January 6, 2018 : Issue #919

• A Better Way to Diagnose and Treat Patients Than Doctors?
• Why Are We Waiting To Treat Diabetes Until A1c Reaches 6.5%?
• Randomized Controlled Trials Vs. Effectiveness Of Real-World Use Of GLP-1’s And DPP4 Therapies
• SGLT-2 Inhibitors Vs DPP-4 Inhibitors Vs. GLP1’s For Type 2 Diabetes
• There’s a New Diabetes Website in Town
  • by Sheri R. Colberg, PhD
• Exclusive: Emily Seto on mHealth Technology

When is a disease not really a disease? The answer is simple: “when the disease is diabetes.” Over the past 40 years there has been great momentum on how to change the perception. We tried lowering the target fasting levels, A1c’s and PPG values and adding new medications and monitoring devices, and slowly but surely we made some inroads.

Even with all this progress we have more patients with diabetes, and even more coming when you count prediabetes. The question is, why? Our publisher, Steve Freed, took a long look at the root causes of this failure, and as you can see in Item #2, it could be simply that we don’t take diabetes control seriously enough, and wait much too long take an aggressive stand.

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We can make a difference!

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Dave Joffe

Editor-in-chief

Have you ever used a type 2 drug as off-label use for a type 1 patient? Follow the link to share your response.

Abbott (ABT) today announced that the FreeStyle® Libre System, the company’s revolutionary new continuous glucose monitoring (CGM) system, is now available to Medicare patients, having met the codes for therapeutic CGM systems used for coverage by the U.S. Centers for Medicare & Medicaid Services (CMS). Coverage includes all Medicare patients with diabetes who use insulin and who meet the eligibility criteria.

What drugs affect glucose levels? Knowing the drugs that can affect blood glucose levels is essential in properly caring for your diabetes patients. Some medicines raise blood sugar in patients while others might lower their levels. However, not all drugs affect patients the same way.

The list includes:

Drugs that may cause hyperglycemia
Drugs that may cause hypoglycemia
Drugs that may cause hyper or hypoglycemia
Drugs that mask hypoglycemia

Make sure your patients who use insulin are aware of the following study results: 

Cold Can Affect Your Insulin:  Insulin Concentration in Vials Randomly Purchased in Pharmacies in the U.S. Can Lose Its Strength in the Cold Supply Chain

The insulin content in vials/cartridges should be 95 U/ml upon release. No independent confirmation of insulin concentration is available when purchased in the pharmacy (the end of the cold supply chain). The study quantitatively measured intact insulin in randomly acquired multidose human insulin vials by standard analytical methods. Eighteen 10 ml vials from two manufacturers (M1 and M2) were randomly acquired. The intact insulin concentration ranged from 13.9 to 94.2 U/ml, mean 40.2 U/ml. No vial met the minimum standard of 95 U/ml. These results imply the cold supply chain impacts insulin concentrations to a larger extent than anticipated. It is recommended that when starting a new container of insulin you check your blood sugars more frequently, J Diabetes Sci Technol. 2017 Dec 1:1932296817747292. doi: 10.1177/1932296817747292. [Epub ahead of print]

A noninvasive or minimally invasive blood glucose monitor is a kind of a holy grail.  Right now, there aren’t any FDA-approved noninvasive glucose trackers on the market. Not only would it be a huge upgrade in lifestyle for those with diabetes, but it could solve some of the problems with patients not following their treatment plans. Up to now every attempt to develop a non-invasive technique to measure blood sugars has failed at a cost of billions of dollars. All of those attempts have run into problems. To start, there’s not very much glucose floating around in your blood, so if you’re using something like sweat to measure glucose levels, there’s just not that much to go on. Blood sugar spills over into tears, spit, sweat, or urine if levels are too high, but as levels drop it becomes virtually undetectable without breaking the skin. Even finger prick tests can wind up with inaccurate results. And if someone has diabetes, inaccurate results could be dangerous, driving people to take insulin if they don’t need it or skip it when they do. But, this device might be the answer. The developer, Yihao Chen in China, said this device might be different. Calibrated properly, he said, the system could be suitable for medical-grade continuous glucose monitoring. Still, the study for this device was small and the research is in early stages. Much more work is needed to determine how accurate and easy-to-use this patch really is.

