Wednesday, August 29, 2012

Managing Type 2 Diabetes: New American Diabetes Association Position Statement

Information sourced from Journal Watch:

New Position Statement for Managing Type 2 Diabetes

A one-size-fits-all approach is rejected.

The American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD) have published a new position statement entitled, "Management of Hyperglycemia in Type 2 Diabetes: A Patient-Centered Approach." The document outlines basic elements of lifestyle modification, oral agents, noninsulin injectable agents, and insulin, and provides management tips that even experienced clinicians might find helpful. Two aspects of the report are particularly noteworthy:

  • Acknowledging "mounting concerns about . . . potential adverse effects [of drug therapies] and new uncertainties regarding the benefits of intensive glycemic control on macrovascular complications," the authors emphasize a patient-centered approach with individualized targets for glycemic control. For example, they recommend more-stringent control (e.g., glycosylated hemoglobin [HbA1c] target, <7%) for motivated patients with new-onset diabetes and long life expectancies, and less-stringent control (e.g., HbA1c goal, 8% or even higher) for less-motivated patients with longstanding diabetes, limited life expectancies, and high risk for adverse outcomes from hypoglycemia.
  • Because the authors reject a one-size-fits-all approach, they make this important statement: "Utilizing the percentage of diabetic patients who are achieving an HbA1c <7% as a quality indicator, as promulgated by various health care organizations, is inconsistent with the emphasis on individualization of treatment goals."

Comment: Many clinicians talk about getting their patients with type 2 diabetes "to goal," as if a single, evidence-based target was applicable to every patient. Others talk about being "dinged" by real or imagined organizations if their patients' HbA1c levels are not in a certain range. In contrast, this position statement supports a more-reasoned approach that involves shared decision making and flexible goals. In a worthwhile accompanying editorial, the author describes the process that resulted in this position statement. One note: Nine of the 10 authors of the statement each have financial ties to numerous pharmaceutical companies.

Allan S. Brett, MD

Published in Journal Watch General Medicine July 24, 2012

CITATION(S):

Inzucchi SE et al. Management of hyperglycemia in type 2 diabetes: A patient-centered approach. Position statement of the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD). Diabetes Care 2012 Jun; 35:1364. [Free full-text PDF | PubMed® abstract]

Cefalu WT. American Diabetes Association–European Association for the Study of Diabetes position statement: Due diligence was conducted. Diabetes Care 2012 Jun; 35:1201. [Free full-text PDF | PubMed® abstract]

Copyright © 2012. Massachusetts Medical Society. All rights reserved.

The above message comes from "Journal Watch", who is solely responsible for its content.

Monday, August 27, 2012

Journal Watch: When Metformin Fails, Which Second-Line Type 2 Diabetes Therapy Is Superior?

Information sourced from Journal Watch:

What Therapy Is Best for Diabetes After Metformin Fails?

In three trials, researchers assess options for second-line diabetes therapy.

Metformin is accepted widely as first-line treatment for patients with type 2 diabetes, but no clear guidelines exist on how to proceed when metformin monotherapy fails. In three new industry-supported studies, researchers compared available second-line treatments.

In an open-label study, 1029 adults with glycosylated hemoglobin (HbA1c) levels between 6.5% and 9.0% while taking metformin were randomized to add either the glucagon-type peptide-receptor agonist exenatide (Byetta; 5–10 µg subcutaneously twice daily) or the sulfonylurea glimepiride (titrated to maximum tolerated daily dose). During 4 years of follow-up, significantly fewer exenatide recipients than glimepiride recipients (41% vs. 54%) reached the primary endpoint of treatment failure (HbA1c level >9% after 3 months of treatment, or HbA1c level >7% at two consecutive readings after 6 months of treatment). Significantly more patients in the exenatide group than in the glimepiride group reached a target HbA1c level of <7% (44% vs. 31%). Patients who received exenatide lost a mean of 3.3 kg, whereas those who received glimepiride gained a mean of 1.2 kg — a significant difference. Hypoglycemia occurred significantly more often in patients taking glimepiride.

