November brings the beginning of the holiday season. We are busy trying new recipes and shopping, even in our world of terrorists and an economy that needs government help. Our leaders tell us to get back to normal, whatever that is, and so we once again bring you abstracts from journals that will shed light on the newest research on diabetes from around the world. Once again, we ask you to e-mail us if you have any questions about diabetes and its complications, and we'll make sure to highlight research on the subject for you. This month we will look at hypoglycemia in type 2 diabetes, a novel insulin preparation, the impact of diabetes on the mortality of females, the benefits of insulin administration, heme oxygenase-1 ability to protect islet cells in transplantation, and finally the cost of diabetes in an employer-based insurance plan.
Again, first we will bring you some headlines that are important for all of us. The first comes from Reuters Health and states that Pharmacia is recalling three lots of Micronase due to the presence of fungal organisms resulting from contaminated raw material. The lot numbers are 84DWB (1.25 mg), 91DYR (2.5 mg) and 67FPP (5 mg).The FDA has reported no infections due to these medications so that persons should continue to take them until replacements can be obtained. Our second headline is also from Reuters Health and says that the FDA has approved a living skin graft manufactured by Advanced Tissue Sciences, Inc. with Smith & Nephew PLC for the treatment of chronic diabetic foot ulcers. The name of this product is Dermagraft and is the first FDA approval of a living dermal substitute in the US. Our last headline, also from Reuters Health, is that Switzerland has approved limited research on embryonic stem cells as long as the projects are strictly supervised and not for commercial purposes. We will watch for the results.
Now for our abstracts from medical journals. The Archives of Internal Medicine 2001;161:1653-1659 has an article titled Hypoglycemia in patients with type 2 diabetes mellitus by Christopher D. Miller, M.D. et al. The authors wanted to examine the prevalence and predisposing factors of hypoglycemia in this population. They looked at 1055 patients. The prevalence of hypoglycemic symptoms was 12% for patients treated with diet alone, 16% for those using oral agents alone, and 30% for those using insulin. Severe hypoglycemia occurred in only 5 patients (0.5%). Multiple logistic regression analysis showed that insulin therapy, lower HbA1c level at follow-up, younger age, and report of hypoglycemia at the baseline visit were independently associated with increased prevalence of hypoglycemia. There were no significant predictors of severe hypoglycemia. The researchers concluded that mild hypoglycemia is common in persons with type 2 diabetes who are undergoing aggressive diabetes management, but severe hypoglycemia is rare. They suggest that concerns about hypoglycemia should not deter efforts to achieve tight glycemic control is this population.
The Journal of Diabetes and Its Complications, Sept/Oct issue has an article about Novel insulin preparation targets liver by Stephen N. Davis, MD. The research at Vanderbilt University was to examine if this hepatic directed vesicle-insulin (HDV-insulin) would prove more suitable than regular insulin in aggressive therapy. It was thought that increased insulin action in the liver would limit hepatic glucose output while increasing hepatic glucose uptake. They also hoped that improved postprandial glycemic control could be obtained with reduced systemic insulinemia. The researchers found that HDV-insulin significantly lowered glucose levels during the test compared with regular insulin, with a mean reduction of 2.2 mmol/L. Plasma levels of insulin and glucagon were equivalent during the 2 series of experiments done. There was little difference in terms of blood lacate, glycerol and plasma NEFA during OGTT indicating similar peripheral actions of the 2 insulins' preparations. Further results supported a preferential hepatic action of the HDV-insulin. The researchers concluded that "HDV-insulin may represent a novel and therapeutic agent for reducing postprandial glycemia in insulin-deficient diabetic patients and . . . this might be achieved without increasing the risk of subsequent hypoglycemia."
