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VOLUME 7 NUMBER 3 • SEPTEMBER 2010
ADA WATCH
SA JOURNAL OF DIABETES & VASCULAR DISEASE
Optimising glucose control in ICU
patients reduces costs (TRIUMPH
three-year results)
Targeting lower glucose levels (9.18 mg/dl,
AACE guideline) in ICU patients has been
shown to reduce length of stay (LOS) and
ICU costs ($8 000) in the extended three-
year period of the TRIUMPH study involving
more than 11 000 patients.
The use of intensive insulin therapy (IIT)
also reduced complications and improved
outcomes. The benefit of IIT was confirmed
in this study, which compared intervention
ICUs to control ICUs, which did not apply
the intensive insulin therapy protocol.
Source: Presidents Poster, 0433-PP. Sadhu AR, Ang AC,
Ingram-Drake LA,
et al
. Length of stay – cost-savings of
intensive insulin therapy in ICU patients – 3-year results
of the TaRgeted InsUlin therapy to iMProve Hospital
outcomes (TRIUMPH) program.
VADT study: further analysis of
results shows intensive glycae-
mic control offered some renal
protection to patients with more
advanced microvascular disease
The Veterans Affairs Diabetes Trial (VADT)
in type 2 diabetes, although not able to
show reduced cardiovascular events com-
pared to average control in this further
analysis of renal outcomes, provided data
not yet published on the microvascular pro-
tection achieved by intensive control (INT).
In the VADT trial, the average age of
patients was 60 years, duration of diabe-
tes was 11 years, with HbA
1c
levels of 9.4%
at the outset of the study. With regard to
renal function, patients were excluded if
the serum creatinine was above 1.6 mg/dl.
Renal progression was evaluated in terms
of worsening urine albumin:creatinine ratio
(ACR) and sustained worsening of esti-
mated glomerular filtration rate (eGFR).
It was found that INT did not independ-
ently attenuate ACR or eGFR progression
but did retard ACR progression by 72% in
those who had photocoagulation, and by
95% in those requiring cataract surgery.
The beneficial effect of INT was also more
evident in patients with a BMI
≥
34 kg/m
2
.
In conclusion, INT had no independent
beneficial renal effect but afforded some
protection in those with more advanced
microvascular disease, lower baseline BP or
higher baseline BMI.
Source: Presidents Poster 0412-PP. Agrawal L, Azad N,
Emanuele N,
et al
. Renal outcomes in Veterans Affairs
Diabetes Trial.
VADT trial: intensive glycaemic con-
trol did not prevent progression of
calcified atherosclerosis in patients
with long-standing type 2 diabetes
The VADT trial was able to show reduced
cardiovascular events in participants with
low levels of calcified coronary athero-
sclerosis at baseline. This newly presented
study evaluated 197 patients with calcified
atherosclerosis at baseline, as measured
by CT scan and after 4.6 years in both the
intensive glycaemic-control arm and the
normal control group.
These scans showed no treatment ben-
efit of intensive versus standard therapy
with regard to either pre-existing coronary
artery calcium (CAC) or abdominal aortic
artery calcium (AAC).
Source: Presidents Poster 0405-PP. Saremi A, Anderson
RJ, Duckworth WC,
et al
. Intensive glucose lowering
therapy and progression of coronary (CAC) and
abdominal aortic artery calcium (AAC) in the Veterans
Affairs Diabetes Trial (VADT).
Once-weekly exenatide injection
improves blood sugar control more
than daily oral sitagliptin or piogli-
tazone and induces more weight
loss (DURATION-2 study)
A convenient, once-weekly injection of
exenatide in patients with type 2 diabe-
tes was more effective at improving blood
sugar control and inducing weight loss
than were either daily oral sitagliptin or
pioglitazone.
In this 26-week, randomised trial, the
patients included all had type 2 diabetes
and had been treated with metformin.
The mean baseline glycosylated haemo-
globin (HbA
1c
) concentration in the cohort
was 8.5%, the mean fasting plasma glu-
cose was 9.1 mmol/l, and the mean body
weight was 88.0 kg.
The study included patients from the
USA, India and Mexico. Patients were ran-
domly assigned to exenatide 2 mg injected
once weekly plus daily oral placebo (170
patients); daily oral sitagliptin 100 mg plus
placebo injected once weekly (172); or
daily oral pioglitazone plus placebo injected
once weekly (172). All patients continued
their metformin treatment throughout the
study.
Four hundred and ninety-one patients
received at least one dose of the study
drug and were included in the final analysis
(160 exenetide, 166 sitagliptin, 165 piogli-
tazone). Treatment with exenatide reduced
HbA
1c
by 1.5%, compared with 0.9% in
the sitagliptin group and 1.2% in the piogl-
itazone group.
Patients in the exenatide group lost on
average 2.3 kg, compared with a mean
weight loss of 0.8 kg in the sitagliptin
group and a mean weight gain of 2.8 kg in
the pioglitazone group. No major episodes
of hypoglycaemia (abnormally low blood
sugar) occurred in any group.
The most frequent adverse events with
exenatide and sitagliptin were nausea (24
and 10%, respectively) and diarrhoea (18
and 0%, respectively); while upper respira-
tory tract infection (10%) and peripheral
oedema (fluid retention/swelling in the
legs) (18%) were the most frequent events
with pioglitazone.
Source: Oral presentation, ADA
Pathogenesis of type 2
diabetes
Intramyocellular lipid accumulation
does not occur in pre-diabetes, but
only after manifestation of hyper-
glycaemia
Using prior gestational diabetes (GDM) as a
model to study early changes in the devel-
opment of type 2 diabetes, the researchers
used magnetic resonance imaging (MRI)
and MR spectroscopy to measure left ven-
tricular function and myocardial lipid accu-
mulation in the cardiac septum of women
with prior GDM with normal glucose toler-
ance, in women with prior DGM and type
2 diabetes, and controls without GDM and
with normal glucose tolerance.
There was no difference in left ventricu-
lar function between the groups except
for stroke volume, which was decreased in
women with type 2 diabetes. Also, these
women showed increased intramyocellu-
lar lipid content compared to the women
with GDM and normal glucose toler-
ance and decreased levels of high-density
lipids, which were inversely related to the
intramyocellular lipid content.
Source: Abstract ADA, 0014-OR. Winhofer Y, Krissak
M, Anderwald C,
et al
. Cardiac function and lipid
metabolism in women with prior gestational diabetes.
Insulin resistance study (IRAS)
shows problems for HBA
1c
levels as
diagnostic tool
The IRAS study of some 417 patients at
risk of developing diabetes has shown that
the 6.5 and 5.7% HbA
1c
thresholds have