A 75-year-old man presents to your office with complaints of occasional mild hypoglycemia. His current antihyperglycemic regimen includes metformin and nateglinide. You would like to modify his treatment regimen to minimize his risk of hypoglycemia. Which one of the following 2-drug combinations would NOT be a suitable substitution?

A. Metformin + pioglitazone
B. Metformin + glipizide
C. Metformin + vildaglipitin
D. Metformin + exenatide

Follow the link for the answer.

Are you aware that loneliness and weak social connections are associated with a reduction in lifespan similar to that caused by smoking 15 cigarettes a day and even greater than that associated with obesity. Loneliness or social isolation takes a major toll on our health linked to the development of diabetes, hypertension, Alzheimer’s disease, and a propensity toward a premature death. In a recent study, they found that people with larger social groups receive fewer type 2 diabetes diagnoses compared to those who are socially isolated. This research shows us that promoting social interaction could prevent or even treat type 2 diabetes. Miranda Schram, an epidemiologist at Maastricht University and study co-author, noted that getting patients to increase physical activity or change their diets is difficult at best, so she decided to look at alternative strategies for intervention. So, they began a study with 2,861 patients ages 40 to 70 with diabetes, prediabetes, or normal blood sugars. Using questionnaires, they observed their social behaviors over a period of three months. What they found out was that women with normal glucose levels had, on average, 12 people in their social networks, while women with prediabetes or diabetes had fewer, about eight to 11 people. The researchers recorded similar statistically significant differences in the social networks of men with normal glucose levels and prediabetes versus men with type 2 diabetes. Women had larger social networks overall. The team found that isolated women had a 112 percent higher chance of type 2 diabetes relative to women with larger social networks, while withdrawn men were 42 percent more likely to have the disease. Men living alone had 94 percent higher odds of type 2 diabetes. Some men noted poor dietary habits at home and lacked people to encourage them to stay healthy. Medical professionals may need to start recognizing and focusing on single, socially isolated men as the most high-risk group. In contrast, women showed a slight advantage over men because of a tendency toward larger social groups. The team found women who live near their friends and have tight-knit relationships fare much better. — Journal BMC Public Health

With millions of possible drug combinations for treatment of diabetes, hypertension, hyperlipidemia and heart disease, new AI program offers more thorough analysis and options.

Getting type 2 diabetes at an early age increases risk for all diabetes complications, including death.

Why patients are not seeing results when it comes to adhering to treatment plans.

How best to decide whether to use one or a combination of the new treatments and individualize the treatment for your patients.

Stay tuned for our four-part series that will begin next week, titled “How To Overcome The Complexities of Treatment Decisions For Your Type 2 Diabetes Patients”  — A method to determine the best and the most cost effective treatment for each individual with their insurance plan, out of the millions of possibilities.

Decades ago, going to an International Diabetic Athletes Association (IDAA) meeting in 1990 helped shaped the future direction of my career in diabetes and exercise. I remember talking with people about managing blood glucose with type 1 diabetes during activities of varying types and intensities, and my interest in compiling such useful information led to my first book attempting to create a guide for exercisers with diabetes in 2001. IDAA later became the Diabetes Exercise & Sports Association (DESA), and it later combined with InsulinDependence.org. Sadly, all those organizations are now defunct, the latest casualties of money problems that many not-for-profit organizations have experienced of late.

Emily Seto is an Assistant Professor and Lead for the health informatics programs at the Institute of Health Policy, Management and Evaluation at the University of Toronto.

Quote of the Week!

“With the new day comes new strength and new thoughts.”

…Eleanor Roosevelt

Diabetes in Control gratefully acknowledges the assistance of the following pharmacy doctoral candidates in the preparation of this week’s newsletter:

Jessica Lambert, Doctor of Pharmacy Candidate 2018, USF College of Pharmacy

Kay Lynn Tran, Doctor of Pharmacy Candidate: Class of 2018; LECOM College of Pharmacy

Your Friends in Diabetes Care
Steve and Dave
Diabetes In Control
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