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Insulin – the sharp end of the needle: experiences of 48 years with diabetes 胰岛素——针尖:糖尿病48年的经验
IF 0.6 Pub Date : 2022-12-22 DOI: 10.15277/bjd.2022.356
H. Alban Davies
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引用次数: 1
Type 2 diabetes: the problem and the solution 2型糖尿病:问题和解决方案
IF 0.6 Pub Date : 2022-12-22 DOI: 10.15277/bjd.2022.366
Roy Taylor
Introduction The 100 years since insulin was discovered have seen major progress in understanding the aetiology of type 1 diabetes. In contrast, type 2 diabetes (T2DM) remained mysterious until recently. Clinical studies and clinical experience had resulted in widespread acceptance of the apparently lifelong, progressive nature of the condition. Discoveries over the last 16 years have permitted these rationalisations to be discarded and the aetiology of T2DM is not now in doubt. It is a condition of excess fat inside the liver and pancreas which can be countered by weight loss. A turbulent 16 years of study has led directly to a therapeutically useful understanding of the condition. Importantly, this can be tailored to the individual.
引言胰岛素被发现100年来,在理解1型糖尿病病因方面取得了重大进展。相比之下,2型糖尿病(T2DM)直到最近仍然神秘莫测。临床研究和临床经验使人们普遍接受这种明显的终身渐进性疾病。过去16年的发现使这些合理化被抛弃,T2DM的病因现在没有疑问。这是一种肝脏和胰腺内脂肪过多的情况,可以通过减肥来对抗。经过16年的动荡研究,人们对这种疾病有了直接的治疗意义。重要的是,这可以针对个人量身定制。
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引用次数: 0
Implementing the new NICE guidelines for type 2 diabetes (NG28): Focusing beyond HbA1c targets and clinically phenotyping patients to the appropriate second-line agent 实施新的2型糖尿病NICE指南(NG28):关注HbA1c靶点和临床表型患者之外的适当二线药物
IF 0.6 Pub Date : 2022-12-21 DOI: 10.15277/bjd.2022.385
L. Varadhan, P. Saravanan, Sarah N Ali, W. Hanif, Vinod Patel
A significant number of cardiovascular outcome trials have been published to support decision-making regarding treatment options after or alongside metformin in people with type 2 diabetes (T2DM), specifically targeting prevention of adverse cardiovascular and renal outcomes. The latest NICE guidelines recommend the use of sodium-glucose transport inhibitors (SGLT2i) in patients with cardiovascular diseases, heart failure and chronic kidney disease with diabetes and recommends the use of glucagon-like polypeptide receptor agonists (GLP-1RA) only in a selected group of patients. A comprehensive summary of the various trials, structured around patient characteristics and clinical outcomes, can help to compare the various classes of drugs and drugs within the class. Since the drug acquisition cost within a class is generally the same in the UK, the drug with the best available evidence in the class should be chosen to maximise clinical benefit for the patient. Clinical phenotyping, a process of aligning a patient to the inclusion criteria and the desired clinical outcomes of a trial, can guide the choice of the best drug within a class.
已经发表了大量心血管结果试验,以支持2型糖尿病(T2DM)患者在二甲双胍治疗后或与二甲双胍联合治疗的决策,特别是针对预防心血管和肾脏不良结果。最新的NICE指南建议在心血管疾病、心力衰竭和糖尿病慢性肾病患者中使用钠-葡萄糖转运抑制剂(SGLT2i),并建议仅在选定的一组患者中使用胰高血糖素样多肽受体激动剂(GLP-1RA)。围绕患者特征和临床结果对各种试验进行全面总结,有助于比较不同类别的药物和该类别中的药物。由于在英国,一类药物的获取成本通常相同,因此应选择该类药物中具有最佳可用证据的药物,以最大限度地为患者带来临床效益。临床表型是一个将患者与纳入标准和试验所需临床结果相一致的过程,可以指导在一个类别中选择最佳药物。
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引用次数: 0
Liraglutide 3.0 (Saxenda) in bariatric patients: a retrospective real-world clinical evaluation of effectiveness 利拉鲁肽3.0(Saxenda)在减肥患者中的疗效回顾性现实世界临床评估
IF 0.6 Pub Date : 2022-12-21 DOI: 10.15277/bjd.2022.350
Amelia Simenacz, Rebekah Wilmington, C. Green, Arash Ardavani, I. Idris
