From the ACP Diabetes Care Guide

Many factors affect the ability of patients to achieve and maintain near-normal blood glucose levels. Collaboratively developed glycemic goals should take into consideration the patient's age, comorbidities, physical limitations, lifestyle, occupation, support system, and financial resources. The patient's ability to recognize and appropriately treat hypoglycemia should be considered as well.

Topics covered in this chapter include:

• Blood Glucose Pattern Management
• The Role of Postprandial Blood Glucose Monitoring
• Blood Glucose Monitors
• Recording Blood Glucose Results
• Hemoglobin A1C
• Fructosamine

NOTE: You may order free copies of the complete ACP Diabetes Care Guide (book and CD-ROM).

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From the ACP Diabetes Care Guide

Persons with diabetes have a 2- to 4-fold higher hospitalization rate than do those without diabetes. Diabetes predisposes to a number of conditions that may lead to hospitalization, including coronary artery disease, cerebrovascular disease, peripheral vascular disease, nephropathy, and infection. Poorly controlled diabetes has been associated with increased infectious complications, delayed wound healing, increased medical costs, increased length of stay, and increased mortality.

The general goals for patients with diabetes in the acute care setting are:

• Avoiding hypoglycemia or hyperglycemia
• Avoiding metabolic abnormalities, such as volume depletion or electrolyte abnormalities
• Meeting nutritional needs
• Assessing educational needs

NOTE: You may order free copies of the complete ACP Diabetes Care Guide (book and CD-ROM).

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From the ACP Diabetes Care Guide

All persons involved in the care of persons with diabetes need to be able to determine when hospitalization is warranted. General hospital admission guidelines for diabetes are summarized (in this chapter). When counseling patients about hypoglycemia and hyperglycemia, emphasize that the best treatment is prevention: be proactive by recognizing the signs early, be prepared to treat, treat appropriately, and seek prompt attention when needed. It is always better to err on the side of safety.

NOTE: You may order free copies of the complete ACP Diabetes Care Guide (book and CD-ROM).

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Determine how often blood glucose should be checked.

Effective and efficient analysis of blood glucose records.

Use of "pattern management" of blood glucose records to make decisions regarding diabetes care.

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This session answers the following questions:

• How should diabetic patients be managed in the operative and perioperative period?
• What is the role of insulin in the critically ill patient?
• How has availability of new insulins (glargine, lispro) changed the approach to therapy?
• What strategies can be used to initiate IV insulin infusions in non-ICU environments?

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In a new randomized controlled trial, both aerobic and resistance exercise improved glycemic/blood sugar control in people with type 2 diabetes. The greatest improvements came from combined aerobic and resistance training.

The study included 251 adults, between ages 39 and 70, who were not exercising regularly and had type 2 diabetes. Participants were assigned to one of four groups: performing 45 minutes aerobic training three times per week, 45 minutes of resistance training three times per week, 45 minutes each of both three times per week, or no exercise.

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A documentary on diabetes, for which physicians can earn CME credit, debuted on the Discovery Channel this month. The documentary, "Diabetes: A Global Epidemic" can also be viewed online or downloaded as a podcast.

The documentary is divided into four hour-long segments:

• Insulin initiation: glycemic control with postprandial glucose monitoring
• Effectively managing anticoagulation
• Insulin initiation: targeting type 2 diabetes
• Diabetes: A global epidemic

The series is supported by an unrestricted educational grant to Discovery Health from Novo Nordisk.

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Thiazolidinediones, primarily rosiglitazone (Avandia), increase the risk of congestive heart failure, acute myocardial infarction and death for older patients with diabetes, a new study found.

The retrospective cohort study used health care databases in Ontario to examine 159,026 diabetes patients age 66 years and older who had been treated with at least one hypoglycemic agent between 2002 and 2005. Follow up was for a median of 3.8 years. The study was published in the Dec. 12 Journal of the American Medical Association.

Patients treated with thiazolidinedione monotherapy had a 60% higher risk of congestive heart failure, a 40% higher risk of acute myocardial infarction and a 29% higher risk of death compared with people taking other hypoglycemic agent combination therapies. Patients treated with thiazolidinedione combination therapy had a 31% higher risk of congestive heart failure, and a 24% higher risk of death, but no higher risk of heart attack, compared with those taking other therapies. The association between thiazolidinedione treatment and cardiac events appears limited to rosiglitazone, the authors said.

Past research has indicated that rosiglitazone and pioglitazone may increase the risk of congestive heart failure, while two meta-analyses have suggested rosiglitazone may increase the risk of acute myocardial infarction. The FDA recently added boxed warnings to the drugs' labels to reflect these risks, but has stopped short of recommending that the drugs be pulled from the market.

"These findings provide evidence from a real-world setting and support data from clinical trials that the harms of thiazolidinediones may outweigh their benefits," though further studies are needed, the authors said. For now, clinicians need to weigh the potential benefits and harms of treatment on an individual basis, especially with high-risk elderly populations, they said.

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Intensive insulin therapy may have a renoprotective effect in critically ill patients, according to a new study.

Two previously published randomized, controlled trials have indicated that tight glucose control protects the kidneys in critically ill patients. Researchers reanalyzed data from these trials to more closely examine the effect of intensive insulin therapy on renal function. The results appear in the March Journal of the American Society of Nephrology.

The study involved data from 2,707 critically ill medical and surgical patients who did not have end-stage renal disease before hospital admission and were randomly assigned to receive intensive or conventional insulin therapy during hospitalization. Overall, the incidence of acute kidney injury was statistically significantly lower in patients receiving intensive insulin therapy than in those receiving conventional therapy (4.5% vs. 7.6%). A greater renoprotective effect was seen among patients who maintained normal glucose levels.

