hyperglycemia

7 Ayurvedic Morning Drinks To Lower High Blood Sugar Levels On Empty Stomach Naturally Without Medication.

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Are you tired of morning blood sugar spikes? Here are the top 7 Ayurvedic drinks that can help you deal with the condition.

High blood sugar levels, also known as hyperglycemia, are a non-reversible health condition that is marked by an excessive presence of sugar or glucose in your blood. In medical terms, this condition is often associated with diabetes a long-term illness that messes with how your body deals with sugar. When left untreated, high sugar levels can put your health at risk, making it important to keep an eye on and manage properly. Fortunately, Ayurveda, the ancient Indian system of medicine, has some natural remedies that can help control and lower blood sugar levels effectively without medication. Yes, you read that right! As per experts, one of the best ways to incorporate Ayurveda in your daily routine to manage blood glucose levels is to start your day with one of of blood glucose-lowering drinks from the books of Ayurveda. In this article, we delve into the power of Ayurvedic drinks in managing high blood sugar levels in the body.

7 Ayurvedic Drinks To Lower Blood Sugar Levels Naturally

Balancing blood sugar levels is a crucial aspect of maintaining well-being, particularly for those with diabetes. Luckily, we have natural solutions right from the ancient wisdom of Ayurveda that not only help regulate blood sugar but are also quite tasty. Here are seven incredible Ayurvedic drinks that can naturally reduce blood sugar levels.

Bitter Gourd Juice

Bitter Gourd, or bitter melon as some call it, is an effective Ayurvedic solution to manage blood sugar. The ‘bitter’ in the bitter gourd juice comes from compounds that function similarly to insulin, helping control glucose absorption. Regular consumption of this juice can keep your blood sugar levels in check

Cinnamon Tea

Cinnamon, aka Dlachini, is a well-known spice that comes packed with numerous health benefits, one of which is its ability to lower blood sugar. Prepare a comforting drink by steeping cinnamon sticks in hot water. It not only enhances insulin sensitivity but is also a tasteful accompaniment for individuals battling diabetes.

Fenugreek Water On Empty Stomach

Fenugreek seeds, which are high in soluble fiber, help slow down the absorption of carbs and sugars. Consuming water infused with fenugreek seeds can prevent blood sugar spikes after eating. This soothing drink is an effective Ayurvedic solution for managing diabetes.

Ashwagandha Tea Every Morning

Stress can cause blood sugar levels to spike, but Ashwagandha, an adaptogenic herb, is known for its ability to relieve stress. A regular cup of calming Ashwagandha tea can help manage stress and maintain stable blood sugar levels.

Amla Juice

Amla, aka Indian gooseberry, is packed with vitamin C and antioxidants. Starting your day with freshly squeezed amla juice can foster pancreatic health, raise insulin sensitivity, and keep blood sugar levels in check. You can either have it on an empty stomach as an amla juice shot or mix it with your morning detox drink.

Neem

Summer is here, and the best thing that you can do for your overall health is add some neem leaves to your lifestyle routine. But did you know that adding Neem to your diet can also help in managing blood glucose levels? The medicinal properties of Neem leaves, including their ability to lower blood sugar, make them a powerful tool in diabetes management. This bitter yet effective drink can bolster immune function.

Turmeric Tea

Tumeric, rich in anti-inflammatory properties is another Ayurvedic herb that can be added to your diet when trying to manage blood sugar levels naturally. With its primary compound curcumin, turmeric lowers blood sugar and combats inflammation. A warm glass of turmeric milk sprinkled with black pepper first thing in the morning not only stabilizes blood sugar levels but also bolsters overall health.

Including the above-mentioned top 7 morning, Ayurvedic drinks into your daily diet can be a holistic way of naturally managing blood sugar levels. However, make sure to consult a dietician or a nutritionist before making any changes to your diet routine.

The Two Levels of Hyperglycemia and a Separate Definition for People With Diabetes

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two stages of hyperglycemia

A Steering Committee made up of representatives from the American Association of Clinical Endocrinologists, the American Association of Diabetes Educators, the American Diabetes Association, the Endocrine Society, JDRF International, The Leona M. and Harry B. Helmsley Charitable Trust, the Pediatric Endocrine Society, and the T1D Exchange formed a decision-making group for the Type 1 DiabetesOutcomes Program.

