Consider The Evidence: Med/Peds Journal Roundup

January 3, 2010

Insulin v. Triple oral therapy for DM

Filed under: diabetes — medblog @ 12:21 pm

Diabetes Care 12/23/09 –   “Insulin is the most effective hypoglycemic agent in our treatment armamentarium and is now recommended by the American Diabetes Association (ADA) guidelines as the second agent added after metformin” (FTA). Despite this fact (or because some of us were unaware of this guideline), physicians often prefer to max out that second and third oral medication before turning to insulin. An article in Diabetes Care looks at a comparison between a three drug regimen and insulin + metformin for newly diagnosed DM.

The study compared 2 groups of 29 subjects that were newly diagnosed diabetics (not a very large study). All patients had a 3 month lead-in with insulin (novolog 70/30 bk, ln) and metformin. The lead-in ensured that all subjects had controlled blood sugar when starting the comparison phase, and all were exposed to insulin administration. Subjects were then randomized to receive metformin + glyburide + pioglitazone or to continue metformin and insulin. Groups were compared on A1C, Quality of Life, and treatment satisfaction.

They found that A1C was similar in both treatment groups. But I think the other endpoints were just as, if not more important to the relevance of the study.   Weight gain, quality of life, and compliance are major factors that sway physician and patient choices on when to start insulin.

The study showed that the weight difference was not significant in the 2 groups – however looking at the raw numbers weight increased by about 4kg in the insulin group and about 7kg in the oral group. This seems like a big difference to me to end up being statistically insignificant. The CI was 0.89 – 8.04kg so I really wonder if the study was adequately powered to look at this. QoL and patient satisfaction were similar in the 2 groups, however I wonder if the patients that really had a problem with insulin were lost during the lead-in period. No information was provided about drop out during the lead-in time and the study ends up being selective for those patients that tolerated a 3 month period on insulin and agreed to enter the study, so I think there is a selection bias going on here.

Overall I think the study shows for those patients with new onset DM that need initial insulin to get them under control, there is little point to switching them back to orals if they are going to require 3 medications. The more perplexing scenario, however, is those patients that the physician believes does not necessarily need insulin as initial therapy but for which insulin or triple oral therapy may be options. And this study does not really address that because all patients were put on insulin for 3 months prior to study onset.

Diabetes Care October 2009 vol. 32 no. 10 1789-1795

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November 20, 2006

Thiazides increase Diabetes, ALLHAT says dont worry

Filed under: archives of internal medicine, diabetes, hypertension — medblog @ 11:08 pm

Archives IM 11/13- ALLHAT data first made news with the conclusion that older, thiazide type diuretics were just as effective at reducing hypertension related disease as newer types of anti-hypertensives. One result of the study that is less well known is that thiazides appeared to increase the risk of incident diabetes. In the last issue of Archives, the ALLHAT investigators addressed this issue more directly.[Article]

The investigators performed post hoc analyses on the subgroups assigned to Ca-channel blockers, ACE-Is, and thiazides. Patients with known diabetes prior to start of therapy were excluded from analysis, as were those without baseline fasting blood glucose(FG) levels.

The data shows that all subjects had an increase in FG, but the thiazide group had a significantly greater increase in fasting glucose levels than the other groups. In addition, subjects in the thiazide group had significantly greater odds of developing diabetes.

Is this a problem? The investigators state that the increase in DM did not result in a greater rate of adverse events compared to the other groups. Are they trying to sweep the issue under the rug? Or are they postulating that the diabetic state induced by thiazides is less malignant than naturally occuring DM? Adverse events data was only 2 years out – not long enough to show effects from new onset DM. The increased risk may have also been partially washed out by the increase in DM among all groups, and the lack of comparison with placebo. I’m not sure I would dismiss the risk as easily as they suggest – but I guess I dont have to worry about grant money…

With both beta-blockers and thiazides being linked to decreased glucose tolerance, the choice of anti-hypertensives is becoming much more complicated.

July 10, 2006

Decaf Drinkers Deftly Dodge Diabetes

Filed under: archives of internal medicine, caffeine, Coffee, diabetes, diet — medblog @ 11:02 am

ArchivesIM 5/26 – While there has been some recent controversy over the risks and benefits of coffee consumption for diseases such as diabetes and MI, the exact cause for these effects is unknown.

In the current Archives, Pereira et al. present further investigation of this phenomenon using data from an 11-year, 28,000 patient observational trial of post-menopausal women. They found a significant inverse relationship between coffee consumption and incidence of diabetes. In the most comprehensively adjusted model, the results were only significant for decaf drinkers. Unfortunately for the majority, the difference in this model was only significant for drinkers of 4-5, and 6+ cups a day.

Now if they can only explain the purpose of drinking decaf coffee at all, let alone more than six cups of it per day??

February 13, 2006

R.I.P. Physical Exam

Filed under: diabetes, NEJM, physical exam, public health — medblog @ 1:46 pm

NEJM 2/9 – This weeks New England has a couple of interesting editorials on the dying art of the physical exam and whether the golden age of the stethoscope is over?

Public Health departments are not just for tracking STDs anymore… an article by Steinbrook describes the NYC effort to require mandatory electronic reporting of HBA1c levels this year. I, for one, hope this is the start of a trend.

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