Background: Glucagon-like peptide-1 analogues such as liraglutide 3.0 mg (Saxenda) have yielded significant weight loss in clinical trials when combined with lifestyle interventions. Despite the recent approval of liraglutide 3.0 mg, its success among patients attending specialist bariatric units remains uncertain.Objective: This study investigated the effectiveness of liraglutide 3.0 mg on weight, body mass index (BMI), treatment tolerability and its effects on glycated haemoglobin (HbA1c).Methods: Clinical data were retrospectively obtained from medical records within Tier 3-4 bariatric weight management clinics. Wilcoxon signed rank tests were employed to establish the statistical significance (p<0.05) of changes in weight and HbA1c.Results: 33 patients were identified (72.7% female with mean baseline age, weight and BMI of 44.8 years, 156.6 kg and 55.0 kg/m2, respectively). Eighteen patients had completed 26 weeks of treatment. Of the 18 patients, the discontinuation rate due to side effects was 15.2%, indicating substantial treatment tolerance. After 26 weeks of treatment, BMI (±standard deviation) was significantly reduced by 7.9±6.3% (p<0.05) and 72.2% of patients achieved at least 5% weight loss. Additionally, a significant decrease in median HbA1c (4.5±4.5 mmol/mol) was observed (p<0.05), concurrent with increased remission from prediabetes.Conclusion: This retrospective study revealed that liraglutide 3.0 mg, together with lifestyle management, reduced weight and improved glycaemic control. These results support liraglutide’s application in certain high-risk populations, including patients waiting for bariatric surgical intervention.
背景:胰高血糖素样肽-1类似物,如3.0 mg利拉鲁肽(Saxenda),在临床试验中与生活方式干预相结合,可显著减轻体重。尽管最近批准了3.0 mg利拉鲁肽,但其在专科减肥病房的患者中的成功率仍不确定。目的:本研究探讨利拉鲁肽3.0mg对体重、体重指数(BMI)、治疗耐受性及其对糖化血红蛋白(HbA1c)的影响。采用Wilcoxon符号秩检验来确定体重和HbA1c变化的统计学意义(p<0.05)。结果:确定了33名患者(72.7%的女性,平均基线年龄、体重和BMI分别为44.8岁、156.6 kg和55.0 kg/m2)。18名患者完成了26周的治疗。在18名患者中,因副作用导致的停药率为15.2%,表明治疗耐受性良好。治疗26周后,BMI(±标准差)显著降低7.9±6.3%(p<0.05),72.2%的患者体重至少减轻了5%。此外,观察到中位HbA1c显著降低(4.5±4.5 mmol/mol)(p<0.05),同时糖尿病前期病情缓解率增加。结论:这项回顾性研究表明,利拉鲁肽3.0 mg,加上生活方式管理,可以减轻体重,改善血糖控制。这些结果支持利拉鲁肽在某些高危人群中的应用,包括等待减肥手术干预的患者。
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引用次数: 1
Use of a simplified local guideline improves “front door” management of diabetes and hyperglycaemia in people admitted to hospital with COVID-19 使用简化的局部指南可改善COVID-19住院患者糖尿病和高血糖的“前门”管理
IF 0.6 Pub Date : 2022-12-21 DOI: 10.15277/bjd.2022.397
Elizabeth Fetherston, S. Tee, `Meilan Kwok, Satish Artham, P. Carey, R. Nayar, D. Bishop, A. Joshi
Background COVID-19, caused by the severe acute respiratory syndromecoronavirus-2 (SARS-CoV-2), was declared a pandemic on 11th March 2020. COVID-19 increases risk of hyperglycaemia regardless of prior diabetes diagnosis. Following results of the RECOVERY trial showing survival benefit in people with COVID-19 who required oxygen, dexamethasone has been used to improve outcomes.1 Dexamethasone (a glucocorticoid) may exacerbate hyperglycaemia in people with diabetes and can precipitate glucocorticoid-induced diabetes in others. In the context of COVID-19 infection, stress-related hyperglycaemia increases risk of mortality during hospitalization.2 In order to improve recognition and management of COVID-19-related hyperglycaemia, the National Diabetes Inpatient COVID response team published relevant guidance.3
背景2020年3月11日,由严重急性呼吸综合征冠状病毒2型(SARS-CoV-2)引起的新冠肺炎被宣布为大流行。新冠肺炎增加了高血糖症的风险,无论先前是否诊断为糖尿病。RECOVERY试验结果显示,需要吸氧的新冠肺炎患者的存活率提高,因此使用地塞米松来改善结果。1地塞米松(一种糖皮质激素)可能会加重糖尿病患者的高血糖症,并可能导致其他患者的糖皮质激素诱导的糖尿病。在新冠肺炎感染的背景下,与压力相关的高血糖会增加住院期间的死亡率。2为了提高对新冠肺炎相关高血糖的认识和管理,国家糖尿病住院患者新冠肺炎应对小组发布了相关指南。3
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引用次数: 0