The Archives of Internal Medicine 2001;161:1717-1723 has an interesting research article titled The impact of diabetes mellitus on mortality from all causes and coronary heart disease in women, a 20 year follow-up by Frank B. Hu, MD et al. This research examines the long-term impact of type 2 diabetes on mortality and fatal coronary heart disease (CHD) in women. The researchers examined prospectively the impact of type 2 diabetes and history of prior CHD on mortality from all causes and CHD among 121,046 women aged 30 to 55 years of age with type 2 diabetes in the Nurses' Health Study who were followed up for 20 years from 1976 to 1996. During 20 years of follow-up, the researchers documented 8464 deaths from all causes, including 1239 fatal CHD events. Compared with women with no diabetes or CHD at baseline, age adjusted relative (RRs) of overall mortality were 3.39 for women with a history of diabetes and no CHD at baseline, 3.00 for women with a history of CHD and no diabetes at baseline, and 6.84 for women with both conditions at baseline. The combination of prior CHD and a long duration of clinical diabetes (i.e.>15 years) was associated with a 30-fold increased risk of fatal CHD. The researchers concluded that data suggests among women a history of diabetes is associated with dramatically increased risks of death from all causes and fatal CHD. The combination of diabetes and prior CHD identifies particularly high-risk women.
Diabetes Care 2001; 24: 1722-1727 has an article titled Route of insulin administration does not affect outcome in diabetes by Dr. Bernard Zinman et al of Mount Sinai Hospital in Toronto. This research examined the differences between glycemic control, reported hypoglycemic events, or quality of life between type 1 diabetic patients treated with continuous subcutaneous insulin infusion (CSII) and those treated with multiple daily insulin injection (MDI). Patients in the CHII group had a mean HbA1c at a baseline of 7.73%, compared with 8.16% for patients in the MDI group. Both groups of patients had significant decreases in HbA1c levels at all time points. Overall, the investigators "found no differences in outcome between the two treatment groups in term of HbA1c levels, hypoglycemic events, or quality of life measures using the Diabetes Quality of Life questionnaire. The findings of our study indicate that the choice of the method of intensive insulin therapy should be a matter of personal preference," Dr. Zinman and his colleagues conclude. "It is important for all patients with type 1 diabetes to have the options to select the therapy that is most suitable for them."
Diabetes 2001;50:19983-1991 has an article on Heme Oxygenase-1 protects islet cells from destruction following transplant by Dr. Luca Inverardi et al from the University of Miami School of Medicine. They found that the introduction of heme oxygenase-1, a ubiquitous stress protein, protects islet cells from local inflammation and improves the function of these cells after transplant in rodents. The findings suggest that "strategies aimed at inducing heme oxygenase-1 up-regulation might result in improved success in islet transplantation as a treatment for diabetes in humans," stated Dr. Inverardi. Indeed, heme oxygenase-1 up-regulation caused a reduction in inflammation or Fas-associated apoptosis in vitro and an improvement in islet cell function after transplantation in vivo. "Islet transplants are susceptible not only to the occurrence of rejection and recurrence of autoimmunity in type 1 diabetes patients, but also to nonspecific inflammatory events that take place at the site of implantation, which contribute significantly to graft failure." The ability to reduce the vulnerability of these cells to local inflammation could have important implications and for the success of islet cell transplantation.
Archives of Internal Medicine 2001;161:1301-1308 has an article titled Health care use of individuals with diabetes in an employer-based insurance population by Sarah B. Laditka, Ph.D. et al. People with diabetes use more health care resources than those without the disease. Much less is known about such differences associated with different types of diabetes. In this study, people with both type 1 and 2 diabetes were identified from claims of a commercial insurer with an enrollment of 828,208. Age and sex-adjusted rates and observed-to-expected ratios for health care services use, costs, and relative value units were compared for persons with diabetes and those the total plan population. The researchers identified 13,563 people with diabetes (4349 with type 1 and 8810 with type 2). The diabetic population was 1.6% of the total population, but had 9.4% of the costs. Individuals with both types of diabetes had higher rates for use of inpatient, outpatient, and professional services. Compared with the total population, inpatient rates for the total diabetic population (for those with type 1 diabetes), were 4.9 (8.3) times higher for established complications of diabetes such as myocardial infarction, 9.8 (22.1) times higher for heart failure, 5.6 (8.3) times higher for coronary artery bypass, and 5.1 (8.9) times higher for cardiac catheterization. The following relative value unit ratios for physician services were substantially higher foe the total diabetes population (for those wit type 1 diabetes):13.2 (27.9) times higher for endocrinologists, 6.3 (12.9) for ophthalmologists, and 9.4 (27.8) for nephrologists. The authors concluded that the use, costs, and intensity of resources used were substantially higher for people with diabetes and markedly higher for the population of type 1 diabetes. Their findings show that people with type 1 diabetes are at substantially higher risk for serious complications than those with type 2 diabetes.
BSP