In surgical patients, oliguria and the need for renal replacement therapy were statistically significantly less common in those receiving intensive insulin therapy compared with conventional therapy (2.6% vs. 5.6% and 4.0% vs. 7.4%, respectively). Medical patients did not derive as much renoprotective benefit from intensive insulin therapy, possibly because patients in this group are usually sicker at hospital admission.

The authors acknowledged several limitations of their study, including examination of a secondary outcome and the limited sample size of some subgroups. However, they concluded that tight glucose control has a renoprotective effect in the critically ill, especially surgical patients.

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A large government trial of diabetes treatments was halted last week after it was found that intensive efforts to lower patients? blood sugar were associated with higher mortality rates.

The ACCORD (Action to Control Cardiovascular Risk in Diabetes) trial included more than 10,000 patients who had diabetes and at least two other risk factors for heart disease. The patients were randomized to either intensively low blood sugar goals (A1c of less than 6%) or standard goals and treatment (A1c between 7% and 7.9%). Over the almost four-year study period, 257 patients in the intensive group had died, compared with 203 patients in the standard group, NIH officials announced last week. Based on that survival difference (which works out to 3 deaths per 1,000 participants per year), officials decided to halt the intensive treatment arm of the trial.

The researchers have not uncovered an explanation for the difference in survival, although an investigation is ongoing. Overall, death rates in both groups were lower than in similar populations in other studies. Because of recent concerns, the researchers specifically looked at rosiglitazone for a link to the increased deaths, but they found no association. The standard treatment arm of the ACCORD study, as well as related trials of blood pressure and lipid treatment, will continue until the planned conclusion date of June 2009.

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Interim results from a large international diabetes study do not confirm findings that recently halted a large U.S. trial, researchers announced last week. The new findings increased debate about how intensive treatment of blood sugar in high-risk diabetic patients affects mortality.

The ACCORD trial, a large NIH-funded study of diabetes treatment, stopped its intensive treatment arm two weeks ago after researchers found a link between treating patients to low blood sugar goals and increased mortality. Concern about the ACCORD trial's findings led researchers on the ADVANCE study, an international trial involving 11,140 high-risk patients with diabetes, to evaluate their data for a similar link.

They found no confirmation of the adverse mortality trend reported by the ACCORD trial, according to the chairman of the ADVANCE Data Monitoring and Safety Committee. He also noted that the ADVANCE trial was based on twice as much data and similar glucose targets as the ACCORD trial. Patients in the ADVANCE trial had an A1c goal of less than 6.5% while ACCORD patients in the low-target group had an average A1c of 6.4%.

Full data from the ADVANCE trial are not yet available, because the arm of the study that assessed the effects of intensive blood sugar treatment was only completed in January. The study began in July 2001 and patients were treated and followed for an average of five years. Researchers said that results are more than 99% complete, so the interim findings should be a reliable guide to the final results. The study should be available in the spring, representatives said.

Doctors and patients should be reassured that the mortality trend found in the U.S. study was not confirmed by the international trial, although more definitive analyses are needed, said a representative of the ADVANCE trial. The results of a third trial, expected later this year, should help to clarify the issue, according to the American Diabetes Association. The association also reaffirmed its recommendation that most people with diabetes work toward an A1c of less than 7% and that high-risk individuals consult individually with their health care providers.

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Intensive control of glucose reduced the incidence of nephropathy in patients with type 2 diabetes but showed no significant effect on other vascular outcomes, according to new results from the ADVANCE trial.

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The newly approved OneTouch Ping Glucose Management System allows patients to calculate and deliver insulin doses without touching their pumps.

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A recent large study found that poor glucose control was associated with a fourfold increase in mortality and major complications following cardiac surgery, regardless of whether patients had been diagnosed with diabetes.

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The U.S. Food and Drug Administration today approved a device that measures glucose levels continuously for up to seven days in people with diabetes. While a standard fingerstick test records a person's glucose level as a snapshot in time, the STS-7 Continuous Glucose Monitoring System (STS-7 System) measures glucose levels every five minutes throughout a seven-day period. This additional information can be used to detect trends and track patterns in glucose levels throughout the week that wouldn't be captured by fingerstick measurements alone. However, diabetics must still rely on the fingerstick test to decide whether additional insulin is needed.

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The hemoglobin A1C (A1C) test can lead to false outcomes resulting in over-treatment or under-treatment of diabetes in people with inherited hemoglobin variants, also called hemoglobinopathies. Hemoglobin S and E are prevalent variants in people of African, Mediterranean, or Southeast Asian descent. These variants interfere with some A1C tests--both laboratory and point-of-care tests. If A1C tests are at odds with blood glucose monitoring results, interference should be considered. Reliable A1C tests, in which hemoglobin variants do not cause interference, are available. More information is available at www.ngsp.org, the National Glycohemoglobin Standardization Program. A1C should be measured at least twice annually to assess control of diabetes but should not be used to diagnose diabetes.

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A new information campaign of the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), part of the National Institutes of Health, highlights the importance of using accurate methods to test hemoglobin A1c in people with diabetes who have sickle cell trait or other inherited forms of variant hemoglobin. The specific needs for testing blood glucose control in these patients are explained in two booklets, "Sickle Cell Trait and Other Hemoglobinopathies and Diabetes: Important Information for Physicians" and "For People of African, Mediterranean, or Southeast Asian Heritage: Important Information about Diabetes Blood Tests" from NIDDK's National Diabetes Information Clearinghouse at: www.diabetes.niddk.nih.gov.

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The ADA has issued their 2008 Comprehensive Guidelines for Diabetes Care

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