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Diabetes Core Update
Diabetes Core Update September 2014
00:18:50
Diabetes Core Update is a monthly podcast that presents and discusses the latest clinically relevant articles from the American Diabetes Association’s four science and medical journals – Diabetes, Diabetes Care, Clinical Diabetes, and...
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- [00:04]
Host
Welcome to the American Diabetes Association Diabetes Core Update, where we will regularly keep you up to date on the latest clinically relevant articles from the American Diabetes Association's four science and medical journals, Diabetes, Diabetes Care, Clinical Diabetes and Diabetes Spectrum. Joining us for this program are Dr. Neal Skolnik, who is a professor of Family medicine at Temple University School of Medicine and associate Director in the Family Medicine Residency Program at Abington Memorial Hospital. Welcome, Dr. Skolmik.
- [00:38]
Dr. Neal Skolnik
Thank you. It's a pleasure to be here.
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Host
And Dr. John Russell, who is a professor of Family Medicine at Temple University School of Medicine and director in the Family Medicine Residency Program at Abington Memorial Hospital.
- [00:50]
Dr. John Russell
Thank you. I'm looking forward to going over this week's articles.
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Host
And now for the articles.
- [00:56]
Dr. Neal Skolnik
We have another excellent issue this week, beginning with an article from Diabetes Care on pancreatic cancer and pancreatic cancer in patients receiving a DPP4 inhibitor. Then another article from Diabetes Care on lifestyle interventions and healthcare cost savings, followed by a discussion of metformin's effect on cancer risk, published in Diabetes Care, then an article from Diabetes Spectrum on the benefits of diabetes nutrition therapy, followed by an article from Diabetes Care on the lifetime costs of diabetes, and finally a discussion of brain activity patterns and cognitive decline in diabetes. Our first article is from Diabetes Care on the incidence of pancreatitis and pancreatic cancer in a randomized controlled multicenter trial, the SAVIR TIMI trial, of a DPP4 inhibitor, saxagliptin. This study had a total of over 16,000 patients with type 2 diabetes greater than 40 years old with established cardiovascular disease or cardiovascular risk factors who were randomized to saxagliptin or placebo and followed for over two years. Trial investigators reported 35 events of pancreatitis in each treatment arm with a hazard ratio of 1.09, which did not reach statistical significance. Cases of definite acute pancreatitis or definite plus possible pancreatitis in the saxagliptin and placebo arms were not significantly different. No differences in time to event onset, concomitant risk factors for pancreatitis, Investigator reported casualty from study medications or disease severity and outcome were found between treatment arms. The investigators report five and 12 cases of pancreatic cancer in the saxagliptin and placebo arms, respectively, for no significant differences.
- [03:05]
Dr. John Russell
John I think this is an important study and certainly the DPP4 inhibitors are becoming a bigger part of management of diabetes and I think the concerns about disorders of the pancreas have been kind of one of these things that's been talked about in whispered undertones. I think this is a large study. You know, 16,000 folks followed for two years and really was not an increase in pancreatitis compared to baseline. You know, I think a little a few of the caveats are it was only a two year study and certainly, you know, might pancreatitis be a phenomenon that's happening kind of further down downstream. But I still think that this is a good study, so I wouldn't be so concerned about that. That also talked about no increase in pancreatic cancer and certainly in this forum we've talked about potential whispers between the incretin based therapies and this happening and nothing was seen. Again, this was only a two year study, so I think this should be a reassuring safety study that we can use these medicines. Our next article is from Diabetes Care and it looked at the impact of an intensive lifestyle intervention on use and cost of medical services among overweight and obese adults with type 2 diabetes. This was the Action for Health and Diabetes or the Ahead trial. It looked at a total of over 5,000 overweight or obese adults with type 2 diabetes and they were randomly assigned to either intensive lifestyle intervention that promoted weight loss or comparison condition of diabetes. Support and Education the use of costs in healthcare services were recorded over an average of 10 years. The intensive lifestyle intervention led to reductions in annual hospitalization by 11%, hospital days by 15%, number of medications by 6%, resulting in cost savings for hospitalization of 10% and medication for 7%. Intensive lifestyle intervention produced a mean relative per person 10 year cost savings of over $5,000. However, this was not evident among individuals with a history of cardiovascular disease. Overall, the per participant average annual cost of healthcare services and medication was 7% less among intensive lifestyle intervention than among the standard group. This resulted with fewer hospitalizations and less medication use.