In another open-label trial, researchers randomized 515 adults with HbA1c levels between 7% and 11% while taking metformin to add either once-daily insulin glargine (Lantus; titrated to a fasting glucose level of 72–99 mg/dL) or the dipeptidyl peptidase-4 (DPP-4) inhibitor sitagliptin (Januvia; 100 mg once daily). After 24 weeks, patients who received insulin glargine had a significantly greater reduction in mean HbA1c level than did those who received sitagliptin (–1.7% vs. –1.1%), and more patients who received insulin glargine reached the HbA1c target of 7% (68% vs. 42%). Mean body weight increased slightly in the insulin glargine group and decreased slightly in the sitagliptin group, and significantly more hypoglycemic events occurred in the insulin glargine group (4.2 vs. 0.5 per patient-year).

In the third trial, researchers randomized 1551 patients with HbA1c levels between 6.5% and 10.0% who were taking metformin alone to the DPP-4 inhibitor linagliptin (Tradjenta; 5 mg daily) or to glimepiride (1–4 mg daily, titrated to fasting plasma glucose ≤110 mg/dL). After 2 years, average HbA1c level was –0.16% in the linagliptin group and –0.36% in the glimepiride group. Thirty percent of patients taking linagliptin and 35% of those taking glimepiride reached HbA1c levels <7%. Average body weight decreased slightly with linagliptin and rose slightly with glimepiride; hypoglycemic events occurred in 7% of patients taking linagliptin and in 36% of those taking glimepiride.

Comment: The choice of diabetes therapies is complex, involving patient acceptance, efficacy, and safety. These trials were limited to surrogate endpoints, and all were industry-sponsored (by the makers of exenatide, insulin glargine, and linagliptin, respectively); also, the insulin glargine–sitagliptin trial was very brief. Nevertheless, these trials highlight some of the strengths and weaknesses of the various options for second-line diabetes therapy; the long-term effects of these therapies on glucose metabolism and clinical endpoints remain to be elucidated.

Bruce Soloway, MD

Published in Journal Watch General Medicine July 10, 2012

CITATION(S):

Gallwitz B et al. Exenatide twice daily versus glimepiride for prevention of glycaemic deterioration in patients with type 2 diabetes with metformin failure (EUREXA): An open-label, randomised controlled trial. Lancet 2012 Jun 16; 379:2270. [Medline® Abstract]

Aschner P et al. Insulin glargine versus sitagliptin in insulin-naive patients with type 2 diabetes mellitus uncontrolled on metformin (EASIE): A multicentre, randomised open-label trial. Lancet 2012 Jun 16; 379:2262. [Medline® Abstract]

Gallwitz B et al. 2-year efficacy and safety of linagliptin compared with glimepiride in patients with type 2 diabetes inadequately controlled on metformin: A randomised, double-blind, non-inferiority trial. Lancet 2012 Jun 27; [e-pub ahead of print]. [Medline® Abstract]

Copyright © 2012. Massachusetts Medical Society. All rights reserved.

The above message comes from "Journal Watch", who is solely responsible for its content.

Do Probiotics Protect Against Antibiotic-Associated Diarrhea? Systematic Review and Meta-analysis

Probiotik efektif untuk mencegah diare akibat pemberian antibiotik

Information sourced from BMJ:
BMJ 2012;344:e3359
Research News

All you need to read in the other general journals

Probiotics protect against diarrhoea associated with antibiotics
JAMA 2012;307:1959-69 [PubMed® abstract]

More evidence that probiotics can help prevent diarrhoea associated with antibiotics has emerged from a meta-analysis of randomised trials. The authors found 82 trials after a systematic search but only 63 reported how many people took the probiotics, how many took the control treatment, and how many developed diarrhoea. Across these 63 trials, probiotics were associated with a 42% reduction in the risk of diarrhoea (relative risk 0.58, 95% CI 0.50 to 0.68; number needed to treat 13, 10.3 to 19.1).
Most trials tested probiotic preparations containing lactobacilli, alone or in mixed cultures. The effect looked consistent in multiple different analyses, including two confined to high quality trials and another that looked specifically at adults taking antibiotics for Helicobacter pylori infections (the most commonly reported indication). The authors are confident their results are as robust as they can be given the generally poor quality of the evidence base.
Most trials were underpowered and badly reported. It is still hard to know the precise mix of micro-organisms that is likely to work best and the characteristics of patients most likely to benefit. Details of the antibiotics being taken were missing from many trials, as were reliable assessments of side effects. Still, we have enough encouraging evidence to justify further research to fine tune these results, say the authors. Diarrhoea associated with antibiotics is common and can be life threatening.
© 2012 BMJ Publishing Group Ltd

Thursday, August 16, 2012

Purine-rich foods intake and recurrent gout attacks

Konsumsi bahan makanan kaya purin (terutama dari sumber hewani) meningkatkan (lima kali lipat) risiko kambuh gout pada pasien2 gout.

