real and synthetic data and is ready for evaluation in multicenter clinical trials. CONCLUSION A clinical decision support system to assist with the management of patients with T2DM was designed, developed, tested, and found to perform well.
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Affiliation(s)
- David Rodbard
- Biomedical Informatics Consultants LLC, Potomac, Maryland 20854-4721, USA.
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Allet L, Armand S, de Bie RA, Golay A, Monnin D, Aminian K, Staal JB, de Bruin ED. The gait and balance of patients with diabetes can be improved: a randomised controlled trial. Diabetologia 2010; 53:458-66. [PMID: 19921145 PMCID: PMC2815802 DOI: 10.1007/s00125-009-1592-4] [Citation(s) in RCA: 180] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2009] [Accepted: 10/06/2009] [Indexed: 11/04/2022]
Abstract
AIMS/HYPOTHESIS Gait characteristics and balance are altered in diabetic patients. Little is known about possible treatment strategies. This study evaluates the effect of a specific training programme on gait and balance of diabetic patients. METHODS This was a randomised controlled trial (n=71) with an intervention (n=35) and control group (n=36). The intervention consisted of physiotherapeutic group training including gait and balance exercises with function-orientated strengthening (twice weekly over 12 weeks). Controls received no treatment. Individuals were allocated to the groups in a central office. Gait, balance, fear of falls, muscle strength and joint mobility were measured at baseline, after intervention and at 6-month follow-up. RESULTS The trial is closed to recruitment and follow-up. After training, the intervention group increased habitual walking speed by 0.149 m/s (p<0.001) compared with the control group. Patients in the intervention group also significantly improved their balance (time to walk over a beam, balance index recorded on Biodex balance system), their performance-oriented mobility, their degree of concern about falling, their hip and ankle plantar flexor strength, and their hip flexion mobility compared with the control group. After 6 months, all these variables remained significant except for the Biodex sway index and ankle plantar flexor strength. Two patients developed pain in their Achilles tendon: the progression for two related exercises was slowed down. CONCLUSIONS/INTERPRETATION Specific training can improve gait speed, balance, muscle strength and joint mobility in diabetic patients. Further studies are needed to explore the influence of these improvements on the number of reported falls, patients' physical activity levels and quality of life. TRIAL REGISTRATION ClinicalTrials.gov NCT00637546 FUNDING This work was supported by the Swiss National Foundation (SNF): PBSKP-123446/1/
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Affiliation(s)
- L Allet
- Department of Epidemiology, Maastricht University and Caphri Research School, Maastricht, the Netherlands.
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