use of HbA1c for new diagnosis of diabetes in those with hyperglycaemia on admission to or attendance at hospital urgently requires research 在入院或住院时高血糖患者中使用HbA1c诊断糖尿病迫切需要研究
IF 0.6 Pub Date : 2022-12-21 DOI: 10.15277/bjd.2022.386
S. Manley, Andreas Karwath, John A. Williams, P. Nightingale, J. Webber, R. Raghavan, Alison Barratt, C. Webster, R. Round, I. Stratton, G. Gkoutos, G. Roberts, Samiul Mostafa, Sandip Ghosh
The prevalence of diabetes in Birmingham is 11% but it is 22% in hospital inpatients. Queen Elizabeth Hospital in Birmingham (QEHB) serves a multi-ethnic population with 6% Afro-Caribbean, 19% South Asian and 70% White European.A clinical audit of 18,965 emergency admissions to QEHB showed that 5% were undiagnosed but had admission glucose in the ‘diabetes’ range and 16% were in the ‘at risk’ range. The proportion of Afro-Caribbeans (7%) and South Asians (8%) in the ‘diabetes’ range was higher than White Europeans (5%). Given the magnitude of the problem, this paper explores the issues concerning the use of reflex HbA1c testing in the UK for diagnosis of diabetes in hospital admissions. HbA1c testing is suitable for most patients but conditions affecting red blood cell turnover invalidate the results in a small number of people.However, there are pertinent questions relating to the introduction of such testing in the NHS on a routine basis. Literature searches on a topical question ‘Is hyperglycaemia identified during emergency admission/attendance acted upon?’, were performed from 2016 to 2021 and 2016 to 2022. They identified 21 different, relevant, research papers - 5 from Australia, 9 from Europe including 4 from the UK, 5 from America and 1 each from Canada and Africa. These papers revealed an absence of established procedures for the management and follow-up of routinely detected hyperglycaemia using HbA1c when no previous diabetes diagnosis was recorded.Further work is required to determine the role of reflex HbA1c testing for diagnosis of diabetes in admissions with hyperglycaemia, and the cost-effectiveness and role of point-of-care HbA1c testing.
伯明翰的糖尿病患病率为11%,但在住院患者中为22%。伯明翰伊丽莎白女王医院(QEHB)为多民族人群提供服务,其中6%为非裔加勒比人,19%为南亚人,70%为欧洲白人。对18965名QEHB急诊入院患者的临床审计显示,5%未确诊,但入院血糖在“糖尿病”范围内,16%在“高危”范围内。非洲裔加勒比人(7%)和南亚人(8%)在“糖尿病”范围内的比例高于欧洲白人(5%)。鉴于这个问题的严重性,本文探讨了在英国住院时使用HbA1c检测来诊断糖尿病的问题。HbA1c检测适用于大多数患者,但影响红细胞周转的情况使少数人的结果无效。然而,在英国国家医疗服务体系(NHS)中引入这种常规检测也存在相关问题。关于“是否在急诊入院/就诊期间发现了高血糖?”这一主题问题的文献检索,分别于2016年至2021年和2016年至2022年进行。他们发现了21篇不同的相关研究论文——5篇来自澳大利亚,9篇来自欧洲,其中4篇来自英国,5篇来自美国,加拿大和非洲各1篇。这些论文揭示了在以前没有糖尿病诊断记录的情况下,缺乏使用HbA1c对常规检测的高血糖进行管理和随访的既定程序。需要进一步的工作来确定糖化血红蛋白检测在诊断糖尿病和高血糖入院中的作用,以及护理点糖化血红蛋白检测的成本效益和作用。
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引用次数: 0
Enhancing inpatient diabetes care by developing a new Capillary Blood Glucose and ketone monitoring chart: a Quality Improvement Project (QIP) 开发新型毛细管血糖酮监测图:质量改进项目(QIP)
IF 0.6 Pub Date : 2022-12-21 DOI: 10.15277/bjd.2022.396
K. Mulla, S. Ravindran, Michele Cui, Simon Broadhurst, Laura Sharp, Zoe Bullock, M. Carroll, Chantal Kong
Background The 2018 National Diabetes Inpatient Audit (NaDIA) reported that people with diabetes mellitus (DM) experienced substantially longer hospital stays, poor glucose control and frequent medication errors.1 Intercurrent illnesses can impact blood glucose readings;2 therefore, DM management may need to be tailored when people with diabetes are hospital inpatients to prevent dysglycaemia, which is associated with harm.1 There has been an increased number of admissions relating to diabetes during the pandemic.3 Hospital admission may be an opportunity to improve glycaemic control, to educate people and potentially to reduce future complications. People who are on glucose-lowering