The development of pulmonary antibodies is a possible concern for inhaled insulin devices. In many devices two thirds of insulin is retained in the upper respiratory tract. The proliferation of antibodies has initially been deemed to be not harmful, but the long term effects are unknown. On a positive note the antibodies do not appear to persist after the insulin dose is terminated. (Joseph D. Brain ScD)
Dyslipidemia in metabolic syndrome plays a strong role in endothelial dysfunction through oxidative stress. Oxidative stress leads to the development of endothelial dysfunction, due to the decrease of NO (a strong vasodilator) and the increase in several inflammatory factors. Glitazones improve endothelium dependent vasodilation via the inhibition of TNFα, an inflammatory factor, as well as, through the inhibition of various immunological factors (chemokines). (Bart Staels Ph.d)
Dr. Lois Jovanovic started off the day with a presentation on the importance of achieving euglycemia—according to her, HbA1c should be below 6%. This is obviously below the ADA recommendation of 7 and the ACE recommendation of 6.5% - but it makes a lot of sense to us as we know there isn’t really a lower threshold for reduction in complications stemming from better control. Among ways to achieve such strict glycemic control, Dr. Jovanovic mentioned frequent self-monitoring of blood glucose and the need to adjust insulin dosages depending on stress level. The “balancing act” of normalizing blood glucose must include exercise, insulin, diet, and stress; the ADA generally neglects to include this fourth factor, she noted. According to Dr. Jovanovic, people must test their blood glucose levels eight to ten times a day in order to achieve HbA1c levels between 5% and 6%. This will be very aggressive for some patients, given the average for all patients with diabetes is just a couple of times a day and even for many intensively controlled patients, only four times per day. We have learned so much more about the importance of stemming glycemic variability and expect to hear only more about this not less in future – it was certainly a key theme of this ADA, and reinforces all the important research on this front by Dr. Irl Hirsch.
Dr. Bo Ahrén from Sweden talked briefly about the ten (10!) GLP-1 analogues and DPP-IV inhibitors that are now in clinical trials – some of these are old and some are newer – we’ll be having a story coming up in DCU on the specific updates on these. He went into more detail on the safety and efficacy of four of these new drugs: Liraglutide (Novo Nordisk), CJC-1131 (ConjuChem), Vildagliptin (Novartis), and Sitagliptin (Merck). Clinical trials show that these GLP-1 analogues and DPP-IV inhibitors reduce HbA1c by about 1%. The drugs are generally well-tolerated and safe, although some of the GLP-1 analogues may cause nausea. What’s interesting about that is that we also heard a number of clinicians that had exp Accoreding to Dr. Ahrén, GLP-1 based therapy is a potential breakthrough for the treatment of Type 2 diabetes – this certainly reinforced all we had heard. Although
When asked if he would consider using gastric bypass surgery on non-obese people with Type 2 diabetes, Dr. Schauer from The Cleveland Clinic said that indeed he would! In fact, there is a currently a prospective study in Australia to evaluate the effects of gastric banding on patients who have BMI’s in the low 30s. We can’t wait to see this, especially given some of the data we’ve seen in terms of type 2 patients and gastric surgery – some of these outcomes are nothing short of amazing, especially in terms of implications from a cost-benefit perspective. Currently, of course, U.S. insurance carriers will not cover this operation unless the patient’s BMI is over 35 and in some cases 40, depending on co-morbidities present.
Dr. George Bakris, while speaking on how to protect cardiovascular and renal function in patients with Type 2 diabetes and metabolic syndrome, emphasized the need to include microalbuminuria as a cardiovascular risk factor. According to him, “the more protein you’re spilling, the more likely you are to die.” Just as we aggressively treat diabetes and continue to lower the recommended HbA1c level, we need to aggressively treat cardiovascular disease. The new blood pressure goal for people with diabetes is 130/80 mmHg or lower.
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