ADA Conference Highlights
New studies and warnings unveiled at CA meeting
Attendees at the 59th annual scientific sessions of the American Diabetes Association (ADA) in San Diego learned that a new trial is coming on the heels of the landmark United Kingdom Prospective Diabetes Study (UKPDS), which followed the treatment of patients with Type 2 diabetes for two decades.
The UKPDS found that 22% of incidences of myocardial infarction (MI), stroke, or angina occurred within first 10 years after Type 2 diabetes diagnosis. A next step is to determine whether a combination of statin and fibrate therapy to lower lipid levels can prevent cardiovascular incidents in these patients (who have not had a stroke, MI, or angina).
The Lipids in Diabetes Study will recruit 5,000 subjects with Type 2 diabetes. The new study will randomize a daily dose of 0.4 mg of the HMG-CoA reductase inhibitor cerivastatin and a 200 mg dose of fenofibrate vs. placebo.
The research is co-sponsored by the ADA and statin manufacturer Bayer (Lipobay and Baycol) and will include researchers from the UKPDS study.
According to the Centers for Disease Control and Prevention (CDC) in Atlanta, 98% of adults with Type 2 diabetes either suffer from cardiovascular disease (CVD) or are carrying risk factors. Yet the CDC says that just one in five patients are regularly taking a simple daily dose of aspirin. The ADA began recommending aspirin therapy in 1997, after published studies dating back to 1988 showed the positive effects of aspirin in patients with CVD or risk factors.
The CDC and the National Center for Health Statistics surveyed 1,503 patients over age 20 who were statistically eligible for aspirin therapy in terms of having a history of MI, stroke, angina, or claudication, or risk factors such as hypertension, obesity, abnormal lipid levels, smoking, or a family history of coronary disease. The survey found that only 37% of patients with cardiovascular disease and 13% of patients with risk factors used aspirin regularly.
According to Deborah Rolka of the CDC’s Diabetes Statistical Division, only patients with aspirin allergy, recent GI bleeding, or active liver disease should not take aspirin as part of diabetes treatment. She says the survey found that demographics played a large role in who was informed about aspirin therapy. Most likely to be taking aspirin were white, non-Hispanic patients age 40 or older who already were suffering from cardiovascular disease. Rolka says more resources and clinic time need to be spent educating younger, poorer, minority patients.
The ADA recommends a daily dose of 81 to 325 mg of an enteric-coated aspirin as a secondary prevention for patients with cardiovascular disease (CVD) and as a primary prevention for patients with CVD risk factors. The ADA also says it has completed a study showing that regular aspirin therapy does not increase the risk for diabetic retino pathy, a bleeding in the eye which was thought to be a condition of aspirin therapy by diabetics.
Four separate studies presented at the scientific sessions warned that adolescents were developing Type 2 diabetes at alarming rates; until recently, the disease mainly has affected overweight adults 45 and older. Obesity is blamed for much of the problem in children, considered part of a generation suffering from poor diets and too little exercise. Diagnosis also has become a factor because most physicians do not expect diabetes to show up in young patients.
"Type 2 diabetes was practically unheard of in young people until the last few years," says Robin Goland, MD, of the Naomi Berrie Diabetes Center at Columbia Presbyterian Hospital in New York City. "Because of the long-term damage that high blood sugar levels can do to blood vessels throughout the body, we might see the devastating complications of diabetes very early, such as heart attack, stroke, blindness, and amputations in 30-year-olds if they are not properly diagnosed and treated early."
Goland submitted a paper detailing a study of 19 patients ages 10 to 17, all of whom were obese and had acanthosis nigricans, and most of whom had relatives with diabetes. "The average blood glucose level of these children was 397 mg/dl, which is extraordinarily high," Goland says. "Because physicians are not expecting to see Type 2 in youngsters, the diagnosis is not made until severe hyperglycemia has developed."
Goland emphasizes that in terms of diagnosis, obesity in children (defined as more than 20% above desired body weight) should be associated with insulin resistance, which is the first step toward the development of Type 2 diabetes.
A similar patient assessment at the University of California at San Diego School of Medicine detailed the cases of 58 patients, of whom 83% were obese, 74% had acanthosis nigricans, and 100% had type 2 diabetes. Studies from Canada and Japan also spelled out an increase in the cases of adolescent Type 2 diabetes.
Depressed patients at greater risk
Patients with Type 2 diabetes also suffering from depression need an interdisciplinary treatment approach in order to treat both conditions successfully, according to research submitted by Patrick Lustman, PhD, professor of medical psychology in the department of psychiatry at Wash ington University School of Medicine in St. Louis.
"Because of physiologic and behavioral interactions between diabetes and depression, each becomes more difficult to control, which increases the risks of cardiovascular disease, diabetic retinopathy, neuropathy, and other problems," says Lustman.
He says his research has found that up to 20% of diabetics suffer from clinical depression, based in part on the unhappiness over the obesity associated with the disease. Depression can lead to poor compliance with diabetes treatment, which makes a patient sicker and, therefore, more depressed.
"But when you treat the depression with psychotherapy or medication or both, it’s easier to control blood sugar levels, and when you treat blood sugar levels, it becomes easier to treat depression. The two conditions are ideal candidates for intensive interdisciplinary treatment."
The hormonal impact of depression, which Lustman says affects a patient’s cortisol levels, may then worsen insulin resistance to increase the atherogenic affects of diabetes, he notes. He also points out that depression tends to recur in diabetes patients, which calls for ongoing treatment by a physician and psychotherapist.
"In contrast to the association of depression seen in other diseases like heart attack and cancer, only in diabetes has it been shown that specific depression treatment can make a difference in the outcome of the underlying disease," he says.
[For more on the 59th Scientific Sessions of the American Diabetes Association or on specific papers submitted to the conference, contact the ADA at 1660 Duke St., Alexandria, VA 22314. Telephone: (703) 549-1500. Web: www.diabetes.org.]