medication(s) should monitor their capillary blood glucose (CBG).4 It is very important to display CBG and ketone readings in a clear, interpretable manner and to document them in a timely fashion to enable pattern recognition and titrate diabetes medications effectively. This allows one to determine the impact of change too. Sharma D et al concluded that a colour-coded CBG chart led to more actions being recorded when dysglycaemia occurred and to reduced mortality.5 Our aspiration was to achieve the same result at Watford General Hospital (WGH). Prior to this project, most people with diabetes had their CBG checked four times a day, but this was not necessarily before meals. It was randomly conducted, which led to an increase in adverse events audited by NaDIA-Harms and an increased number of referrals to the diabetes team. This required urgent intervention from the diabetes team. There were no clear instructions for ward staff outlining when to check the patient’s CBG or ketones at WGH. It is difficult to establish a pattern of hypoglycaemia or hyperglycaemia using the current line graph, which makes titration of diabetes medications tough. Moreover, there were no sections for nursing staff to add notes for any interventions carried out for dysglycaemia. After reviewing charts used at different hospitals, the team decided to develop a new chart, which looks similar to the one that people with diabetes use at home. The new Joint British Diabetes Society guidelines (JBDS) promote self-management of diabetes as an inpatient;4 a familiar chart would promote this.
背景2018年全国糖尿病住院患者审计(NaDIA)报告称,糖尿病患者住院时间明显延长,血糖控制不佳,用药错误频繁。1并发疾病会影响血糖读数;2因此,当糖尿病患者住院时,可能需要对糖尿病管理进行调整,以防止与危害相关的低血糖。1在疫情期间,与糖尿病相关的入院人数有所增加。3住院可能是改善血糖控制、教育人们并有可能减少未来并发症的机会。服用降糖药物的人应该监测他们的毛细血管血糖(CBG)。4以清晰、可解释的方式显示CBG和酮体读数并及时记录它们,以实现模式识别和有效滴定糖尿病药物,这一点非常重要。这也使人们能够确定变革的影响。Sharma D等人得出结论,当出现低血糖时,彩色编码的CBG图可以记录更多的行动,并降低死亡率。5我们的愿望是在沃特福德综合医院(WGH)取得同样的结果。在这个项目之前,大多数糖尿病患者每天检查四次CBG,但这不一定是在饭前。这是随机进行的,导致NaDIA Harms审计的不良事件增加,糖尿病团队的转诊人数增加。这需要糖尿病团队的紧急干预。病房工作人员没有明确指示何时在WGH检查患者的CBG或酮。使用当前的折线图很难确定低血糖或高血糖的模式,这使得糖尿病药物的滴定变得困难。此外,没有为护理人员添加任何针对低血糖症的干预措施注释的章节。在审查了不同医院使用的图表后,该团队决定开发一种新的图表,看起来与糖尿病患者在家使用的图表相似。新的英国糖尿病协会联合指南(JBDS)促进了住院患者对糖尿病的自我管理;4熟悉的图表会促进这一点。
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引用次数: 0
Impressions from EASD 2022 来自EASD 2022的印象
IF 0.6 Pub Date : 2022-12-21 DOI: 10.15277/bjd.2022.392
C. Day
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引用次数: 0
Sustaining improvement in diabetes-related ketoacidosis management through a Quality Improvement ProjectSustaining improvement in diabetic ketoacidosis management through Quality Improvement Project 通过质量改进项目持续改进糖尿病酮症酸中毒管理通过质量改进项目持续改进糖尿病酮症酸中毒管理
IF 0.6 Pub Date : 2022-12-21 DOI: 10.15277/bjd.2022.398
L. Rengarajan, Katrina Nash, E. Ooi, Catherine Cooper, Amy Birchenough, M. Owen, Sanjay Saraf, A. Karamat, P. De, S. Krishnasamy, P. Narendran, P. Kempegowda
Introduction Diabetes-related ketoacidosis (DKA) is a life-threatening complication of diabetes which requires rapid assessment and treatment.1 Although mortality has decreased over the years, DKA still causes considerable morbidity and mortality amongst adults, adolescents and children.2 Existing quality improvement projects (QIP) have demonstrated that use of evidence-based protocols and order sets is able to improve outcomes associated with DKA management.3,4 However, we did not find any studies demonstrating sustainable improvements over a long period. People presenting with DKA represent a considerable financial and resource burden.5 Reducing the duration of DKA would therefore substantially reduce the disease and resource burden associated with diabetes.
