Erratum to: DiabetologiaDOI 10.1007/s00125-012-2534-0In the text box ‘Properties of currently available glucose-lowering agents that may guide treatment choice in individualpatients with type 2 diabetes mellitus ’ vildagliptin was incor-rectly assigned footnote ‘a’ (Limited use in the USA/Europe)instead of footnote ‘b’ (Not licensed in the USA).

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Management of hyperglycaemia in type 2 diabetes: a patient-centered approach. Position statement of the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD)

Glycemic management in type 2 diabetes mellitus has become increasingly complex and, to some extent, controversial, with a widening array of pharmacological agents now available (1–5), mounting concerns about their potential adverse effects and new uncertainties regarding the benefits of intensive glycemic control on macrovascular complications (6–9). Many clinicians are therefore perplexed as to the optimal strategies for their patients. As a consequence, the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD) convened a joint task force to examine the evidence and develop recommendations for antihyperglycemic therapy in nonpregnant adults with type 2 diabetes. Several guideline documents have been developed by members of these two organizations (10) and by other societies and federations (2,11–15). However, an update was deemed necessary because of contemporary information on the benefits/risks of glycemic control, recent evidence concerning efficacy and safety of several new drug classes (16,17), the withdrawal/restriction of others, and increasing calls for a move toward more patient-centered care (18,19).

This statement has been written incorporating the best available evidence and, where solid support does not exist, using the experience and insight of the writing group, incorporating an extensive review by additional experts (acknowledged below). The document refers to glycemic control; yet this clearly needs to be pursued within a multifactorial risk reduction framework. This stems from the fact that patients with type 2 diabetes are at increased risk of cardiovascular morbidity and mortality; the aggressive management of cardiovascular …

https://care.diabetesjournals.org/content/diacare/35/6/1364.full.pdf

Management of Hyperglycemia in Type 2 Diabetes: A Patient-Centered Approach: Position Statement of the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD)

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Erratum: Management of hyperglycaemia in type 2 diabetes: A patient-centered approach. Position statement of the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD) (Diabetologia (2013) 56 (680))

The study group.

Context and Objective: Nonalcoholic fatty liver disease (NAFLD) and its more severe form with steatohepatitis (NASH) are common in patients with type 2 diabetes mellitus (T2DM). However, they are usually believed to largely affect those with elevated aminotransferases. The aim of this study was to determine the prevalence of NAFLD by the gold standard, liver magnetic resonance spectroscopy (1H-MRS) in patients with T2DM and normal aminotransferases, and to characterize their metabolic profile. Participants and Methods: We recruited 103 patients with T2DM and normal plasma aminotransferases (age, 60 ± 8 y; body mass index [BMI], 33 ± 5 kg/m2; glycated hemoglobin [A1c], 7.6 ± 1.3%). We measured the following: 1) liver triglyceride content by 1H-MRS; 2) systemic insulin sensitivity (homeostasis model assessment-insulin resistance); and 3) adipose tissue insulin resistance, both fasting (as the adipose tissue insulin resistance index: fasting plasma free fatty acids [FFA] × insulin) and during an oral glucose...

High Prevalence of Nonalcoholic Fatty Liver Disease in Patients with Type 2 Diabetes Mellitus and Normal Plasma Aminotransferase Levels.

The prevalence of type 2 diabetes continues to increase at an alarming rate around the world, with even more people being affected by prediabetes. Although the pathogenesis and long-term complications of type 2 diabetes are fairly well known, its treatment has remained challenging, with only half of the patients achieving the recommended hemoglobin A1c target. This narrative review explores the pathogenetic rationale for the treatment of type 2 diabetes, with the view of fostering better understanding of the evolving treatment modalities. The diagnostic criteria including the role of hemoglobin A1c in the diagnosis of diabetes are discussed. Due attention is given to the different therapeutic maneuvers and their utility in the management of the diabetic patient. The evidence supporting the role of exercise, medical nutrition therapy, glucose monitoring, and antiobesity measures including pharmacotherapy and bariatric surgery is discussed. The controversial subject of optimum glycemic control in hospitalized and ambulatory patients is discussed in detail. An update of the available pharmacologic options for the management of type 2 diabetes is provided with particular emphasis on newer and emerging modalities. Special attention has been given to the initiation of insulin therapy in patients with type 2 diabetes, with explanation of the pathophysiologic basis for insulin therapy in the ambulatory diabetic patient. A review of the evidence supporting the efficacy of the different preventive measures is also provided.

