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30 Things You Should Know About Managing Diabetes. Diabetes Forecast. 61(4): 54-56. April 2008.

This article presents some common issues that are important for managing diabetes by grouping them into brief suggestions or reminders in six sections: insulin; blood glucose monitoring; hypoglycemia and hyperglycemia; medications; kidney complications, or diabetic nephropathy; and eye complications, or diabetic retinopathy. The author presents this information in a brief, easy-to-read format, to bring readers up to date and to prevent being overwhelmed with the mass of information that is available on diabetes. Specific topics covered include the use of insulin in type 2 diabetes, insulin storage, blood glucose meter accuracy, health insurance coverage for test strips, the importance of written records, how to treat hyperglycemia, how to treat hypoglycemia, symptoms, different types of medications available for type 2 diabetes, individual responses to medication, the role of a pharmacist, why kidneys get damaged by diabetes, recommended screening tests for kidney function, blood pressure control, annual screening for eye problems, and the role of cholesterol.

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American Diabetes Association: Clinical Practice Recommendations 2008. Diabetes Care. 31(Suppl 1): S1-S110. January 2008.

This special supplement issue of Diabetes Care journal contains the latest update of the American Diabetes Association’s (ADA) major position statement, “Standards of Medical Care in Diabetes.” The position statement contains all of the ADA’s key recommendations, including national standards for diabetes self-management education (DSME). This special issue presents selected position statements about certain topics not adequately covered in the standards. These topics are the diagnosis and classification of diabetes mellitus, nutrition recommendations and interventions for diabetes, diabetes care in schools and daycare settings, diabetes management in correctional institutions, hypoglycemia and employment or licensure, third-party reimbursement for diabetes care, self-management education, and supplies. A brief summary of the revisions made for the 2008 clinical practice recommendations begins the special supplement, followed by a more detailed executive summary of the changes. The publication includes a list of technical reviews, a list of committee reports and consensus statements, and a list of position statements.

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Beating the Lows: What You Need to Know About Hypoglycemia. Diabetes Forecast. 61(2): 29-30. February 2008.

This article helps readers newly diagnosed with diabetes to understand hypoglycemia, the condition of low blood glucose levels. The author reviews the causes, symptoms, treatment, and prevention of hypoglycemia, focusing on practical approaches to everyday activities and diabetes care. Blood glucose levels can drop too low when a person with diabetes exercises longer or harder than usual, eats too little, delays a meal, eats too few carbohydrates, mistakenly takes too much insulin, or drinks alcohol on an empty stomach. Combinations of insulin, sulfonylureas, or meglitinides with other diabetes pills and injectable drugs carry a risk of hypoglycemia. Symptoms of hypoglycemia can include nervousness, shakiness, hunger, lightheadedness, sweating, irritability, impatience, chills, sleepiness, nausea, and confusion or other unusual behavior. The author briefly describes hypoglycemia unawareness, which can happen in a person who experiences repeated episodes of hypoglycemia. This occurs more often in people who practice tight diabetes control. Readers are encouraged to test their blood glucose levels as soon as they feel the symptoms of a potential episode of hypoglycemia. To counter mild-to-moderate hypoglycemia, patients should eat or drink something containing 15 grams of carbohydrate, wait 15 minutes, and test their blood glucose again. This pattern can be repeated if needed. The article concludes with a list of suggestions that can help prevent hypoglycemia. 1 figure.

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Blood Glucose Monitoring: A Practical Guide for Use in the Office and Clinic Setting. Diabetes Spectrum. 21(2):100-111. Spring 2008.

