Summary Background Drugs for neuropathic pain have incomplete efficacy and dose-limiting side-effects when given as monotherapy. We assessed the efficacy and tolerability of combined nortriptyline ...and gabapentin compared with each drug given alone. Methods In this double-blind, double-dummy, crossover trial, patients with diabetic polyneuropathy or postherpetic neuralgia, and who had a daily pain score of at least 4 (scale 0–10), were enrolled and treated at one study site in Canada between Nov 5, 2004, and Dec 13, 2007. 56 patients were randomised in a 1:1:1 ratio with a balanced Latin square design to receive one of three sequences of daily oral gabapentin, nortriptyline, and their combination. In sequence, a different drug was given to each randomised group in three treatment periods. During each 6-week treatment period, drug doses were titrated towards maximum tolerated dose. The primary outcome was mean daily pain at maximum tolerated dose. Analysis was by intention to treat. This trial is registered, number ISRCTN73178636. Findings 45 patients completed all three treatment periods; 47 patients completed at least two treatment periods and were analysed for the primary outcome. Mean daily pain (0–10; numerical rating scale) was 5·4 (95% CI 5·0 to 5·8) at baseline, and at maximum tolerated dose, pain was 3·2 (2·5 to 3·8) for gabapentin, 2·9 (2·4 to 3·4) for nortriptyline, and 2·3 (1·8 to 2·8) for combination treatment. Pain with combination treatment was significantly lower than with gabapentin (−0·9, 95% CI −1·4 to −0·3, p=0·001) or nortriptyline alone (−0·6, 95% CI −1·1 to −0·1, p=0·02). At maximum tolerated dose, the most common adverse event was dry mouth, which was significantly less frequent in patients on gabapentin than on nortriptyline (p<0·0001) or combination treatment (p<0·0001). No serious adverse events were recorded for any patients during the trial. Interpretation Combined gabapentin and nortriptyline seems to be more efficacious than either drug given alone for neuropathic pain, therefore we recommend use of this combination in patients who show a partial response to either drug given alone and seek additional pain relief. Future trials should compare other combinations to their respective monotherapies for treatment of such pain. Funding Canadian Institutes of Health Research.
Recent reports from North America and Europe have documented an annual increase in the incidence of differentiated thyroid carcinoma. We sought to investigate the relation between rates of detection, ...tumour size, age and sex.
Using the Ontario Cancer Registry, we identified 7422 cases of differentiated thyroid carcinoma diagnosed from Jan. 1, 1990, to Dec. 31, 2001. We obtained pathology reports for a random 10% of the 7422 patients for each year of the study period. The sample represented all Cancer Care Ontario regions. We compared the size of the patients' tumours by year, sex and age.
As expected, the incidence of differentiated thyroid carcinoma increased over the 12-year period. A significantly higher number of small (< or = 2 cm), nonpalpable tumours were resected in 2001 than in 1990 (p = 0.001). The incidence of tumours 2-4 cm in diameter remained stable. When we examined differences in tumour detection rates by age and sex, we observed a disproportionate increase in the number of small tumours detected among women and among patients older than 45 years.
Our findings suggest that more frequent use of medical imaging has led to an increased detection rate of small, subclinical tumours, which in turn accounts for the higher incidence of differentiated thyroid carcinoma. This suggests that we need to re-evaluate our understanding of the trends in thyroid cancer incidence.
Population-based studies of diabetes may be limited by sampling and capture. Our study utilizes the Ontario Diabetes Database, which captures all persons in Ontario, Canada with non-gestational ...diabetes. Based on sensitive and specific cohort definitions adults with T2DM were identified. Study objectives are to investigate: the demographic and the clinical characteristics of type 2 diabetes patients in Ontario, Canada over a time frame from Apr 1, 2002 to Sept 31, 2017. We also compare the demographics and clinical characteristics of T2DM patient populations from the cohorts to understand the impact T2DM definitions have on characterizing the disease. We identify 1,093,812 and 783,228 in the cohorts (Table 1) . In the sensitive and specific cohorts, the mean age of a patient with T2D is 64 to 65 years old and 52 to 54% are male, respectively. Roughly 56 to 64% of patients have a 1-year mean HbA1c of <7%, with ∼ 25 to 32% at 7.0%-8.5%, respectively. Overall, covariates of interest in our demographics and clinical characteristics analysis are similar for both cohorts. Our results show multiple comorbidities in this population; hypertension (∼ 77-79%) , dyslipidemia (∼55%) , chronic ischemic heart disease (∼28%) and angina (∼21%) . The comorbidities further illustrate a substantial proportion of T2DM patients suffer comorbid heart diseases.
