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PCCJ_diabetes_supplement 10/14/09 8:50 AM Page 2

JOURNAL REVIEW doi:10.3132/pccj.2009.039

Tight control of type 2 diabetes reduces heart


attacks and heart disease events
and some even suggesting possible harm. To look at was that patients gained 2.5 kg more in weight than
this, researchers analysed five prospective those on standard treatment and experienced
randomised controlled trials, including a total of higher rates of hypoglycaemia (38.1% vs 28.6%) and
33,040 participants, that compared intensive serious hypoglycaemia (2.3% vs 1.2%).
glucose-lowering regimens with standard

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treatment. Those treated intensively had
haemoglobin A1c (HbA1c) concentrations of

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The findings suggest that strict glucose control should
6.6%-7.0%, while controls had HbA1c values be part of effective diabetes management,

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between 7.3% and 8.4%. Overall, patients treated significantly reducing coronary events compared with

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intensively with combinations of oral drugs or oral standard control. The study authors estimate that
drugs plus insulin had HbA1c concentrations that treating 200 patients with type 2 diabetes intensively

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were, on average, 0.9% lower than controls for five years would prevent around two non-fatal

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Tight control of glucose reduces the risk of heart (6.6% vs 7.5%). heart attacks and three coronary heart disease events.
attack and coronary heart disease events in Results showed that patients whose glucose These benefits are not as large as those associated

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patients with type 2 diabetes, according to a large levels were tightly controlled benefited from a 17% with tight control of blood pressure or lipids, but they
seem too important to ignore. Aiming for an HbA1c of
meta-analysis. reduction in non-fatal myocardial infarction (odds
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7% seems to be reasonable. However, we need to be
Intensive glucose control has previously been ratio 0.83) and a 15% reduction in coronary heart
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alert to the risk of hypoglycaemia, particularly in older
shown to reduce microvascular events in people disease events (OR 0.85). However, there was no
people.
with type 2 diabetes, but the effects on difference in the rates of stroke (OR 0.93) or all-
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Ray KK, Seshasai SR, Wijesuriya S et al. Lancet


macrovascular disease have been less clear with cause mortality (OR 1.02).
2009; 373: 1765-72.
individual trials failing to show consistent benefits The downside of intensive glucose management
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Review warns of high risk of type 2 diabetes in


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women suffering gestational diabetes


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Women who have gestational diabetes mellitus programmes or perhaps suggest the best time for
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(GD) during pregnancy have a more than seven-fold reassessment. Since the risk of type 2 diabetes seems
increased risk for the development of type 2 to be maintained for several years, consideration of
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diabetes after delivery that persists for their whether any form of continuous assessment would
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lifetime, a systematic review and meta-analysis lead to health gains is important.”


has warned.
© iStock.com/Emiliano Rodriguez

Gestational diabetes – defined as glucose


intolerance that is first detected during pregnancy
– affects up to 1 in 20 pregnancies. It has previously The high risk of developing type 2 diabetes in
been known that women with gestational diabetes women with gestational diabetes confirms the need
are at increased risk of developing type 2 diabetes, for long-term follow-up of these women and
but the size of the risk and the timescale have not underlines the importance of the six-week post-birth
been known. UK researchers conducted a meta- Women with gestational diabetes also had increased diabetes check. This check could provide a useful
analysis of 20 cohort studies that included nearly blood pressure and lipid levels. opportunity to alert women to symptoms of future
700,000 women; 10,859 of these developed type 2 The authors conclude that further studies are diabetes, to provide advice on diet and exercise, and
diabetes. needed to establish features for the identification of consider treatments to delay or prevent onset of
Analysis showed that women with gestational diabetes. Early identification and treatment of
a mother with GD at particularly high risk of
cardiovascular risk factors could also help to reduce
diabetes were around seven-and-a-half times more developing type 2 diabetes. They add: “The increase
premature cardiovascular and renal diseases in this
likely to develop type 2 diabetes after pregnancy in relative risk of type 2 diabetes reported in this
group of women.
than those with normal blood sugar control during meta-analysis might help motivate mothers to
Bellamy L, Casas J-P, Hingorani AD, Williams D.
pregnancy (risk ratio 7.43), rising to an increased attend screening programmes, and healthcare
Lancet 2009; 373: 1773-79.
risk of 9.34 for women with the longest follow-up. professionals to increase uptake to these
S2 PCCJ VOLUME 2, SUPPLEMENT 1, JULY/AUGUST/SEPTEMBER 2009
PCCJ_diabetes_supplement 10/14/09 8:50 AM Page 3

JOURNAL REVIEW

Metabolic changes leading to diabetes Study shows no increase in


cardiovascular morbidity or
begin several years before diagnosis mortality with rosiglitazone
linear trends in non-diabetics, except for insulin
secretion that did not change during follow-up. In
those developing diabetes, there was a linear
increase in fasting glucose, followed by a steep
increase (from 5.79 mmol/L to 7.4 mmol/L) starting
three years before diagnosis of diabetes. Post-meal
© iStock.com/Jacob Wackerhausen

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glucose levels also showed a rapid increase starting
three years before diagnosis.