Their goal was to develop a consensus on definitions for hypoglycemia, hyperglycemia, time in range, DKA, and patient reported outcomes and while their decisions were informed via input from researchers, industry, and people with diabetes they relied on published evidence, their own clinical expertise, and Advisory Committee feedback.

We recently wrote about their definitions for hypoglycemia, here.

Level 1 Hyperglycemia

Level 1 hyperglycemia is defined by this group as a blood glucose concentration of >180 mg/dL (10.0 mmol/L) but ≤250 mg/dL (13.9 mmol/L).

The committee wrote that “In clinical practice, measures of hyperglycemia differ based on time of day (e.g., pre- vs. postmeal). This program, however, focused on defining outcomes for use in product development that are universally applicable.”

They believe that based on glucose profiles and post meal blood glucose data in those with no diabetes tell us that at or  over 140 mg/dL (7.8 mmol/L) is high blood sugar. However, since most people spend most of their day over that blood sugar level, they believe the guideline for measuring hyperglycemia should be different in those with diabetes.

Since the current guidelines for those with diabetes indicate that after meal blood sugar shouldn’t ever go over 180 mg/dL (10.0 mmol/L), the committee states that they would define high blood sugar starting at that point.

Changing Definitions to Keep Up With Patients?

It’s appropriate to clarify that this definition seems to be largely informed by the majority of patients with diabetes and not by what is deemed healthy in persons with no diabetes.

In other words, no matter what we call a blood sugar level of just under 180 mg/dL (10.0 mmol/L), the body will not discern between how hard it is to achieve a lower blood sugar and the damage that is known to be incurred through an elevated blood sugar.

The chronic and serious condition of type 2 diabetes is diagnosed with a fasting blood sugar of only 126 mg/dL (7 mmol/L) or higher on two separate tests, according to the Mayo Clinic. Some diabetes complications have been shown to occur with only slightly elevated blood sugar levels.

Is it a good idea to define high blood sugar differently for those with diabetes? Could this information be used by people with diabetes as a guide for their blood sugar goals? Would this be like the hypothetical example of telling an overweight person they’re not overweight if the definition of “overweight” has been changed due to a majority obese population?

Level 2 Hyperglycemia

Level 2 hyperglycemia is considered as “very elevated glucose as defined by a glucose concentration of >250 mg/dL (13.9 mmol/L).”

The committee states that over these levels, a patient’s risk for DKA is increased and the A1c levels associated with that glucose level are linked to a “high likelihood of complications”.

They write in their report that this definition “allows for the assessment of the ability of therapies and technologies to provide better glucose outcomes and to limit exposure to level 1 and level 2 hyperglycemic blood glucose values,” and that the definition is basically intended to apply to those with type 1 diabetes at any point of the day.

BG Levels

More Research Needed

The committee explains that we need more research in order to improve our understanding of how an individual high blood sugar vs sustained high blood sugar affects a person with diabetes over time.

They write that we could also use more research to improve our knowledge regarding to ties between high blood sugar and microvascular disease and other complications as well as ” the role of genetic factors and a patient’s ability to recognize when hyperglycemia is occurring”.

Hyperglycemia associated with slowed brain matter growth in young children with type 1 diabetes

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Continued exposure to hyperglycemia could be detrimental to brain development in young children with type 1 diabetes, with slower brain matter growth over time compared with children without the condition, according to research published in Diabetes.

Nelly Mauras, MD, of Nemours Children’s Clinic, Jacksonville, Florida, and colleagues from the multicenter Diabetes Research in Children Network (DirecNet), detected differences in total and regional growth in brain areas involved in complex sensorimotor processing and cognition.

Nelly Mauras

Nelly Mauras

“We have been keenly interested in the role of abnormal glucose levels on diabetes complications; the younger the children are when they get diabetes, the more we worry about their complications,” Mauras told Endocrine Today. “Hyperglycemia is potentially damaging to the developing brain.”