引言糖尿病相关酮症酸中毒(DKA)是一种危及生命的糖尿病并发症,需要快速评估和治疗。1尽管近年来死亡率有所下降,但DKA仍会在成年人中造成相当大的发病率和死亡率,青少年和儿童。2现有的质量改进项目(QIP)已经证明,使用循证协议和顺序集能够改善与DKA管理相关的结果。3,4然而,我们没有发现任何研究表明长期可持续的改进。患有糖尿病酮症酸中毒的人会带来相当大的经济和资源负担。5因此,缩短糖尿病酮症酸中毒的持续时间将大大减少与糖尿病相关的疾病和资源负担。
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引用次数: 0
origins of type 2 diabetes medications 2型糖尿病药物的起源
IF 0.6 Pub Date : 2022-12-21 DOI: 10.15277/bjd.2022.388
Clifford J Bailey
The origins of diabetes medications provide an intriguing catalogue of clinical serendipity and scientific design. Use of insulin (beyond 1922) gave recognition to insulin resistance and the categorisation of type 2 diabetes (T2DM). The first sulphonylurea (carbutamide, 1956) emerged from its use as an antibacterial sulphonamide prone to cause hypoglycaemia, and biguanides were first used to treat diabetes in 1957 despite their glucose-lowering properties having been known since the 1920s. Alpha-glucosidase inhibitors arose from a screening programme for amylase inhibitors by Bayer in the 1970s and acarbose was introduced in 1990. The first thiazolidinedione (ciglitazone; not developed) was identified in a screening programme for triglyceride-lowering compounds by Takeda in the late 1970s and gave rise to pioglitazone (approved 1999), although first to market was troglitazone (from Warner Lambert 1997, withdrawn 2000). Exendin, an analogue of the incretin hormone glucagon-like peptide-1 (GLP-1), was identified in 1992 in the saliva of a lizard (Heloderma suspectum), and took until 2005 to be marketed as exenatide. To promote the efficacy of endogenous GLP-1, its rapid inactivation by the enzyme dipeptidylpeptidase-4 (DPP4) was blocked by clever molecular design of the first DPP4 inhibitors (vildagliptin and sitagliptin, approved in 2006). SGLT2 inhibitors are based on phlorizin, identified in apple tree bark (1835) and modified (2000) to avoid intestinal degradation: further modifications to increase selectivity against SGLT2 gave dapagliflozin and canagliflozin - approved 2012 and 2013, respectively, in Europe.
糖尿病药物的起源提供了一个有趣的临床偶然性和科学设计目录。胰岛素的使用(1922年以后)使人们认识到胰岛素抵抗和2型糖尿病(T2DM)的分类。第一个磺脲类药物(carbutamide, 1956年)是作为一种容易引起低血糖的抗菌磺胺类药物而出现的,而双胍类药物在1957年首次被用于治疗糖尿病,尽管它们的降血糖特性早在20世纪20年代就已为人所知。α -葡萄糖苷酶抑制剂起源于20世纪70年代拜耳公司对淀粉酶抑制剂的筛选计划,阿卡波糖于1990年引入。第一噻唑烷二酮(西格列酮;(未开发)在20世纪70年代末武田在一个降低甘油三酯化合物的筛选项目中发现,并产生了吡格列酮(1999年批准),尽管首先上市的是曲格列酮(1997年来自Warner Lambert, 2000年撤回)。Exendin是一种胰高血糖素样肽-1 (GLP-1)的类似物,于1992年在蜥蜴(Heloderma suectum)的唾液中被发现,直到2005年才以艾塞那肽的名称上市。为了提高内源性GLP-1的疗效,通过巧妙的分子设计,首批DPP4抑制剂(2006年批准的维格列汀和西格列汀)阻断了其被二肽基肽酶-4 (DPP4)快速失活的过程。SGLT2抑制剂的基础是在苹果树皮中发现的phlorizin(1835年),并进行了修饰(2000年)以避免肠道降解:进一步修饰以增加对SGLT2的选择性,使达格列净和卡格列净分别于2012年和2013年在欧洲获得批准。
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引用次数: 0
期刊
British Journal of Diabetes
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