By Max Bingham, PhD

The 1-h blood glucose measurement taken during an oral glucose tolerance test (OGTT) is likely a significant predictor of future type 2 diabetes, according to Pareek et al. (p. 171). The measurement is also likely to have a higher sensitivity than the 2-h value, with an acceptable specificity, for detecting patients at high risk, and it can also predict risk of diabetes complications and mortality. The prospective study focused on just under 5,000 men who were selected from prespecified birth cohorts and who underwent an OGTT with blood glucose measurements performed at 0, 1, and 2 hours. The men were then followed for up to 39 years to track incidence of type 2 diabetes and a variety of complications and mortality. The researchers report that elevated 1-h glucose measurements were associated with an increased risk of type 2 diabetes; the 1-h measurement performed better than a diagnosis of impaired glucose tolerance using the 2-h measurement. They also suggest that the 1-h measurement is likely better at predicting risk of diabetes complications, such as major cardiovascular complaints, retinopathy, and other microvascular complaints as well as mortality. They conclude that the 1-h measurement during an OGTT is likely a “powerful predictor of future type 2 diabetes” and that “simple logistics favor the use of a 1-h blood glucose versus 2-h OGTT.” Commenting more widely on the research, author Manan Pareek told Diabetes Care: “Accumulating evidence suggests that a shortened oral glucose tolerance test is a very useful marker of risk. We believe that targeting individuals with an abnormal 1-hour blood glucose level has the potential to substantially reduce cardiometabolic burden, particularly considering its high sensitivity. As such, an important next step would be to examine, preferably in a randomized setting, whether such a strategy is clinically beneficial and cost-effective.”

Pareek et al. Enhanced predictive capability of a 1-hour oral glucose tolerance test: a prospective population-based cohort study. Diabetes Care 2018;41:171–177

A telemedicine approach to the care of diabetes patients with foot ulcers is reportedly noninferior to standard care in terms of healing time, according to Smith-Strøm et al. (p. 96). While there was no significant difference between the groups in terms of healing time, death, and patient satisfaction, there were significantly fewer amputations in the telemedicine group. The authors report that the direction of effects for healing, death, health care consultations, and patient satisfaction all favored the telemedicine approach. The study involved recruiting patients from across three areas in Norway between 2012 and 2016 and reportedly involved 94 patients who received care with telemedicine and 88 who received standard care alone. The primary end point was healing time within 12 months; there were also a variety of secondary end points. As the authors point out, the design of the study was to specifically determine noninferiority of the primary end point in the telemedicine approach. They state that based on previous research, it was important to examine whether telemedicine follow-up was a safe alternative for patients with diabetes-related foot ulcers. On the basis of their study, the authors report that a telemedicine approach toward dealing with foot ulcers in patients with diabetes shows promise. Their additional analyses suggest that the distance patients have to travel to clinics might also be significant in terms of the apparent benefit enjoyed by patients who use the telemedicine approach. According to author Marjolein M. Iversen: “This was a complex study, but we are very encouraged by the promising results. Most important was the ‘proof of concept’ that telemedicine follow-up was noninferior to standard care in terms of healing time and safe in terms of death and amputation. Telemedicine follow-up has the potential to be further developed with increasingly simpler and better telemedicine solutions.”

Smith-Strøm et al. The effect of telemedicine follow-up care on diabetes-related foot ulcers: a cluster-randomized controlled noninferiority trial. Diabetes Care 2018;41:96–103

An update on the progress of the Risk Assessment and Management Programme–Diabetes Mellitus (RAMP-DM) suggests that the approach can delay disease progression, prevent complications, and reduce requirements for hospital care in comparison to usual care for diabetes. The study by Wan et al. (p. 49) is a 5-year update on the progress of RAMP-DM, a program launched in 2009 in Hong Kong to improve the quality of care for primary care patients with diabetes. Patients enrolled in the program reportedly undergo an initial structured and systematic protocol-driven health assessment to determine a risk profile, which is then used to design a program of care that is specific for each patient but crucially involves access to a multidisciplinary care team. According to the authors, their analysis is based on ∼27,000 patients enrolled in RAMP-DM and matched control subjects who received usual care. Patients were then evaluated for nine diabetes-related complications as well as all-cause mortality. The authors report that after a median follow-up of 4.5 years the cumulative incidence of any event was 23.2% in the RAMP-DM group but 43.6% in the usual care group. Specifically, RAMP-DM led to greater relative reductions in risk for cardiovascular disease (56.6%), mortality (66.1%), and microvascular complications (11.9%). Additionally, there was lower risk for emergency room attendance (41.2%), specialist outpatient attendance (35.0%), and overnight hospitalizations (58.5%). Study author Esther Yee Tak Yu reports that: “A systematic structured risk assessment coupled with multidisciplinary care management could enhance routine doctor follow-up consultations in usual care in order to provide timely detection of risk factors and subsequent treatments to prevent further deterioration. As a result, significant reduction in diabetic complications, mortality, and secondary or tertiary service utilization rates were achieved for patients with diabetes. A key next step is to investigate the optimal frequency of repeat RAMP-DM and the evaluation of cost-effectiveness and budget impact of RAMP-DM.”

Wan et al. Five-year effectiveness of the multidisciplinary Risk Assessment and Management Programme–Diabetes Mellitus (RAMP-DM) on diabetes-related complications and health service uses—a population-based and propensity-matched cohort study. Diabetes Care 2018;41:49–59

A detailed analysis by Montvida et al. (p. 69) of claims data from the U.S. for antidiabetes drugs suggests that between 2005 and 2016, metformin was increasingly used (60–77%) as a first-line treatment for type 2 diabetes. Conversely, rates of sulfonylureas use dropped (20–8%) over the same period as first-line therapy; as a second-line therapy it remained the most used, although proportionally over the period its use dropped (60–46%). As well as metformin and sulfonylureas, the study also covers usage rates of thiazolidinedione, insulin, dipeptidyl peptidase-4 inhibitors (DPP-4i), glucagon-like peptide 1 receptor agonists (GLP-1RA), the newer sodium–glucose cotransporter 2 inhibitors, and four less commonly used therapies. According to the authors, the study used electronic medical records of just over one million individuals with type 2 diabetes who initiated any antidiabetes therapy between 2005 and 2016, and then tracked any additional intensification with a second- or even third-line therapy in the same period. As well as the dynamics with metformin and sulfonylureas, they reveal considerable increases in insulin usage (7–17%) and DPP-4i (0.4–21%) as second-line therapies. Meanwhile, proportional use of thiazolidinedione as either a first- or second-line therapy declined over the study period. Rates of intensification with insulin and sulfonylureas reportedly did not decline over the same period. They also report that it took slightly longer for patients to need insulin when on DPP-4i and GLP-1RA in comparison to sulfonylureas. The authors say that while patients are mostly initiated on metformin as a first-line therapy, they tend to move onto second-line therapy when HbA1c remains high. However, perhaps the most intriguing insight is that despite the availability of modern alternatives, sulfonylureas remain the most popular second-line therapy. Sodium–glucose cotransporter 2 inhibitors only accounted for 7% of all diabetes drug usage as a second-line therapy. The authors report that the higher costs of newer drugs may account for the low rates but more studies are needed to properly understand this aspect.

Montvida et al. Long-term trends in antidiabetes drug usage in the U.S.: real-world evidence in patients newly diagnosed with type 2 diabetes. Diabetes Care 2018;41:69–78

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