Changes in matter, not cognition

The researchers longitudinally assessed gray and white matter volume in children aged 4 to 9 years with type 1 diabetes (n=144; average duration, 2.5 years) and without (n=72); one-fourth of the control group were siblings of the patient group.

All children underwent unsedated high-resolution structural brain MRIs at baseline and 18 months, Mauras said. “Using state-of-the-art software, the imaging coordinating center at Stanford was able to compartmentalize the brain images into different gray and white matter regions..”

Comprehensive age-specific neurocognitive testing was done at the same time points, Mauras explained. “We performed tests on their IQ, memory, cognition and mental processing skill — basically their ability to reason.”

For patients with type 1 diabetes, continuous glucose monitoring (6 days, adding up to 1,440 blood glucose readings per patient per day) and HbA1C measurements were performed every 3 months over the course of the study, she said.

“We found the rate of brain growth, both for gray and white matter, was slower in children with diabetes than that of healthy age-matched controls,” Mauras said.

Gray matter areas, including left precuneus, right temporal, frontal and parietal lobes, and right medial-frontal cortex, showed less growth in patients with diabetes. White matter areas, including splenium of the corpus callosum, bilateral superior-parietal lobe, bilateral anterior forceps and inferior-frontal fasciculus, also showed slower growth in children with diabetes.

No between-group differences were observed in cognitive and executive functions scores at 18 months.

“These differences in the brain that affect a multiplicity of processing functions were not accompanied by changes in cognition, which is good news,” Mauras said. “But the fact that marked differences were seen gives us some concern.”

Unanticipated findings

The observed changes in brain matter were associated with higher cumulative hyperglycemia and glucose variability; they were not linked with hypoglycemia, which Mauras said could be due to the paucity of hypoglycemic events during the study.

Based on previous knowledge that brain development problems are more likely when children are diagnosed at younger ages and exposed to more hypoglycemia, a main concern until now has been avoiding low blood glucose.

“We often let the blood sugars run on the high end by decreasing the amount of insulin we give these youngsters or feeding them more, so we avoid hypoglycemia altogether,” Mauras said.

“We anticipated the greatest association was going to be with hypoglycemia incidence, but we found it was actually hyperglycemia that showed the greatest association with these brain findings.”

The DirecNet investigators called the findings “remarkable” because the patient age group was so young and the period with diabetes so short; Mauras said providers have generally believed, and told parents, it takes at least 10 years to develop diabetes complications.

“The study participants were just diagnosed within a 3-year timeframe, which is a relatively short duration for the disease to show structural brain changes,” Karen Winer, MD, of the National Institute of Child Health and Human Development (NICHD), an investigator on the study, told Endocrine Today.

Karen Winer

Karen Winer

With four papers published earlier in 2014 demonstrating detailed differences in brain structure between the cohorts with diabetes and controls, the DirecNet investigators  have received an NIH grant, through NICHD, to continue following the children longitudinally over the next 5 years.

“Is the brain ‘plastic?’ Does it recover? Does it get worse?” Mauras asked. “How do these cognitive tests change over time, now that these kids are getting older and progressing through puberty?” — by Allegra Tiver

Hospital Admissions for Hypoglycemia Now Exceed Those for Hyperglycemia in Medicare Beneficiaries.

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We were pleased to read the recent Centers for Disease Control and Prevention report1 that myocardial infarction, stroke, and hyperglycemia rates have been reduced for patients with diabetes mellitus. However, Lipska et al2 inform us that during the same time period, from 1999 to 2011, the opposite trend is occurring for hypoglycemia, and rates of hospital admissions for hypoglycemia have risen by 11.7% in US Medicare beneficiaries. In fact, there were 40% more admissions for hypoglycemia than for hyperglycemia over the 12-year period. The 1-year mortality rate after a hypoglycemia admission was higher (22.6%) than the rate after a hyperglycemia admission (17.6%) in 2010. Our patients are now more likely to experience adverse events related to overtreatment of diabetes mellitus. Striving for too low a hemoglobin A1c target level puts patients at risk for this dangerous adverse effect.