Disclosure
R.L. Houlden: Advisory Panel; Novo Nordisk Canada Inc. Research Support; AstraZeneca. Speaker's Bureau; Abbott Diagnostics, Boehringer Ingelheim International GmbH, Dexcom, Inc., Eli Lilly and Company, Medtronic, Novo Nordisk Canada Inc., Sanofi. S. Golden: Other Relationship; Novo Nordisk Canada Inc. W. Shi: Other Relationship; Novo Nordisk Canada Inc. A.A. Kukaswadia: Other Relationship; Novo Nordisk. A. Sharma: Other Relationship; Novo Nordisk Canada Inc. K. Quansah: Employee; Boehringer Ingelheim (Canada) Ltd., Novo Nordisk Canada Inc. A.R. Liu: Employee; Novo Nordisk A/S, Novo Nordisk Canada Inc.
Introduction
This study compared two previously validated sensitive and specific diabetes case definitions to explore the impact of different classification methods in Ontario ICES administrative ...data.
Methods
This study included patients captured by the Ontario Diabetes Database with type 2 diabetes using either the sensitive cohort definition (≥ 2 physician visits for diabetes within 1 year or ≥ 1 drug claim for diabetes or ≥ 1 hospitalization with diabetes), or the specific cohort definition (≥ 3 physician visits for diabetes within 1 year), between October 1, 2013 to September 30, 2015. Each cohort's demographic and clinical features were described using descriptive analysis.
Results
Using sensitive and specific definitions, 1,093,812 and 783,228 patients with type 2 diabetes were identified, respectively. Overall, the demographic and clinical characteristics were similar between cohorts. Patients in the sensitive cohort had mean age of 64.1 years and were 52.4% male, compared to 64.8 years and 53.6% male in the specific cohort. In the sensitive and specific cohorts respectively, 64.4% and 55.7% of patients reported one-year mean HbA1c of < 7% (53 mmol/mol) and 25.3% and 31.5% reported levels between 7.0–8.5% (53–69 mmol/mol).
Conclusions
Although sample sizes were different between sensitive and specific cohorts, demographic and clinical characteristics were similar.
In a randomized trial, the combination of morphine and gabapentin led to better pain control than either agent alone in patients with diabetic neuropathy or postherpetic neuralgia. The dose of each ...agent was lower when used in combination than when used alone. Adverse effects were not more severe with the combined formulation.
The combination of morphine and gabapentin led to better pain control than either agent alone in patients with diabetic neuropathy or postherpetic neuralgia.
Neuropathic pain is a common complication of cancer, diabetes mellitus, degenerative spine disease, infection with the human immunodeficiency virus, the acquired immunodeficiency syndrome, and other infectious diseases, and it has a profound effect on quality of life and expenditures for health care.
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Gabapentin and opioids have been proposed as two of several first-line treatments for neuropathic pain.
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However, the maximal tolerated doses of these drugs, administered as single agents, reduce pain by only 26 to 38 percent, owing to incomplete efficacy, dose-limiting adverse effects, or both.
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The combination of mechanistically distinct analgesic agents may result in additivity or synergism . . .
Breast cancer increases the risk of type 2 diabetes 1.07- to 4.27-fold, depending on patient and treatment characteristics, such as postmenopausal status, hormone therapy, and treatment with adjuvant ...chemotherapy. We evaluated the current evidence and considered the role of increased screening for type 2 diabetes in this at-risk population. This narrative review was conducted using Embase and MEDLINE databases. Keywords including diabetes and breast cancer were used. Articles were limited to those published in English between 2000 and 2022. It appears that the increased risk of diabetes begins at or just after breast cancer diagnosis, and remains elevated for at least 10 to 15 years, with greatest risk in the first 2 years after diagnosis. Subsets of patients with breast cancer appear to be at higher risk of developing type 2 diabetes, including those who were treated with adjuvant chemotherapy or hormone therapy. Further investigation is needed to develop specific screening recommendations for this population. If screening is performed with a glycated hemoglobin test during breast cancer treatment, then hemoglobin should be measured at the same time given the association of breast cancer therapy with anemia. Presence of breast cancer should not be a major factor when choosing among available antihyperglycemic agents. Overall, patients with breast cancer appear to be at an increased risk of developing type 2 diabetes. This increased risk suggests the need for further investigation to develop specific screening recommendations for this at-risk population.
