Diabetes Care Journal: RESEARCH STUDIES in FOCUS

By Liz Ho 21 Jul 09

Assessing Glycemic Control in Maintenance Hemodialysis Patients With Type 2 Diabetes

Kazempour-Ardebili, Sara et al. (UK) Diabetes Care. 32(7):1137-1142, July 2009.

OBJECTIVE: The study hypothesizes that 1) 48-h continuous glucose monitoring (CGM) provides additional,
clinically relevant, information to that provided by the A1C measurement and 2) glycemic profiles differ
significantly between day on and day off dialysis.

RESEARCH DESIGN AND METHODS: With the use of GlucoDay S, 48-h CGM was performed in 19 type 2
diabetic subjects undergoing hemodialysis to capture consecutive 24-h periods on and off dialysis. Energy
intake was calculated using food diaries. A1C was assayed by a high-performance liquid chromatography
method.

RESULTS: 17 subjects (13 male) with a mean (range) age of 61.5 years (42-79 years) and diabetes duration of
18.8 years (4-30 years) were analysed.
Dialysis Non-Dialysis
Day Day
Mean 24 hours 9.8 12.6 P=0.013
glucose (+/-3.8) (+/- 5.6)
6hr Nocturnal 9.5 12.9 P<0.05
Glucose (+/-4.4) (+/-7.0)
• 10 out of 17 had their lowest reading within 12 hours of starting dialysis
• 3 out of 17 subjects had <2.5mmol/L for 30 minutes.
• Lowest reading captured is 1.38mmol/L.
• Yet no patients reported symptoms of hypoglycemia.

CONCLUSIONS: Glucose values are significantly lower on dialysis days than on nondialysis days despite
similar energy intake. The risk of asymptomatic hypoglycemia was highest within 24 h of dialysis. Physicians
caring for patients undergoing hemodialysis need to be aware of this phenomenon and consider enhanced
glycemic monitoring after a hemodialysis session. CGM provides glycemic information in addition to A1C, which
is potentially relevant to clinical management.

Hypoglycemia and Clinical Outcomes in Patients With Diabetes Hospitalized in the General Ward.
Turchin, Alexander et al. (US) Diabetes Care. 32(7):1153-1157, July 2009.

OBJECTIVE: Study aimed to determine whether hypoglycemic episodes are associated with higher mortality in
diabetic patients hospitalized in the general ward.

RESEARCH DESIGN AND METHODS:

-- Retrospective cohort study analyzed 4,368 admissions of 2,582 patients with diabetes hospitalized in the
general ward of a teaching hospital.
-- Explore associations between the number and severity of hypoglycemic (<=3.0mmol/L) episodes and
inpatient mortality, length of stay (LOS), and mortality within 1 year after discharge.

RESULTS:
• 7.7% of admissions had hypoglycemia
• Each additional day with hypo was associated with 85.3% increase in the odds of inpatient death (P =
0.009) Odds of death within 1 year of discharge, is increased by 65.8% (P = 0.0003).
• Odds of inpatient death rose threefold for every decrease 0.5mmol/L in the lowest blood glucose
during hospitalization (P = 0.0058).
• LOS increased by 2.5 days for each day with hypoglycemia (P < 0.0001).

CONCLUSIONS: Patients with hypoglycemia have increased LOS and higher mortality both during and after
admission. Measures should be undertaken to decrease the frequency of hypoglycemia in this high-risk patient
population.
Hypoglycemia Unawareness Is Associated With
Reduced Adherence to Therapeutic Decisions in
Patients With Type 1 Diabetes: Evidence from a
clinical audit.
Smith, Charlotte B. et al. (UK)
Diabetes Care. 32(7):1196-1198, July 2009.
OBJECTIVE: Study compared adherence to treatment
changes by hypoglycemia awareness status.
Longitudinal Analysis of Depressive Symptoms
and Glycemic Control in Type 2 Diabetes.
Aikens, James E. et al. (US)
Diabetes Care. 32(7):1177-1181, July 2009.
OBJECTIVE: Compare depressive symptoms relation
to subsequent or prior glycemic control in type 2
diabetes and to test whether patient characteristics
modify these longitudinal associations.