 

http://archinte.jamanetwork.com/Mobile/article.aspx?articleID=1871565&utm_source=dlvr.it&utm_medium=facebook&utm_campaign=feed_posts

From the desk of Zedie.

Certain Antibiotics Tied to Blood Sugar Swings in Diabetics.

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Diabetes patients who take a certain class of antibiotics are more likely to have severe blood sugar fluctuations than those who take other types of the drugs, a new study finds.

The increased risk was low but doctors should consider it when prescribing the class of antibiotics, known as fluoroquinolones, to people with diabetes, the researchers said. This class of antibiotics, which includes drugs such as Cipro(ciprofloxacin), Levaquin (levofloxacin) and Avelox(moxifloxacin), is commonly used to treat conditions such as urinary tract infections and community-acquired pneumonia.

One expert said the study should serve as a wake-up call for doctors.

“Given a number of alternatives, physicians may consider prescribing alternate antibiotics … in the place of fluoroquinolones (particularly moxifloxacin) to patients with diabetes,” said Dr. Christopher Ochner, assistant professor of pediatrics and adolescent medicine at the Icahn School of Medicine at Mount Sinai, in New York City. “In general, this study demonstrates that closer attention needs to be paid to particular drug-condition interactions.”

The study included about 78,000 people with diabetes in Taiwan. The researchers looked at the patients’ use of three classes of antibiotics: fluoroquinolones; second-generation cephalosporins (cefuroxime, cefaclor, or cefprozil); or macrolides (clarithromycin or azithromycin).

The investigators also looked for any emergency-room visits or hospitalizations for severe blood sugar swings among the patients in the 30 days after they started taking the antibiotics.

The results showed that patients who took fluoroquinolones were more likely to have severe blood sugar swings than those who took antibiotics in the other classes. The level of risk varied according to the specific fluoroquinolone, according to the study, which was published in the journal Clinical Infectious Diseases.

The incidence of hyperglycemia (high blood sugar) per 1,000 people was 6.9 for people taking moxifloxacin, 3.9 for levofloxacin and 4.0 for ciprofloxacin. The incidence of hypoglycemia (low blood sugar) was 10 per 1,000 for moxifloxacin, 9.3 for levofloxacin and 7.9 for ciprofloxacin.

The incidence of hyperglycemia per 1,000 people was 1.6 for those taking the macrolide class of antibiotics and 2.1 for those on cephalosporins. The incidence of hypoglycemia per 1,000 people was 3.7 for macrolides and 3.2 for cephalosporins.

“Our results identified moxifloxacin as the drug associated with the highest risk of hypoglycemia, followed by levofloxacin and ciprofloxacin,” wrote Dr. Mei-Shu Lai, at National Taiwan University, and colleagues.

They said doctors should consider other antibiotics if they have concerns that patients might experience severe blood sugar swings.

“The study … does not prove a causal connection between particular fluoroquinolones and blood sugar dysregulation,” Ochner said. But he believes that it provides evidence that people with diabetes may be at special risk from moxifloxacin in particular.

“If moxifloxacin is to be prescribed to diabetic patients, there should be some additional expected benefit that justifies the increase in incurred risk,” Ochner said.

But another expert said there could be other explanations for why people on fluoroquinolones had more blood sugar fluctuations.

“It is hard to draw conclusions that fluoroquinolones themselves are the culprit, as all of these patients had infections, and infection can lead to hypo- or hyperglycemia in persons with diabetes,” said Dr. Alyson Myers, an endocrinologist at North Shore University Hospital in Manhasset, N.Y.

“In addition, those in the fluoroquinolone group were more likely to have chronic kidney disease or steroid use – the former can increase rates of hypoglycemia and the latter can increase rates of hyperglycemia,” Myers said. “Another confounding factor would be the type of diabetes treatments that patients were receiving, as sulfonylureas and insulin are both associated with greater risks of hypoglycemia than other diabetes medications.”

Source: Drugs.com

Fluoroquinolones Up Risk for Severe Dysglycemia in Diabetes.