- [05:30]
Dr. Neal Skolnik
Neil John, if we had a medicine that could do this, everyone would run out, pay whatever they needed to have that medicine. And yet we had the power in our hands to reduce hospitalizations, reduce health care costs. But what it requires is a lot of effort. It's interesting in the Look Ahead trial what you just went over is the decrease in total health care costs. In addition, other reports on the Look Ahead trial show that even though it didn't reach its primary endpoint of decreasing cardiovascular illness, it did improve blood pressure, improve lipid control, improved diabetes control, sleep quality, and even decreased the incidence of depression. So lifestyle works to yield a lot of wonderful benefits. In addition, it does so as you just pointed out at a significant cost savings that over 10 years averages over $500 per year. Incidentally, we expect that cost savings to increase over time because we expect that the amount of savings accrued will continue to increase as we have less illness over time. Last time I looked, our local gym was charging about $30 a month for membership. So with that $500 cost savings, we could more than pay for a gym membership and have a little leftover to go out for a movie. I think lifestyle intervention is something that very simply we ought to be promoting heavily with all of our patients. Our next article from Diabetes Care is on Metformin does not affect cancer risk. A cohort study in the UK this study was a retrospective cohort study from the Clinical Practice Research Datalink and it was designed to investigate the association between the use of metformin compared with other anti diabetes medicines and its association with cancer risk. A total of over 95,000 participants with type 2 diabetes who started taking metformin and other oral anti diabetes medicines within 12 months of their diagnosis were followed for first incident cancer diagnosis without regard to any subsequent changes in therapy. A total of 51,000 individuals were metformin initiators and over 18,000 were sulfonylurea initiators as well as 3,800 first incident cancers being diagnosed during a medium follow up of 5 years. Compared with initiators of sulfonylureas, initiators of metformin had a similar incidence of total cancer and colorectal, prostate, lung or postmenopausal breast cancer.
- [08:27]
Dr. John Russell
John so I'm always excited to see large studies that come out of the United Kingdom because with their national healthcare system it is very easy for them to look at large hunks of data. So there's been kind of words that kind of fluttered around that perhaps metformin can decrease the growth of cancers in certain cancers. And that's been postulated, there have been studies that have gone on. So looking at this study of a large number of people from The United Kingdom, 95,000 people, certainly the people who got metformin statistically didn't do a whole lot different than the people who got sulfonylureas. Again, it's a one year trial and you know, I'm not necessarily sure a causative agent that within one year of starting it is really going to kind of change your malignancy rate kind of one way or the other. So I would have been a lot more interested in the study had it gone on a longer period of time. But over one year it certainly does not increase anyone's cancer risk and at this point I would probably say over the first year it does not decrease anyone's cancer risk. Our next article is from Diabetes Spectrum and it looked at new diabetes nutrition therapy recommendations. What you need to know so a review of the research conducted during the past decade reveals that diabetes nutrition therapy continues to be an effective management strategy for improving glycemic control and other metabolic parameters such as cholesterol and blood pressure. Effective nutrition therapy interventions can be provided either in one on one session were in group diabetes education classes. The research demonstrated that diabetic nutrition therapy could lower A1C levels from anywhere from 0.3 to 1 in people with type 1 diabetes and people with type 2 diabetes can achieve A1C reductions from 0.5 to 2 when you implement the nutrition therapy is important. If you implement nutrition therapy in someone with newly diagnosed type 2 diabetes with an A1C of A approximately 9, you could result in a decrease of up to 2%, whereas newly diagnosed people who have an A1C level of around 6.6 would experience only a decrease of 0.4. So looking at some of the nutrition therapy guidelines which were given the standard evidence level ratings, individuals who have diabetes should receive individualized medical nutrition therapy as needed to achieve treatment goals, preferably provided by a registered dietitian familiar with the components of diabetes. Medical nutrition therapy gets an A rating for individuals with type 1 diabetes. Participating in an intensive flexible insulin therapy education program Using carb counting meal planning approach can result in improved glycemic control. Also gets an A rating for individuals using fixed daily insulin doses. Consistent carbohydrate intake with respect to time and amount can result in improved glycemic control and reduced the risk for hypoglycemia. Got a B rating and a simple diabetes meal planning approach such as portion control or healthful food choices may be better suited to individuals with type 2 diabetes identified with health literacy and numeracy concerns. This may also be an effective meal planning strategy for older adults. Got a C rating. Other things the use of substituting low glycemic index foods for higher glycemic index foods may moderately improve. Glycemic control only got a C rating. So certainly our nutritionists should be a big part of what we're doing.