RESEARCH DESIGN AND METHODS: Case notes of
90 type 1 diabetic patients were analyzed
retrospectively, identifying awareness status and
insulin regimens over four visits. The proportion of
patients adhering to advice and percent advice taken
were calculated.
RESULTS:
• 31 patients with hypo awareness and 19
patients with hypo unawareness were
identified.
• 74.2% in hypo awareness group and 68.4%
of hypo unawareness group had insulin
regimens
• Patients with hypo unawareness were older
(P = 0.001)
• Unaware group had longer diabetes duration
(P = 0.002)
• Unaware group had lower A1C (P = 0.007).
• They also reported severe hypoglycemia (P =
0.002)
• 87% of Aware group is adherent and only
53.8% in the Unaware group (P = 0.046))
• Aware group adherence score is 75.3
compared to 42.5 in Unaware group (P =
0.001).
RESEARCH DESIGN AND METHODS:
-- On two occasions separated by 6 months,
depressive symptoms and glycemic control were
assessed in 253 adults with type 2 diabetes.
1) Examined depressive symptoms as both a predictor
and outcome of glycemic control and
2) Explore whether medication regimen (e.g., insulin
versus oral drugs)
RESULTS and CONCLUSIONS:
• Depressive symptoms do not necessarily lead to
worsened glycemic control.
• In contrast, insulin-treated patients in poor
glycemic control are at moderate risk for
worsening of depressive symptoms.
• These patients should be carefully monitored to
determine whether depression treatment should
be initiated or intensified.

CONCLUSIONS: Reduced adherence to changes in

insulin regimen in hypoglycemia unawareness is
compatible with habituation to hypoglycemic stress.
Therapies aimed at reversing repetitive harmful
behaviors may be useful to restore hypoglycemia
awareness and protection from severe hypoglycemia.
Insulin Analogs Versus Human Insulin in the Treatment of Patients With Diabetic Ketoacidosis: A
randomized controlled trial
Umpierrez, Guillermo E. et al. (US)
Diabetes Care. 32(7):1164-1169, July 2009.

OBJECTIVE: Compare safety and efficacy of insulin analogs and human insulins both during acute intravenous
treatment and during the transition to subcutaneous insulin in patients with diabetic ketoacidosis (DKA).

RESEARCH DESIGN AND METHODS:

Patients with DKA were randomly assigned to receive intravenous treatment with regular or glulisine insulin until
resolution of DKA.
After resolution of DKA, (1) patients treated with intravenous regular insulin were transitioned to subcutaneous NPH
and regular insulin twice daily (n = 34). (2) Patients treated with intravenous glulisine insulin were transitioned to
subcutaneous glargine once daily and glulisine before meals (n = 34).

RESULTS:
• No differences in mean duration of treatment or amount of insulin infusion until resolution of DKA.
• After transition to subcutaneous insulin, no differences in mean daily blood glucose levels
• Patients treated with NPH and regular insulin had a higher rate of hypoglycemia (blood glucose
<3.9mmol/L). Fourteen patients (41%) treated with NPH and regular insulin had 26 episodes of
hypoglycemia and 5 patients (15%) in the glargine and glulisine group had 8 episodes of hypoglycemia (P
= 0.03).

CONCLUSIONS: Regular and glulisine insulin are equally effective during the acute treatment of DKA. A transition
to subcutaneous glargine and glulisine after resolution of DKA resulted in similar glycemic control but in a lower rate
of hypoglycemia than with NPH and regular insulin. IV regular insulin is still preferred as the cost is relatively
cheaper than insulin analogs.

The Second-Meal Phenomenon in Type 2 Diabetes.

Jovanovic, Ana et al. (UK) Diabetes Care. 32(7):1199-1201, July 2009.

OBJECTIVE: In health, the rise in glucose after lunch is less if breakfast is eaten. Study evaluated the second-meal
effect in type 2 diabetes.

RESEARCH DESIGN AND METHODS: Metabolic changes after lunch in eight obese type 2 diabetic subjects were
compared on 3 days: breakfast eaten, no breakfast, and no breakfast but intravenous arginine 1 h before lunch.

RESULTS:
Comparable insulin levels was observed.
Rise in plasma glucose after lunch was considerably less if breakfast had been eaten
Breakfast eaten: No Breakfast: and No Breadfast + IV Arginine 1hr: 7.88 (+/
Breakfast No Breakfast No Breakfast
+ 1hr
Arginine B4
Lunch
Rise in Plasma 0.68 (+/- 12.32 (+/- 7.88 (+/- 1.03) (P<0.0001
Glucose 1.49). 1.73) )
(mmol/L)
Plasma free fatty acid concentration at lunchtime moderately related to plasma glucose rise after lunch (r = 0.67, P
= 0.0005).