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A new nationwide cohort study has shown that patients with diabetes who use oral fluoroquinolone antibiotics are at greater risk for severe dysglycemia than those using other antibiotics.

And although the risk was low — hyperglycemia or hypoglycemia related to fluoroquinolones occurred in fewer than 1 in 100 patients studied in the trial in 78,000 diabetics — doctors should still exercise caution, say Hsu-Wen Chou, MS, from the National Taiwan University, Taipei, and colleagues in their paper published onlineAugust 15 in Clinical Infectious Diseases.

The risks also appear to vary according to the type of fluoroquinolone antibiotic used, and 1 in particular, moxifloxacin (Avelox, Bayer), appears to most increase the likelihood of hypoglycemia, an effect that is heightened among patients receiving concomitant insulin or sulfonylurea treatment, coauthor Wang Jiun-Ling, MD, from I-Shou University and E-Da Hospital, Kaohsiung, Taiwan, told Medscape Medical News.

“Clinicians should consider hypoglycemic risks when treating diabetic patients with infection and prescribe fluoroquinolones cautiously,” said Dr. Wang. “If patients have a higher risk of hypoglycemia or develop hyper- or hypoglycemia during fluoroquinolone use, another class of antibiotic — such as beta-lactam or macrolide — should be considered.”

And patients should also be made aware of the risks, he added. “Those with diabetes who need to take fluoroquinolones should better understand the signs and symptoms of hypoglycemia and check blood glucose where necessary.”

Those With Renal Disease Also at Greater Risk

Dr. Chou and colleagues explain in their paper that fluoroquinolones, used to treat urinary-tract infections and community-acquired pneumonia among other things, are being increasingly prescribed because of their broad spectrum of action. But this greater use has spawned concerns regarding rare but severe adverse effects, which include tendon rupture, QT-interval prolongation, and dysglycemia.

In fact, one fluoroquinolone antibiotic, gatifloxacin (Tequin, Bristol-Myers Squibb), was already withdrawn from the US market in 2006 due to the risk for severe dysglycemia. However, there are insufficient data describing the likelihood of dysglycemia with other fluoroquinolones, they say.

Using the claims database for Taiwan’s national insurance program, the researchers analyzed data from 78,433 outpatients with mostly type 2 diabetes who had received a new prescription for an antibiotic from January 2006 to November 2007.

The antibiotics were divided into 3 classes: fluoroquinolones (levofloxacin, ciprofloxacin, or moxifloxacin); second-generation cephalosporins (cefuroxime, cefaclor, or cefprozil); or macrolides (clarithromycin or azithromycin).

A “study event” was defined as an emergency-department visit or hospitalization for dysglycemia among these patients within 30 days of the start of their antibiotic therapy.

Diabetic patients using oral fluoroquinolones faced greater risk for severe dysglycemia than those using antibiotics in other classes.

After multinomial propensity score adjustment, the odds ratio for hyperglycemia was 1.75 for levofloxacin, 1.87 for ciprofloxacin, and 2.48 for moxifloxacin compared with use of macrolides.

For hypoglycemia, the adjusted odds ratios (AORs) were 1.79, 1.46, and 2.13 for the same drugs, respectively, compared with macrolides.

This adverse effect was also more likely to occur in patients who suffered from comorbid kidney disease as well as those who were concomitantly treated with insulin or sulfonylureas, the researchers note.

“Our results showed a class effect regarding increased risk of severe dysglycemia among diabetic patients administered fluoroquinolones in Taiwan. Hypoglycemic risk varied according to the specifics of each drug and was most commonly associated with moxifloxacin. Clinicians should consider these risks when treating patients with diabetes and prescribe fluoroquinolones cautiously,” they conclude.

Sourrce: Medscape.com

 

 

Source: http://www.sciencedirect.com

 

Fluoroquinolones Linked to Dysglycemia in Patients with Diabetes.

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Fluoroquinolones are associated with increased risk for both hyperglycemia and hypoglycemia among patients with diabetes, compared with other antibiotics, according to a study in Clinical Infectious Diseases.

Researchers in Taiwan used national insurance claims data to identify roughly 78,000 outpatients with diabetes who received a new prescription for an oral antibiotic.

