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Given the epidemiology of diabetes, it is understandable that there is a shift in routine management from secondary to primary care. Whether there is enough support for primary care is debatable but usually there is enough guidance to manage non insulin treated patients – and even those on non complex insulin regimes. So far so good! However, there is a risk that patients with T1DM may get caught up in the rush to transfer care out of hospital. In fact, this week’s episode of Pulse describes a commissioning intention of a CCG to actively promote it. However, it is often not understood that T1 and T2 diabetes behave like two separate conditions when it comes to glucose lowering. Furthermore, there is a major difference in the education that these patients require, specifically the intricacies of carbohydrate counting, correction doses and the detailed awareness of the profiles of a variety of rapid and longer acting insulin, not to mention pump therapy. Type 1 patients often possess. There is also the higher risk of hypoglycaemia including unawareness with all the associated issues including the impact on driving. Whilst it is possible that practices have the skills to manage T1 patients, it is unlikely that this can be done without significant support from specialist care. This can come in a variety of ways including education sessions, virtual or e-consultation to name a couple. It is unclear from the proposals as to how this will be done. Furthermore, there is no acknowledgement that T1 patients are often highly motivated and educated about their condition, commonly having more knowledge about ‘their’ diabetes than the health care professional treating them. Significant input would be necessary to convince these patients that the transfer of care does not come at the expense of clinical care. Overall, the location of care is not important, ensuring that the right patient is seen by the right clinician is vital to ensure that this group of patients are not disadvantaged. Dr. Mark Freeman
The combined effects of ARBs on ESRD and CVD and mortality in patients with diabetic nephropathy varies considerably between patients. A substantial proportion of patients remain at high risk for both outcomes despite ARB treatment (Diabetes, Obesity and Metabolism)
Reflections From a Diabetes Care Editors’ Expert Forum
At index acute myocardial infarction, diabetes was common and associated with significant long-term excess mortality, over and above the effects of comorbidities, risk factors and cardiovascular treatments (Journal of Epidemiology & Community Health)
A modern, updated approach to glycaemic control in people with diabetes, in fact, must focus not only on reaching and maintaining optimal HbA1c levels as soon as possible, but to obtain this result by reducing postprandial hyperglycaemia and glycaemic variability, while avoiding hypoglycaemia (Diabetes Research and Clinical Practice)
This study demonstrates some increased clinical signs of ocular surface disease but not an increase in subjective symptoms of dry eyes, with increasing severity of DPN (British Journal of Ophthalmology)
Our study suggests that plant-based diets, especially when rich in high-quality plant foods, are associated with substantially lower risk of developing T2D. This supports current recommendations to shift to diets rich in healthy plant foods, with lower intake of less healthy plant and animal foods (PLoS Medicine)
Long-term pioglitazone treatment is safe and effective in patients with prediabetes or T2DM and NASH (Annals of Internal Medicine)
This issue of Diabetes Care presents today’s AP state of the art, including reports on multinational home-use AP trials, studies in young children, the use of multihormonal approaches to mitigate meal-related hyperglycemia, and discussions of AP study designs and outcome measure (Diabetes Care)
Diabetes remission up to 3 years after RYGBP and LAGB was proportionally higher with increasing postsurgical weight loss. However, the nearly twofold greater weight loss–adjusted likelihood of diabetes remission in subjects undergoing RYGBP than LAGB suggests unique mechanisms contributing to improved glucose metabolism beyond weight loss after RYGBP (Diabetes Care)
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