- [11:55]
Dr. Neal Skolnik
Neil John, you know it's interesting from a physician point of view there's been such an increase in the number of diabetes medicines available that are focus has been on keeping up with that change in information and learning how to use the different medications and that's occurred to a degree that it's easy to forget. The benefits of Focus on nutrition I was struck that when you talked about the benefits of diabetes nutrition therapy that they were around the same as adding an additional drug that for patients who have A1Cs around 9 that you might expect to get a 2% decrease in A1C. For patients who had A1Cs that were lower 6.5, you mentioned a decrease of 0.4%. That's almost exactly what we see with a lot of the newer agents. So it's once again a reminder to go back to fundamentals. For patients who are newly diagnosed or for patients who have had the diagnosis of diabetes for a while and might have forgotten or become demotivated about paying attention to their diet, it is certainly a good idea to refer them back to a certified diabetes educator, nutritionist, dietitian.
- [13:19]
Dr. John Russell
For.
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Dr. Neal Skolnik
Directed education and motivation about paying attention to correct eating patterns. Our next study is from Diabetes Care on the Lifetime Costs of Diabetes and its Implications for Diabetes Patients Prevention. In this study, the authors derived estimates using data representative of the US national population from the 2006-2009 Medical Expenditure Panel surveys combined with the National Health Interview Surveys. The excess lifetime medical spending for people with diabetes calculated in current dollars was $124,000, $91,000, $53,000 and $35,000 for age of diagnosis at age 40, 50, 60 or 65 years of age. Or to say it a different way, if you're diagnosed between age 40 and 50 over approximately $125,000 of excess medical costs is what an individual may expect to accrue.
- [14:32]
Dr. John Russell
JOHN so this is a pretty exciting macroeconomic study. I'm not sure it's necessarily shocking, but it certainly underscores that if we can find our 40 year old patients who do not yet have diabetes and prevent them from having diabetes over the course of their lifetime, which might be an additional 40, 45 years, we would save a significant amount of money. Plus we would save, you know, patients from all the, all the complications that would go along with diabetes. How we're going to do this is going to be very interesting. And until we actually have a healthcare system that is truly, truly based on trying to prevent disease instead of having to treat disease, I'm not completely sure how we're going to completely do this. And we have to have a system where the cost of preventing diabetes costs less than the cost of treating diabetes. So Certainly for type 2 diabetics in waiting, we need to encourage people to go to the medical nutritionist and maybe learn about eating long before they have diabetes. We have to encourage people to go to the gym, to lose weight, to be smarter with their choices. They will benefit and society will benefit as well. Our next article is from Diabetes and it looked at test induced brain activity patterns in type 2 diabetes, a potential biomarker for cognitive decline. Patients with type 2 diabetes are at increased risk for dementia and cognitive decline. This study looked at 22 patients with type 2 diabetes who were matched with appropriate serologic controls of 29 patients between 45 and 65 years of age. All the patients received functional MRI studies during encoding and deactivation studies and other measures of executive function. The researchers found that the results showed decreases that were related to the height of A1C and hyperglycemia.
- [16:31]
Dr. Neal Skolnik
Neil John this is interesting because both during encoding when we try to remember something and then retrieval when we're remembering something from the past, there were similar changes on functional MRI to that which we see in patients who have early Alzheimer's dementia and who eventually develop progressive dementia. We know from other studies that the incidence of dementia is a good deal higher in patients with diabetes than the population at large, and there also has been some data from the ACCORD study that there isn't a relationship between intensive glucose control and dementia outcomes. What this study suggests though is that at least early changes are related to glucose control. And so this study look shows that on cognitive challenge encoding or retrieval, we're seeing the changes on functional MRI have a relationship to how well we're doing with glucose control, not necessarily intensive glucose control. What do we know from this? Again, it is another study that reminds us that diabetes has multiple adverse outcomes, one of which is an increased instance of dementia and here at least some early information that perhaps the way we approach it and levels of sugar control may affect and improve outcomes. For more information and links to the articles that we discussed in this issue, just go to www.diabetesjournals. until next week. Keep listening and keep learning.
- [18:40]
Dr. John Russell
Sam.