Ann Rheum Dis doi:10.1136/annrheumdis-2011-201215
Extended report

Purine-rich foods intake and recurrent gout attacks
Yuqing Zhang, Clara Chen, Hyon Choi, et al
Correspondence to Yuqing Zhang, Boston University, Boston University School of Medicine, 715 Albany Street, A203, Boston, Massachusetts MA 02118, USA
Abstract

Objective To examine and quantify the relation between purine intake and the risk of recurrent gout attacks among gout patients.
Methods The authors conducted a case-crossover study to examine associations of a set of putative risk factors with recurrent gout attacks. Individuals with gout were prospectively recruited and followed online for 1 year. Participants were asked about the following information when experiencing a gout attack: the onset date of the gout attack, clinical symptoms and signs, medications (including antigout medications), and presence of potential risk factors (including daily intake of various purine-containing food items) during the 2-day period prior to the gout attack. The same exposure information was also assessed over 2-day control periods.
Results This study included 633 participants with gout. Compared with the lowest quintile of total purine intake over a 2-day period, OR of recurrent gout attacks were 1.17, 1.38, 2.21 and 4.76, respectively, with each increasing quintile (p for trend <0.001). The corresponding OR were 1.42, 1.34, 1.77 and 2.41 for increasing quintiles of purine intake from animal sources (p for trend <0.001), and 1.12, 0.99, 1.32 and 1.39 from plant sources (p=0.04), respectively. The effect of purine intake persisted across subgroups by sex, use of alcohol, diuretics, allopurinol, NSAIDs and colchicine.
Conclusions The study findings suggest that acute purine intake increases the risk of recurrent gout attacks by almost fivefold among gout patients. Avoiding or reducing amount of purine-rich foods intake, especially of animal origin, may help reduce the risk of gout attacks.
Copyright © 2012 BMJ Publishing Group Ltd & European League Against Rheumatism. All rights reserved.
The above message comes from BMJ, who is solely responsible for its content.

Friday, August 10, 2012

A Prospective Study of Weight Training and Risk of Type 2 Diabetes Mellitus in Men

Efek olah raga aerobik untuk pencegahan diabetes telah lama diketahui. Bagaimana efek olah raga beban ?
 
Penelitian ini membuktikan bahwa olah raga beban juga efektif menurunkan risiko diabetes melitus tipe 2. Kombinasi keduanya adalah yang terbaik.

A Prospective Study of Weight Training and Risk of Type 2 Diabetes Mellitus in Men
Anders Grøntved, MPH, MSc; Eric B. Rimm, ScD; Walter C. Willett, MD, DrPH; Lars B. Andersen, PhD, DrMED; Frank B. Hu, MD, PhD
Arch Intern Med. Published online August 06, 2012. doi:10.1001/archinternmed.2012.3138
Background  The role of weight training in the primary prevention of type 2 diabetes mellitus (T2DM) is largely unknown.
Methods  To examine the association of weight training with risk of T2DM in US men and to assess the influence of combining weight training and aerobic exercise, we performed a prospective cohort study of 32 002 men from the Health Professionals Follow-up Study observed from 1990 to 2008. Weekly time spent on weight training and aerobic exercise (including brisk walking, jogging, running, bicycling, swimming, tennis, squash, and calisthenics/rowing) was obtained from questionnaires at baseline and biennially during follow-up.
Results  During 508 332 person-years of follow-up (18 years), we documented 2278 new cases of T2DM. In multivariable-adjusted models, we observed a dose-response relationship between an increasing amount of time spent on weight training or aerobic exercise and lower risk of T2DM (P < .001 for trend). Engaging in weight training or aerobic exercise for at least 150 minutes per week was independently associated with a lower risk of T2DM of 34% (95% CI, 7%-54%) and 52% (95% CI, 45%-58%), respectively. Men who engaged in aerobic exercise and weight training for at least 150 minutes per week had the greatest reduction in T2DM risk (59%; 95% CI, 39%-73%).
Conclusions  Weight training was associated with a significantly lower risk of T2DM, independent of aerobic exercise. Combined weight training and aerobic exercise conferred a greater benefit.