Le cancer du sein augmente le risque de diabète de type 2 de 1,07 à 4,27 fois en fonction des caractéristiques de la patiente et du traitement tels la postménopause, la thérapie hormonale et le traitement par chimiothérapie adjuvante. Nous avons évalué les données probantes actuelles et tenu compte du rôle du dépistage accru du diabète de type 2 dans cette population à risque. La présente revue narrative a été réalisée à partir des bases de données Embase et MEDLINE. Les mots clés, notamment le diabète et le cancer du sein, ont été utilisés. Les articles étaient limités aux articles publiés en anglais entre 2000 et 2022. Le risque accru de diabète commence au diagnostic ou juste après, et demeure élevé durant au moins 10 à 15 ans, mais ce risque est plus grand durant les 2 premières années après le diagnostic. Les sous-ensembles de patientes atteintes du cancer du sein semblent montrer un risque plus élevé de diabète de type 2, particulièrement les patientes traitées par une chimiothérapie adjuvante ou une thérapie hormonale. D’autres études sont nécessaires pour élaborer des recommandations particulières pour cette population. Si le dépistage est réalisé par une analyse de l’A1c durant le traitement du cancer du sein, l’hémoglobine devrait être mesurée au même moment étant donné l’association entre la thérapie du cancer du sein et l’anémie. La présence du cancer du sein ne devrait pas être un facteur important lors du choix entre les divers antihyperglycémiants existants. Les patientes atteintes du cancer du sein sont exposées à un risque plus élevé d’avoir le diabète de type 2. Ce risque accru montre la nécessité de réaliser d’autres études afin d’élaborer des recommandations particulières pour cette population à risque.
As part of a larger project to develop quality standards in perioperative diabetes management, the goal of this project was to assess self-reported management of surgical patients with diabetes ...across healthcare institutions and specialties in Canada.
Current practice of perioperative management of patients with diabetes was assessed using multiple-choice questions based on commonly encountered clinical scenarios involving patients with type 1 and type 2 diabetes. The survey was sent to a broad stakeholder group of individuals involved in perioperative medicine in academic and community settings across Canada.
Responses to clinical case scenarios demonstrated more consistent approaches for patients with type 1 diabetes undergoing cardiac surgery, possibly reflecting more robust evidence. There was more variability in the management of noninsulin antihyperglycemic agents and hyperglycemia in patients with type 2 diabetes undergoing noncardiac surgery.
Given the variability in clinical practice, standards and clinical tools are required for perioperative and periprocedural glycemic management in Canada to inform practice, improve the experience and outcomes for people with diabetes and provide a foundation for quality improvement initiatives and benchmarking.
Dans le cadre d’un plus vaste projet qui porte sur l’élaboration de normes de qualité relatives à la prise en charge périopératoire des patients diabétiques, l’objectif du présent projet était d’évaluer la prise en charge autodéclarée de scénarios concernant les patients diabétiques admis pour une intervention chirurgicale entre des établissements de santé et des spécialités du Canada.
Nous avons évalué la pratique actuelle de la prise en charge périopératoire des patients diabétiques à l’aide de questions à choix multiples fondées sur des scénarios cliniques fréquemment rencontrés chez les patients atteints du diabète de type 1 ou de type 2. Nous avons envoyé l’enquête à un vaste groupe d’intervenants composé d’individus qui œuvrent en médecine périopératoire dans des milieux universitaires et communautaires du Canada.
Les réponses aux scénarios issus de cas cliniques ont démontré davantage d’approches cohérentes chez les patients atteints du diabète de type 1 qui subissaient une intervention chirurgicale du cœur, possiblement en raison de données probantes plus solides. Il y avait une plus grande variabilité de la prise en charge des antihyperglycémiants non insuliniques et de l’hyperglycémie chez les patients atteints du diabète de type 2 qui subissaient une intervention chirurgicale autre qu’une intervention du cœur.
Compte tenu de la variabilité de la pratique clinique, des normes et des outils cliniques sont nécessaires pour la prise en charge périopératoire et péri-interventionnelle de la glycémie au Canada afin d’orienter la pratique, d’améliorer l’expérience et les résultats cliniques des personnes diabétiques, et de fournir une base aux initiatives d’amélioration de la qualité et à l’analyse comparative.