This article describes a method for evaluating and interpreting self-monitoring of blood glucose (SMBG) results in the office and clinic setting. The authors contend that such interpretation in the presence of patients may facilitate improved patient-provider discussion, clinical decisions, and the ability to manage glycemic patterns. They outline key steps that should be included in a systematic review of SMBG data: identifying the degree of blood glucose control using mean and standard deviation or variance, identifying patient safety concerns with regard to hypoglycemia, understanding the factors influencing blood glucose control by noting trends and patterns, suggesting strategies for achieving improved blood glucose control, and providing reinforcement to patients with diabetes that this information is valuable and useful in their care. Specific topics include patient records and logbook reviews, meter memories and computation, meter downloads and analysis, problems with basal glucose control, problems with prandial glucose control, frequency of testing, and continuous glucose monitoring (CGM). The article includes case studies that illustrate the process for using and interpreting electronic SMBG downloads. One chart summarizes selected diabetes management software programs. 5 figures. 4 tables. 17 references.

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Case Study: Conception as a Potential Consequence of Diabetes Treatment. Clinical Diabetes. 26(2): 83-84. Spring 2008.

This article presents a case report of a 45-year-old caucasian woman with a medical history of type 2 diabetes, polycystic ovarian syndrome (PCOS), hypertension, and gastroesophageal reflux disease. She had a history of one normal, healthy pregnancy and delivery without complication. The authors describe her clinical care, notably the antihyperglycemic medications, including pioglitazone, which has a potential effect of increasing fertility in women with PCOS. The authors review the patient’s nonadherence to some of the antihyperglycemic agents, her concerns about hypoglycemia, patient education needs, her unexpected pregnancy, and the changes in medications that were required as a result of the pregnancy, notably, weaning off the analgesics that were prescribed for her neuropathic pain. The patient experienced a miscarriage at approximately 8 weeks’ gestation, after which she expressed interest in attempting another pregnancy. She was encouraged to improve her glycemic control and blood pressure before attempting another pregnancy. The authors describe the relationship between PCOS and insulin resistance, the mechanisms by which metformin and thiazolidinediones increase fertility in women with PCOS, and the importance of preconception care in all women with diabetes. Tight glycemic goals should be met before conception to reduce the risks of spontaneous abortions and fetal malformations. Medication alterations to improve safety during pregnancy should include discontinuation of oral hypoglycemic agents, statins, and angiotensin-converting enzyme (ACE) inhibitors. 9 references.

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Choosing an Insulin Regimen for Patients With Type 2 Diabetes. Clinical Diabetes. 26(2): 63-64. Winter 2008.

This article reports on a randomized, controlled study undertaken to compare three insulin regimens used for patients with type 2 diabetes: biphasic insulin aspart twice daily, prandial insulin aspart three times daily, or basal insulin detemir once daily—with the option of using twice daily if needed. Participants were 708 adult patients (64 percent male), with a mean age of 61.7 years, with type 2 diabetes, glycosylated hemoglobin (A1C) levels between 7 and 10 percent on oral hypoglycemic drugs, and a willingness and ability to inject insulin and perform self-monitoring of blood glucose (SMBG). Patients were recruited from 58 clinical centers in the United Kingdom and Ireland. After 52 weeks, the mean A1C was 7.3 percent for the biphasic insulin group; 7.2 percent for the group on prandial insulin; and 7.6 percent for basal insulin. Few patients achieved an A1C of less than 6.5 percent. Hypoglycemia was experienced more in the biphasic and prandial groups than in the basal insulin group; no severe hypoglycemia occurred. This article summarizes these research results, referring readers to the original publication of the study (Holman et al., New England Journal of Medicine, volume 357, 2007). The author provides a commentary about this study, supporting the work that helps clinicians determine appropriate insulin regimens for their patients with type 2 diabetes. The author cautions that the outcomes obtained in clinical care may differ from those achieved in the research setting, which included more structured patient assessment and follow-up. 2 references.

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Combined Therapy with Insulin Plus Oral Agents: Is There Any Advantage? An Argument in Favor. Diabetes Care. 31(Suppl 2): S125-S130. February 2008.

