Clinical Briefs

By Louis Kuritzky, MD, Clinical Assistant Professor, University of Florida, Gainesville. Dr. Kuritzky is a consultant for GlaxoSmithKline and is on the speaker's bureau of GlaxoSmithKline, 3M, Wyeth-Ayerst, Pfizer, Novartis, Bristol-Myers Squibb, AstraZeneca, Jones Pharma, and Boehringer Ingelheim.

Early intensive anti-diabetic treatment may improve b-cell function

Source: Chen HS, et al. Beneficial effects of insulin on glycemic control and b-cell function in newly diagnosed type 2 diabetes with severe hyperglycemia after short-term intensive insulin therapy. Diabetes Care 2008; 31:1927-1932.

Approximately 50% of b-cell function has been lost at the time of initial diagnosis of type 2 diabetes. The UKPDS suggested that neither insulin, metformin, nor oral agents demonstrated any particular advantage as far as progressive subsequent decline in b-cell function is concerned. Whether intensive initial glucose control with insulin followed by routine diabetic control with either insulin or oral agents improves control and/or beta cell function was the subject of this publication by Chen et al.

Newly diagnosed type 2 diabetics with severe hyperglycemia (n = 74) were hospitalized and received intensive basal-prandial insulin therapy to maintain near-normal fasting, preprandial, and bedtime glucose; once good glycemic control had been attained and maintained for 10-14 days, subjects were discharged and randomized to either continued maintenance of tight control with basal-prandial insulin or oral agents (metformin and/or sulfonylurea titrated to maintain FBS 90-130 mg/dL).

The insulin-maintenance group had significantly greater improvements in A1c at 6 months, although FBS levels were similar to the oral agent group. A comparison of b-cell function at 6 months indicated that patients receiving basal-prandial insulin treatment had better outcomes than those on oral agents.

Evolution of management techniques for type 2 diabetes continues to suggest an earlier and more prominent role for insulin therapy. These data suggest that how one gets to goal may be important, and that early introduction of insulin may have advantages over oral agents.

The Swedish Diabetes CVD Risk Score

Source: Cederholm J, et al. Risk prediction of cardiovascular disease in type 2 diabetes: A risk equation for the Swedish National Diabetes Register. Diabetes Care 2008;31:2038-2043.

Cardiovascular disease (CVD) risk prediction helps to identify persons at high risk, stratify treatment groups, and motivate healthful behaviors and modification of risk factors. Diabetic patients are at particularly high risk of CVD, yet currently available risk scoring systems have not performed particularly well.

The Swedish National Diabetes Register provided the patient population from which a new CVD risk predictor has been developed.

During a mean follow-up of 5.6 years (n = 11,646 adult diabetics), 1482 first cardiovascular events occurred. Risk factors with strong association to CVD events were confirmed to be A1c, age at onset of diabetes, duration of diabetes, gender, BMI, smoking, SBP, use of antihypertensive medication, and use of lipid-lowering medication. When these risk factors were used in randomly selected subgroups from the population, accuracy of CVD risk prediction was excellent.

Because this risk prediction tool utilizes information that is generally readily clinically available, and is structured to inform us about predicted 5-year risk (rather than 10-year risk in several other popularly used risk scores), the Swedish Diabetes CVD Risk Score may find popular utility.

Ethnic disparity in colon polyps detected during routine screening

Source: Lieberman DA, et al. Prevalence of colon polyps detected by colonoscopy screening in asymptomatic black and white patients. JAMA 2008; 300:1417-1422.

Both the incidence and rate of mortality of colon cancer (CCa) is higher in black men and women than whites; CCa also occurs at a younger age in blacks than in whites. Health care access issues, lesser adherence to screening recommendations, or less frequent screening recommendations by health care providers to some minority groups might explain some—but not all—of this disparity. Sociopolitical and economic issues aside, there may simply be a greater incidence of CCa and precancer (i.e., polyps) in black men and women.

Lieberman et al evaluated data from sites (n = 67) routinely performing screening colonoscopy in asymptomatic individuals. During the 2004-2005 interval, 80,061 white and 5464 black persons underwent screening colono-scopy. The primary endpoint of the data analysis was the prevalence of large polyps (> 9.0 mm).

Overall, black women were 62% more likely than white women to have a large polyp discovered on screening colonoscopy; black men were 16% more likely to have a large polyp found. This information should encourage clinicians to be particularly vigilant that black men and women participate in timely screening colonoscopy.