Within 30 days of starting the antibiotic, patients taking moxifloxacin, levofloxacin, or ciprofloxacin had 1.75 to 2.48 times the risk for hyperglycemia-related emergency department visits or hospitalizations, relative to patients taking macrolides. Risks were similarly elevated for episodes of hypoglycemia. Moxifloxacin was associated with the highest risk for dysglycemia.

The authors conclude: “Clinicians should consider these risks when treating patients with diabetes and prescribe fluoroquinolones cautiously.”

Source: Clinical Infectious Diseases article

HKDC1, BACE2 could predict gestational diabetes before pregnancy.

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Data collected from the Hyperglycemia and Adverse Pregnancy Outcomes Study have led researchers to identify variants in two novel genes which they said are associated with measures of glucose and insulin levels among pregnant women.

 “With additional study and verification of these and other risk genes, we could one day have genetic risk profiles to identify individuals at elevated risk for developinggestational diabetes,” M. Geoffrey Hayes, PhD, from the division of endocrinology, metabolism, and molecular medicine at Northwestern University Feinberg School of Medicine, said in a press release.

 

Hayes and colleagues conducted a discovery genome-wide association study in a large cohort of pregnant mothers from various ancestries from the Hyperglycemia and Adverse Pregnancy Outcomes Study (n=4,437). The women were administered an oral glucose tolerance test at approximately 28 weeks gestation to determine genetic loci linked to measures of maternal metabolism, researchers wrote.

The researchers identified two novel genome-wide significant associations in glucose metabolism and HKDC1 and insulin secretion and BACE2 within two genes. Researchers wrote that these data suggest the genes’ underlying roles could play a significant role in hypoglycemia during pregnancy compared with women who are not pregnant.

“Together with the results of earlier studies, our findings suggest that the roles of HKDC1 in glucose metabolism and BACE2 in insulin secretion are more important during pregnancy than in the nongravid state,” researchers wrote.

Source: Endocrine Today

 

Intensive insulin for type 2 diabetes: the risk of causing harm.

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The ACCORD study showed that aggressive intensification of glycaemic control in patients with type 2 diabetes can increase mortality (hazard ratio [HR] 1·22, 95% CI 1·01—1·46), including death from cardiovascular causes (1·35, 1·04—1·76).1 The reason for this unexpected finding is unknown. Of note was the high percentage of intensively treated patients receiving insulin therapy (77%) or thiazolidinedione therapy (with or without insulin) (92%), and their greater weight gain (3·5 kg vs0·4 kg).1 Results of post-hoc analyses did not support the hypothesis that increased hypoglycaemia in patients who were intensively treated caused the excess deaths.2 The analyses showed, however, that a higher baseline HbA1c and a failure to improve average HbA1c throughout the study were linked to the increased mortality.3

In view of the findings of the ACCORD study, we propose that development of insulin resistance in crucial tissues such as the heart is a protective response to persistently raised glucose concentrations. We postulate that overriding insulin resistance in attempts to lower glucose with exogenous insulin—particularly in overweight and obese patients with the most refractory hyperglycaemia—could undo this protection and cause harm.

For decades the dogma has been that insulin resistance is mostly pathological. However, regulation of insulin sensitivity is an integral component of normal metabolic physiology, including, at times, the induction of insulin resistance. For example, in response to even short-term overfeeding, skeletal and cardiac muscle develops insulin resistance,4 which promotes diversion of excess nutrients to adipose tissue for safe storage. We, and others, have proposed that this induction of insulin resistance protects important tissues from nutrient-induced dysfunction.5