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Management of type 2 diabetes: evolving strategies for the treatment of patients with type 2 diabetes

Introduction: Diabetic ketoacidosis (DKA) is a common complication of diabetes encountered in the acute care setting. Emergent management of DKA is essential as positive outcomes are seen with timely resolution. Some strategies for timely resolution include initial fluid resuscitation, administration of insulin, and management of electrolytes and fluid. Additionally, rebound DKA occurs in patients and may prolong hospitalization and lead to additional complications. The goal of this study was to evaluate the use of a novel protocol suite for the management of DKA in a community hospital setting. Methods: The study design is a pragmatic, retrospective cohort with historical control conducted at a suburban hospital setting. A novel DKA protocol was implemented which included a change to initial volume resuscitation at 250mL/hr, initiation of insulin bolus in the emergency department with repeat dosing if necessary, insulin drip initiation in the ICU with criteria based dosing, and transition to dextrose-containing fluid when blood glucose (BG) is < 250mg/dL. Instead of discontinuing the insulin drip when BG < 100mg/dL, it was continued with dextrose boluses until DKA resolution. Additionally, a weight-based insulin transition protocol was utilized to transition the patient to long-acting insulin with a basal-bolus plus sliding scale approach. The primary objective of the study was incidence of rebound DKA. Secondary outcomes include duration of insulin drip, hospital length of stay, and hypoglycemic events. Results: A total of 165 patients were included in the study, 84 in the pre-implementation group and 81 in the post-implementation group. Baseline demographics were similar between groups in terms of age, sex, ethnicity, type of diabetes, and insulin-dependence. Rebound DKA was seen in 59.5% of patients in the pre-group and 7.7% in the post-group (p< 0.001). Hospital length of stay was similar between groups (4.3 days vs. 3.9 days, p=0.4). Insulin drip duration was shorter in the post-group (27.2 hrs vs. 22.3 hrs, p=0.02). Fewer hypoglycemic events were noted in the post-group as well. Conclusions: The implementation of a novel DKA protocol in a community hospital setting was associated with lower rates of DKA rebound, shorter total duration of insulin drip, and fewer hypoglycemic episodes. 

218: the implementation of a novel dka treatment protocol in a community hospital setting

With Continuous Subcutaneous Insulin Infusion (CSII) multiple basal rates need to be utilized to avoid nocturnal hypoglycemia, the dawn phenomenon, postprandial hyperglycemia and preprandial hypoglycemia. With the availability of the Hybrid Closed-Loop Therapy (HCLT) systems, the use of multiple basal rates has become unnecessary and counterproductive. When transferring to a HCLT system we utilize a single basal rate for twenty-four hours. By utilizing a single basal rate we have improved multiple metrics of glycemic control in many patients. To illustrate the benefits of transfer to a single basal rate in a HCLT system we present a relevant case.

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Insulin Delivery Utilizing Hybrid-Closed-Loop Therapy is More Effective When a Single Basal Rate Rather Than Multiple Basal Rates is Utilized - A Case Report

Long-acting pasireotide and bromocriptine provided biochemical control of growth hormone and prolactin in a patient with plurihormonal pituitary macroadenoma, allowing near-complete tumor excision while restoring pituitary function and avoiding adjunctive radiotherapy. Pasireotide initiation resulted in hyperglycemia, which stabilized after a few months and resolved upon pasireotide discontinuation (ACCESS; NCT01995734).

Successful debulking of plurihormonal pituitary macroadenoma with long-acting pasireotide and dopamine agonist combination therapy

Patients with type 2 diabetes are at an increased risk of developing heart failure and chronic kidney disease. The presence of these co-morbidities substantially increases the risk of morbidity as well as mortality in patients with diabetes. The clinical focus has historically centred around reducing the risk of cardiovascular disease by targeting hyperglycaemia, hyperlipidaemia and hypertension. Nonetheless, patients with type 2 diabetes who have well-controlled blood glucose, blood pressure and lipid levels may still go on to develop heart failure, kidney disease or both. Major diabetes and cardiovascular societies are now recommending the use of treatments such as sodium-glucose co-transporter-2 inhibitors and non-steroidal mineralocorticoid receptor antagonists, in addition to currently recommended therapies, to promote cardiorenal protection through alternative pathways as early as possible in individuals with diabetes and cardiorenal manifestations. This review examines the most recent recommendations for managing the risk of cardiorenal progression in patients with type 2 diabetes.

https://onlinelibrary.wiley.com/doi/pdfdirect/10.1111/dom.15181

Terri W. Jerkins

Papers

Management of type 2 diabetes: evolving strategies for the treatment of patients with type 2 diabetes

218: the implementation of a novel dka treatment protocol in a community hospital setting

Insulin Delivery Utilizing Hybrid-Closed-Loop Therapy is More Effective When a Single Basal Rate Rather Than Multiple Basal Rates is Utilized - A Case Report

Successful debulking of plurihormonal pituitary macroadenoma with long-acting pasireotide and dopamine agonist combination therapy

Management of the 'wicked' combination of heart failure and chronic kidney disease in the patient with diabetes.