Clinical Briefs

By Louis Kuritzky, MD, Clinical Assistant Professor, University of Florida, Gainesville. Dr. Kuritzky is an advisor for Endo, Kowa, Pricara, and Takeda.

What’s the Durability of Lifestyle Change in Type 2 Diabetes?

Source: Jakicic JM, et al. Four-year change in cardiorespiratory fitness and influence on glycemic control in adults with type 2 diabetes in a randomized trial: The Look AHEAD trial. Diabetes Care 2013;36:1297-1303.

Embarking on lifestyle change is widely reinforced early on by numerous incidental happenstances. First, response to diet is most prominent in the early weeks of dieting. Second, relative gains in fitness and strength are most obvious in the early weeks of dieting. Third, most support programs providing advisors for diet, exercise, and psychological aspects are “front-loaded” (greater frequency/intensity at first) to try and establish optimum patterns early on. Fourth, as one gains positive initial steps, observers and friends tend to be avid supportive “cheerleaders,” a response that diminishes as the going gets tougher, occasional ground is lost, or ground gained is less visible.

Jakicic et al report on the outcome at 4 years in the Look AHEAD Research Group trial. Overweight or obese type 2 diabetics (n = 3942) were randomized to intensive lifestyle intervention (ILI) or standard care. ILI included weekly instructional/support sessions × 24, continuing with lesser (but still frequent) support on diet and exercise throughout 4 years time. Goal exercise time was 175 minutes a week of brisk walking or the equivalent. As perhaps is intuitive, the intervention group achieved and maintained better fitness levels, better A1c, and better weight control. Structured ILI programs can provide sustained benefits in overweight and obese type 2 diabetics.

Perimenstrual Asthma: A High-Risk Phenotype

Source: Rao CK, et al. Characteristics of perimenstrual asthma and its relation to asthma severity and control: Data from the severe asthma research program. Chest 2013;143:984-992.

SOME WOMEN WITH ASTHMA NOTE A worsening of asthma related to onset of menses. In the National Heart, Lung, and Blood Institute Severe Asthma Research Program (SARP), 17% of women (92/483) reported that menses were a trigger for their asthma symptoms. Exploration of perimenstrual asthma (PMA) as a distinct phenotype has been prompted by the recognition of an association between PMA and asthma acuity. Indeed, near-fatal and fatal asthmatic events have been linked to PMA.

Evaluation of women identified with PMA from SARP found that nearly twice as many PMA subjects met criteria for classification as severe asthma than women without PMA. In addition, levels of asthma control were worse in PMA subjects, and they experienced greater urgent health care utilization. Aspirin sensitivity was found three times more often in PMA patients (30% vs 10%), as were nasal polyps (16% vs 5%).

At the current time, PMA is not a widely appreciated entity. In the United States, there are still approximately 5000 asthma deaths per year. Any phenotypic prototype that can help to identify an asthma population at greater risk of fatal or near-fatal asthma might be a step toward reducing the mortality burden of asthma.

Risk of New Onset Diabetes with Statins

Source: Danaei G, et al. Statins and risk of diabetes: An analysis of electronic medical records to evaluate possible bias due to differential survival. Diabetes Care 2013;36:1236-1240.

THE OFT-QUOTED “9% INCREASE IN NEW onset diabetes (NODM) due to statins” sounds pretty scary. What is left out of the aforementioned quote, however, is that the increased risk is a relative, not absolute, increase. To make the issue more concrete: In one of the largest meta-analyses (n = 91,000), we learned that statins increase risk for diabetes. Among 45,521 statin-treated patients, there were 2226 NODM cases (compared to 2052 of 45,619 placebo recipients); the incidence of NODM then was 4.89% in the statin group, compared to 4.5% in the placebo group, for an underwhelming risk increase of 0.39%. This would translate into a number needed to treat of 250 patients receiving a statin to induce one new case of diabetes. Not nearly so scary, huh?

The most recent analysis of NODM compiled data from the electronic medical records of 500 United Kingdom general practices (n = 285,864). Similar to the above mentioned meta-analysis, the absolute annual incidence in the United Kingdom dataset was 1.59% in statin users compared to 1.13% in nonusers.

Statins can cause NODM, but in trials of secondary prevention, risk of NODM is far outweighed by risk reduction for cardiovascular events.