This article, from a special supplement of Diabetes Care magazine that reports the proceedings of the 1st World Congress on Controversies in Diabetes, Obesity, and Hypertension (CODHy) held in Berlin in 2006, considers the use of combined therapy with insulin plus oral agents for patients with type 2 diabetes. The authors describe an argument in favor of combined therapy in a recent debate examining the advantages and limitations of this approach. They describe the pharmacologic rationale for combining agents, present some new physiologic evidence for combining an oral agent with insulin, and offer a few examples of clinical studies showing advantages of combined therapy over insulin used alone. The authors conclude that, when oral therapy is continued during insulin therapy, enhancing either the availability or effectiveness of endogenous insulin, glycemic stability may improve and may lead to better overall glycemic control with similar hypoglycemic risk, or equal glycemic control with less hypoglycemia. In the case of metformin, combination with insulin limits the risk of weight gain. The authors call for additional, longer term medical outcome studies that compare insulin alone with insulin plus oral therapy. 5 figures. 28 references.

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Continuous Glucose Monitoring: The Future of Diabetes Management. Diabetes Spectrum. 21(2):112-119. Spring 2008.

This article brings readers up to date on continuous glucose monitoring (CGM), technology used to provide real-time information about interstitial fluid glucose levels as part of a diabetes management plan. CGM provides short-term feedback about the effectiveness of diabetes interventions such as insulin administration, and it provides warnings when glucose concentrations become dangerously high or low. The authors stress that CGM has made the attainment of near-normal blood glucose concentrations an achievable goal for most patients with diabetes. However, they note that several challenges remain to be addressed, including the high cost of the devices, limitations in approved clinical uses, and insurance coverage for the technology. The article reviews the strengths and weaknesses of current CGM technology and provides information about how these devices can best be used in clinical practice for the care of people with diabetes. The authors conclude that CGM can offer diabetes patients a major advance in improving glycosylated hemoglobin (A1C) values and reducing the occurrence of disruptive hypoglycemia. 3 figures. 2 tables. 20 references.

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Diabetes Technology During the Past 30 Years: A Lot of Changes and Mostly for the Better. Diabetes Spectrum. 21(2): 78-83. Spring 2008.

This article offers a critical review of the changes in technology in the field of diabetes care and management, including those in glucose measurement, insulin administration, and types of insulin. The author describes the technology and equipment but focuses more on issues of patient compliance and quality of life. The author stresses that diabetes is still all-encompassing, needing attention multiple times a day, whether it’s checking blood glucose levels, calculating each meal and snack, or remaining vigilant to symptoms of hypoglycemia. Technological advances have not eased this burden of managing diabetes. Other topics addressed include parent-child relations, the members of the patient care team, attempts to match insulin dosage to food intake, the need for mathematical skills on the part of patients or parents, self-monitoring of blood glucose (SMBG), point-of-care glycosylated hemoglobin (A1C) tests, analog insulins, insulin pumps, patient selection for new technologies, and the use of continuous glucose monitoring (CGM). 5 figures. 35 references.

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Dipeptidyl Peptidase-IV Inhibitors: Pharmacological Profile And Clinical Use. Clinical Diabetes. 26(2): 53-57. Spring 2008.

This article reviews a new category of medications, the dipeptidyl peptidase-IV (DPP-IV) inhibitors, notably sitagliptin, the first DPP-IV to be approved. Sitagliptin is approved for the management of hyperglycemia in patients with type 2 diabetes; a second agent, vildagliptin, is in the approval process. The DPP-IV agents accentuate the activity of endogenously produced antihyperglycemic incretin hormones, such as GLP-1, and are generally well tolerated. The author reviews the pharmacology and clinical use of these agents. Topics include clinical trials of these drugs; side effects, contraindications, and precautions; pharmacokinetics and drug interactions; and dosage and indications. The author concludes that DPP-IV inhibitors are a safe and effective method for modestly reducing hyperglycemia in patients with type 2 diabetes, without causing weight gain, significant hypoglycemia, or other major side effects. They are given orally and can be taken in a single daily dose. 1 table. 35 references.

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