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Insulin sensitivity decreased steeply during the

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five years prior to diagnosis. Finally, pancreatic beta-
cell function increased between four and three years

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prior to diagnosis – presumably as the body tried to
Changes in blood glucose, insulin sensitivity and compensate for rising glucose levels – but then

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Adding the insulin sensitiser rosiglitazone to
insulin secretion begin several years before the decreased in the three years up to diagnosis.

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glucose-lowering therapy in patients with type 2
onset of type 2 diabetes, according to latest results
diabetes does not increase overall cardiovascular
from the Whitehall II study, which indicate the

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morbidity or mortality compared with standard
scope for prevention.
These findings show the opportunities for screening treatment, according to a recent study.
The prospective study followed up 6,538 UK civil
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and prevention of type 2 diabetes. Although most The multicentre, open-label RECORD study
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servants (71% male) without type 2 diabetes at
prevention studies focus on people with prediabetes, randomly assigned 4,447 patients with type 2
baseline for almost 10 years. Over this time 505
they suggest that prevention might be more effective diabetes on metformin or sulphonylurea
cases of diabetes were diagnosed. The researchers
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before this metabolically unstable period. More monotherapy with average HbA1c values of 7.9% to
then looked back at blood glucose levels both
research is needed to successfully identify people at addition of rosiglitazone or a combination of
before a meal (fasting) and after a standard glucose
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this stage of disease development. If a person could metformin plus sulphonylurea. The mean HbA1c
test, insulin sensitivity (the capacity of tissues such be kept on the linear part of the fasting glucose (or achieved in the rosiglitazone group was lower than
as muscle and liver to adequately respond to
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post-load glucose) trajectory, the onset of diabetes in the control group at five years.
insulin), and the function of the insulin-producing might be substantially delayed.
beta-cells of the pancreas. Results showed similar rates of cardiovascular
Tabák AG, Jokela M, Akbaraly TN et al. Lancet
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Results showed that changes in glucose hospitalisation or cardiovascular death (321 people
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2009; 373: 2215-21. in the rosiglitazone group and 323 in controls) over
concentrations and insulin sensitivity followed
an average of 5.5 years of follow-up (hazard ratio
0.99). The risk of cardiovascular death was reduced
QOF improves diabetes care
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by 16% (HR 0.84) and stroke by 28% (HR 0.72) with


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Significant improvements in the care of patients with people with diabetes who did not meet the QOF case rosiglitazone, while the risk of myocardial infarction
diabetes have been achieved since the introduction of definitions. The introduction of QOF seemed to lead was increased by 14% (HR 1.14).
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the Quality and Outcomes Framework (QOF) but to an increase in the number of patients with type 2 The risk of heart failure was also increased, with
patients not included in the indicators may miss out, diabetes with HbA1c levels of 7.5% (odds ratio 1.05, 61 hospitalisations and deaths in the rosiglitazone-
a study of UK general practices has shown. p=0.02). However, there was no improvement in the treated group and 29 in controls (HR 2.10). Upper
The study compared a range of measures in the management of patients with type 1 diabetes, and and distal lower-limb fracture rates were also higher,
care of patients with diabetes in 147 general practices no reduction in the number of patients with type 2 mainly in women, with rosiglitazone.
in the three years before the introduction of the QOF diabetes who had HbA1c levels greater than 10%.
with the three years afterwards. Results showed
significant improvements in outcome measures during This study provides reassurance that addition of
the entire six-year period, with consecutive annual The management of people with diabetes has rosiglitazone to metformin or sulphonylurea
improvements before the introduction of incentives. improved since the late 1990s, but the impact of the monotherapy does not increase the risk of
However, the study authors cautioned that the current QOF on care has not been straightforward. Targets cardiovascular morbidity or mortality in patients with
diagnostic case definition for the QOF does not need to be made more challenging if people are to type 2 diabetes, as had been suggested in some
capture up to two-thirds of people with type 1 diabetes benefit. Many patients whose care may be previous studies. However, the findings confirm that
and one-third of people with type 2 diabetes. suboptimal may not currently be captured in the rosiglitazone increases the risk of heart failure and
After the introduction of the QOF, existing trends of Quality and Outcomes Framework assessment. some fractures, mainly in women.
improvement in glycaemic control, cholesterol levels, Calvert M, Shankar A, McManus RJ et al. BMJ Home PD, Pocock SJ, Beck-Nielsen H et al. Lancet
and blood pressure were attenuated, particularly in 2009; 338: b1870. 2009; 373: 2125-35.

PCCJ VOLUME 2, SUPPLEMENT 1, JULY/AUGUST/SEPTEMBER 2009 S3