XI. STRATEGIES FOR IMPROVING DIABETES CARE D iabetes is a chronic illness that requires continuing medical care and patient self-management education to prevent acute complications and to reduce the risk of long-term complications. Diabetes care is complex and requires that many issues, beyond glycemic control, be addressed. A large body of evidence exists that supports a range of interventions to improve diabetes outcomes. These standards of care are intended to provide clinicians, patients, researchers, payors, and other interested individuals with the components of diabetes care, treatment goals, and tools to evaluate the quality of care. While individual preferences, comorbidities, and other patient factors may require modification of goals, targets that are desirable for most patients with diabetes are provided. These standards are not intended to preclude more extensive evaluation and management of the patient by other specialists as needed. For more detailed information, refer to Bode (Ed.): Medical Management of Type 1 Diabetes (1), Burant (Ed): Medical Management of Type 2 Diabetes (2), and Klingensmith (Ed): Intensive Diabetes Management (3). The recommendations included are diagnostic and therapeutic actions that are known or believed to favorably affect health outcomes of patients with diabetes. A grading system (Table 1), developed by the American Diabetes Association (ADA) and modeled after existing methods, was utilized to clarify and codify the evidence that forms the basis for the recommendations. The level of evidence that supports each recommendation is listed after each recommendation using the letters A, B, C, or E.

Standards of Medical Care in Diabetes

1. Type 1 diabetes (due to b-cell destruction, usually leading to absolute insulin deficiency) 2. Type 2 diabetes (due to a progressive insulin secretory defect on the background of insulin resistance) 3. Gestational diabetes mellitus (GDM) (diabetes diagnosed in the second or third trimester of pregnancy that is not clearly overt diabetes) 4. Specific types of diabetes due to other causes, e.g., monogenic diabetes syndromes (such as neonatal diabetes and maturity-onset diabetes of the young [MODY]), diseases of the exocrine pancreas (such as cystic fibrosis), and drugor chemical-induced diabetes (such as in the treatment of HIV/AIDS or after organ transplantation)

Classification and diagnosis of diabetes

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Hyperglycemia and Adverse Pregnancy Outcomes

Metformin is a widely-used drug that results in clear benefits in relation to glucose metabolism and diabetes-related complications. The mechanisms underlying these benefits are complex and still not fully understood. Physiologically, metformin has been shown to reduce hepatic glucose production, yet not all of its effects can be explained by this mechanism and there is increasing evidence of a key role for the gut. At the molecular level the findings vary depending on the doses of metformin used and duration of treatment, with clear differences between acute and chronic administration. Metformin has been shown to act via both AMP-activated protein kinase (AMPK)-dependent and AMPK-independent mechanisms; by inhibition of mitochondrial respiration but also perhaps by inhibition of mitochondrial glycerophosphate dehydrogenase, and a mechanism involving the lysosome. In the last 10 years, we have moved from a simple picture, that metformin improves glycaemia by acting on the liver via AMPK activation, to a much more complex picture reflecting its multiple modes of action. More work is required to truly understand how this drug works in its target population: individuals with type 2 diabetes.

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The mechanisms of action of metformin

Metformin use in gestational diabetes mellitus.

Gestational diabetes mellitus (GDM) is a heterogeneous condition, as exemplified by our inability to agree upon screening and diagnostic criteria. Not all women with GDM carry the same long-term risk of diabetes. We therefore propose a triage system to identify women with GDM who are at higher risk of converting to diabetes mellitus, in a shorter time frame after pregnancy. Such women can be offered personalized risk assessment information.

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Gestational Diabetes Mellitus—Triage for Preventive Intervention

I read with great interest the article by Tempe et al., in which the authors have assessed the efficacy of glyburide in the treatment of gestational diabetes mellitus (GDM). They compared the maternal and fetal outcomes between two groups treated either with insulin or glyburide. There was no significant difference in terms of glycemic control, maternal or fetal health outcomes. The results of their study are in line with previously published randomized controlled trials (RCT) comparing glyburide with insulin in GDM, including one from India. I hereby further discuss the issue, regarding use of glyburide in pregnancy. Although the results are encouraging from all RCT performed in this context, except one, all are with less than 50 patients in each arm. The outcomes are short term, limited to neonatal and maternal health outcomes for the pregnancy period. No study (RCT) has evaluated the long-term effects on the offspring. Further, the enrollment of patients in trials was beyond the first trimester, well beyond the period of organogenesis. Hence, based on this data, the effects of glyburide on development of congenital malformation in the offspring cannot be derived. It should also be kept in mind, that little randomized evidence is available evaluating the use of oral antidiabetic agents (OAA) in women with pre-existing diabetes mellitus/ impaired glucose tolerance. The information is also limited for the other commonly used drug, metformin. Recently, in first follow-up of the Metformin in Gestational Diabetes (MiG) study, infants of women with GDM who had been randomized to receive either metformin or insulin during pregnancy were examined at 2 years of age. A healthier fat distribution was found in the randomized arm with metformin use in pregnancy. Insulin, on the other hand has established safety. It is neither transported through placenta, nor through breast-feeding. Therefore, it remains the optimal antidiabetic treatment during pregnancy and lactation. No OAA has yet been US Food and Drug Administration approved for use in pregnancy. However, in view of similar efficacy of OAA (metformin and glyburide) and insulin in women with GDM (RCT based results), selected patients of GDM who decline insulin therapy may be candidates for OAA. The women should be fully informed regarding lack of long-term safety data of OAA for use in pregnancy.

Yashdeep Gupta

Papers

Metformin use in gestational diabetes mellitus.

Gestational Diabetes Mellitus—Triage for Preventive Intervention

Comment on 'Glyburide as treatment option for gestational diabetes mellitus'.

Comment on: Shriraam et al., awareness of gestational diabetes mellitus among women in a primary health center in south India

Vitamin D and Interleukins in Chronic Rhinosinusitis with Polyposis