The myocardium, with its high energy needs, adapts to the predominant nutrient source, which is free fatty acids (FFA) during fasting and glucose in the fed state. In poorly controlled type 2 diabetes, the reciprocal relationship between FFA and glucose is lost and both are simultaneously raised. This places the myocardium at increased risk of nutrient overload and myocardial glucolipotoxicity.5, 6 We propose, however, that insulin resistance is a safeguard against glucolipotoxicity because it limits myocardial glucose uptake. Treatment of patients with the most refractory hyperglycaemic and hyperlipidaemic type 2 diabetes with large amounts of exogenous insulin could override this block against glucose entry, providing all the ingredients for glucolipotoxicity,6 a process that we have termed insulin-mediated metabolic stress. In the heart, this process would cause a metabolic cardiomyopathy. Jagasia and colleagues7 provided evidence that insulin resistance is easier to override in the myocardium than in skeletal muscle in patients with type 2 diabetes. Exogenous insulin tripled myocardial glucose uptake without compensatory reduction in FFA uptake,7 which is consistent with the capacity of exogenous insulin to drive excess nutrients into the heart. If the same mechanisms of insulin-mediated metabolic stress can function in skeletal muscle, inappropriate high-dose insulin use in patients with type 2 diabetes could also induce a metabolic myopathy that impairs the patient’s ability to exercise.

If our proposition is correct—that intensive treatment of type 2 diabetes with insulin is potentially harmful to overweight and obese patients with the most refractory hyperglycaemia—there should be support for it in clinical trials. In the major trials of intensive versus conventional glucose control, and insulin versus other glucose-lowering therapies, whenever high use of insulin was associated with weight gain of greater than 1 kg per year (ACCORD,1 VADT,8 DIGAMI-29), cardiovascular or all-cause mortality, or both, were increased, reaching statistical significance only in the higher powered ACCORD study. UKPDS, ADVANCE, and ORIGIN did not show increased cardiovascular disease or mortality in the intensive control or insulin therapy groups. However, the patient characteristics and the aggressiveness of insulin use differed greatly from those in ACCORD. Careful analysis showed that UKPDS, ADVANCE, and ORIGIN were not studies of intensive insulin use in obese patients with the most refractory hyperglycaemia. While results of population-based studies have shown increased risk of mortality in patients with type 2 diabetes treated with insulin, they are observational and should be interpreted with caution.10

Patients with type 2 diabetes should be considered individually, because their relative need for insulin resistance as a protective mechanism and the potential for long-term benefit from tight blood glucose control will differ. For example, an overweight individual with type 2 diabetes unable to exercise because of comorbidities will have much more difficulty achieving lifestyle change to overcome a state of positive energy balance (figure). In these patients, insulin resistance might be necessary to protect crucial tissues such as the heart and skeletal muscle against excess nutrient entry. An aggressive approach to lower blood glucose with insulin will override this protection, increasing the risk of insulin-mediated metabolic stress in these key tissues (figure). Furthermore, these patients are least likely to be able to adequately achieve lower HbA1cconcentrations—the group that was at highest risk in ACCORD.3 Careful amelioration of very high blood glucose, however, will be necessary in these individuals. At the other end of the spectrum, a patient with type 2 diabetes who can avoid positive energy balance by lifestyle change will be at much lower risk of the harmful consequences of an aggressive approach to glucose lowering with insulin.

The safety of insulin sensitisers is probably associated with the mechanism by which they work. Those that enhance nutrient detoxification should be beneficial. Such agents are very different from insulin in that they reduce and do not override insulin resistance. Metformin and thiazolidinedione drugs both have mechanisms of action that include nutrient detoxification.5 The development of new insulin sensitisers that do not have a nutrient detoxification mechanism might not be advisable.

Further studies of the effect of insulin therapy on myocardial and skeletal muscle nutrient uptake, storage, and function in obese patients with type 2 diabetes are necessary to further explore the concept of insulin-mediated metabolic stress. Ultimately, carefully designed randomised clinical trials with long-term outcome data will be necessary to assess the safety of insulin therapy, and how best to use it, in obese patients with type 2 diabetes who do not achieve acceptable glycaemic control by other therapies. The results of the ACCORD study suggest that the combination of insulin with thiazolidinedione agents should be used with considerable caution.1 The use of insulin in combination with newer agents that avert positive energy balance, such as the glucagon-like peptide 1 mimetics, warrants particular attention in this challenging group of patients.

Source: Lancet

 

New Position Statement for Managing Type 2 Diabetes.

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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.

Source: Journal Watch General Medicine