Practical Diabetes International

• Survey of diabetes centres 2009
  In the 1990s the development of diabetes centres was regarded as one of the major advances in diabetes care. With today's emphasis on service redesign and reconfiguration, this survey set out to explore the role of diabetes centres in the 21st century.The survey found that a minimum standard for the term ‘diabetes centre’ needs to be defined and that out of hours support/access for people with diabetes was limited. Diabetes centres supported high quality multidisciplinary team working and this was facilitated by the team being co-located. Many of the medical consultants had dual roles with acute trusts that included responsibilities for acute medicine, so easy access to acute trusts facilitated effective use of medical time. The future key role for diabetes centres is to be the hub for integration of diabetes services and actively support primary and community diabetes care. Copyright © 2010 John Wiley & Sons.
  
  
• From history to reality: sodium glucose co-transporter 2 inhibitors – a novel therapy for type 2 diabetes mellitus
  The human kidney has a key role in the regulation of blood glucose predominantly by reabsorption of glucose from the glomerular filtrate via sodium glucose co-transporter 2 (SGLT-2) channels. These are expressed in the proximal renal tubules and are blocked by SGLT-2 inhibitors, which are novel pharmacological agents currently in development. Specific SGLT-2 inhibition results in significant increases in renal glucose excretion causing a net calorie loss and consequent weight loss, coupled with a lowering of blood glucose due to removal of glucose from the circulation. The main side effect of SGLT-2 inhibitors appears to be an increase in genital infections, although concerns remain about the potential adverse effects of dehydration and electrolyte imbalance. Dapagliflozin is the SGLT-2 inhibitor that is the furthest along in development, and is currently in phase III clinical trials.In this review article we consider the role of the kidney in glucose homeostasis in normal and diabetic subjects. We also review the history and concept of SGLT-2 inhibition, and discuss the future potential clinical utility of this promising new class of drugs. Copyright © 2010 John Wiley & Sons.
  
  
• Diabetes centres: adapting to change
  The evolution of diabetes centres in the UK, with co-location of clinical teams, has resulted in examples of success in improving clinical efficiency, communication and patient-centred care.
  
  
• Hyperglycaemia as a result of stress and possible drug interactions: a case report
  We report the case of a six-year-old male paediatric patient diagnosed with type 1 diabetes following an emergency department admission for treatment of an asthma attack.The patient's elevated blood glucose level of 22.9mmol/L was consistent with current guidelines for the diagnosis of diabetes. However, he remained on the same dose of insulin for three years (despite steady, normal growth). During this time he had no problems with blood glucose control and no hypoglycaemic attacks. The diagnosis of diabetes was, therefore, questioned. The values for steroid induced hyperglycaemia were markedly higher in this patient than anecdotal values. This prompted the suspicion that the steroid induced hyperglycaemia had been further exacerbated by salbutamol administration in the setting of an acute stress response.The findings of this case illustrate the importance of understanding drug induced hyperglycaemia in the presence of intercurrent illness. Copyright © 2010 John Wiley & Sons.
  
  
• Type 1, tents, take-aways and toilets: how to manage at a music festival
  Maintaining optimal glycaemic control in people with type 1 diabetes is challenging. Attending a weekend music festival encompasses lifestyle activities that increase the challenge. These include: increased exercise, and changes in eating and alcohol consumption. The practicalities of blood glucose monitoring and insulin injections are also a consideration.The aim of this project was to identify realistic problems for people with type 1 diabetes attending a music festival, and to review current written advice and available literature in order to provide relevant information.No literature was identified. Fifty people with type 1 diabetes aged 18–40 years were randomly selected and sent a questionnaire enquiring about experiences.Thirteen responded (26%). The mean duration of diabetes was 11.7 years (range 1.5–28 years). All 13 respondents had attended a music festival; of these, 46% had attended one for the first time. Some of the concerns included: hypoglycaemia (31%), lack of food (23%), losing insulin and equipment (23%), and maintaining blood glucose levels (23%). Anxieties regarding hypoglycaemia resulted in 38% running blood glucose levels higher than normal. Thirty-eight percent experienced hypoglycaemia, the reasons being: increased activity (38%), eating less carbohydrate (8%), and reduced blood glucose testing (8%). Twenty-three percent attended the first aid tent: 15% regarding injections and 8% for non-diabetic reasons.An information leaflet regarding managing diabetes when attending a festival has been designed which includes feedback and tips from patients. The leaflet was evaluated by 50 people with type 1 diabetes, and 20 health care professionals.Currently, negotiations are underway with Diabetes UK, T in the Park festival organisers and the St Andrew's Ambulance Service to have an advice stand at the festival. Copyright © 2010 John Wiley & Sons.
  
  
• Translating type 2 diabetes genetics: what does it add to clinical practice?
• Red cones and ketones
• Efficacy of a staged diabetes management programme in achieving glycaemic goal in a low socio-economic Hispanic population
  The aim of this study was to identify the efficacy of a staged diabetes management (SDM) clinic serving a low socio-economic Hispanic population in achieving glycaemic goal.We analysed prospectively collected data from patients discharged from the clinic in 2008 with an admission HbA1c >8% (64mmol/mol) and >one clinic visit. Adjusted odds ratios (AOR) were determined for factors significantly associated with glycaemic goal achievement.Both those patients who achieved the clinic HbA1c goal of ≤8% (n=277) and those who did not (n=209) had a clinically significant decrease in HbA1c (-3.13±1.80, -1.08±1.78). After adjustment, the following were associated with failure to achieve goal: higher admission HbA1c (%) 11.0±1.8 vs 10.3±1.7, AOR (95% CI) 1.22 (1.08, 1.37), p=0.0016; higher admission insulin (IU/kg/day) 0.56±0.58 vs 0.26±0.41, AOR 2.08 (1.09, 4.00), p=0.026; greater increase in insulin (IU/kg/day) 0.23±0.46 vs 0.09±0.32, AOR 2.38 (1.15, 5.00), p=0.02; and a longer stay (days) 229±110 vs 172±84, AOR 1.007 (1.003, 1.012), p=0.0008.In this SDM clinic, most patients achieved significant reduction in HbA1c. The study identified factors associated with a lower likelihood of achieving goal thereby demonstrating the value of review of the response to an SDM protocol in indicating areas for further improvement. Copyright © 2010 John Wiley & Sons.
  
  
• Acute hepatic steatosis: an unusual manifestation of poorly controlled type 1 diabetes
• ABCD position statement on haemoglobin A1c for the diagnosis of diabetes
• Exenatide-induced hypomagnesaemia causing seizures
  A 58-year-old Caucasian man with type 2 diabetes diagnosed in 1996 was started on exenatide (Byetta). His weight was 117kg and he had a body mass index (BMI) of 39kg/m2. He was taking 126 units of insulin per day with metformin. Previous attempts at weight loss had been unsuccessful. Over a period of six months, he lost 20kg in weight (BMI 30kg/m2). He reported nausea and vomiting, attributed to the exenatide, but because he was pleased with the weight loss he wanted to continue on exenatide. He had two episodes of witnessed generalised tonic–clonic seizures. He was teetotal and was not taking diuretics. He was found to be hypomagnesaemic with normal serum calcium and normal 24-hour urinary magnesium excretion, excluding renal magnesium loss. It was concluded that his seizures were caused by nutritional hypomagnesaemia due to recurrent vomiting as a consequence of exenatide treatment. Copyright © 2010 John Wiley & Sons.
  
  
• Digoxin