Fasting from dawn to dusk during Ramadan, including abstaining from water and food, is 1 of the pillars of Islam and is observed by the majority of Muslims. Most research concerning diabetes and ...fasting during Ramadan originates from Middle Eastern or South Asian countries; however, differences exist in hours of work and fasting, pharmacotherapy and blood glucose monitoring between these countries and Canada.
An expert forum of 7 Canadian experts and 1 international expert collaborated to develop Canadian guidelines using the same evidence-based principles, with the exception of an independent methods review used for the Diabetes Canada clinical practice guidelines. Diabetes Canada scientific leadership and Canadian health-care providers performed independent external reviews. Religious leaders endorsed the position statement and provided letters of support. An informed patient participated in the position-statement development. Each recommendation was approved with 100% consensus of the expert forum.
Recommendations for risk stratification, education, pharmacotherapy and blood glucose monitoring for adults with type 1 and type 2 diabetes who intend to fast during Ramadan have been developed.
This is the first Canadian position statement on the topic of Ramadan fasting and diabetes. It was developed by an expert faculty and endorsed by Diabetes Canada, and provides guidance about pharmacotherapy and glucose monitoring for health-care providers so that they can assist Canadian Muslims living with diabetes to observe fasting during Ramadan safely.
Le jeûne de l'aube au crépuscule pendant le Ramadan, incluant une abstinence d'eau et de nourriture, est l'un des piliers de l'islam et est observé par la majorité des musulmans. La plupart des recherches concernant le diabète et le jeûne pendant le Ramadan proviennent des pays du Moyen-Orient ou d'Asie du Sud; Cependant, il existe des différences concernant les heures de travail et de jeûne, la pharmacothérapie et la surveillance de la glycémie entre ces pays et le Canada.
Un forum d'experts composé de sept experts canadiens et d'un expert international a collaboré afin d'établir des lignes directrices canadiennes en utilisant les mêmes principes que celles utilisées pour les lignes directrices de pratique clinique de Diabète Canada, fondées sur des données probantes, à l'exception d'un examen de méthodes indépendantes. La direction scientifique de Diabète Canada et les prestataires de soins canadiens ont effectué des examens externes indépendants. Les chefs religieux ont approuvé l'énoncé de principe et ont fourni des lettres de soutien. Un patient informé a participé á l'élaboration de l'énoncé de principe. Chaque recommandation a été approuvée avec 100% de consensus au sein du forum d'experts.
Des recommandations ont été établies pour la stratification des risques, l'éducation, la pharmacothérapie et la surveillance de la glycémie chez les adultes atteints de diabète de type 1 et de type 2 qui ont l'intention de jeûner pendant le Ramadan.
Ceci constitue le premier énoncé de principe canadien au sujet du jeûne du Ramadan et du diabète. Il a été élaboré par un expert universitaire et approuvé par Diabète Canada et il fournit des conseils sur la pharmacothérapie et la surveillance de la glycémie aux prestataires de soins de santé afin qu'ils puissent aider les musulmans canadiens à observer le jeûne pendant le ramadan en toute sécurité.
Continuous subcutaneous insulin infusion (CSII) is an effective method of intensive therapy for patients with type 1 diabetes; however, most studies have not examined long-term glycemic control. We ...evaluated the long-term efficacy of CSII in a cohort of adult patients with type 1 diabetes.
This was a retrospective observational study of 200 patients with type 1 diabetes who initiated CSII at a single outpatient clinic in Kingston, ON, Canada between January 1998 and December 2012. Data were collected from 3 months prior to and up to 15 years after initiation of CSII and included glycated hemoglobin (HbA1c) level and demographic factors potentially associated with glycemic control.
Mean age and duration of diabetes at CSII initiation were 35.4 years and 22.4 years, respectively. Mean duration of CSII at the time of analysis was 6 years. Mean HbA1c at initiation of CSII was 8.7% and decreased to a nadir of 7.5% 6 months post-initiation (SD = 1.0) (P < 0.001). This increased over time (range, 7.8-8.2%) but remained lower than the pre-CSII HbA1c (P < 0.001). Shorter duration of diabetes prior to CSII initiation, history of missed appointments, mental illness, and active smoking were predictors of higher HbA1c on CSII. Pre-CSII HbA1c predicted long-term HbA1c on CSII.
The data demonstrate that in a clinic setting, patients on CSII maintain lower HbA1c values over a 1-10-year period compared with pre-CSII values. Poor pre-CSII HbA1c, history of missed appointments, mental illness, and active smoking are predictors of those less likely to achieve an HbA1c target of ≤ 7.0%.
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