Purpose of Review
Telehealth has the potential to positively transform the quality and cost-effectiveness of complex diabetes management in adults. This review explores the landscape of telemedicine ...approaches and evidence for incorporation into general practice.
Recent Findings
Telemedicine for diabetes care is feasible based on over 100 randomized clinical trials. Evidence shows modest benefits in A1c lowering and other clinical outcomes that are better sustained over time vs. usual care. While telemedicine interventions are likely cost-effective in diabetes care, more research is needed using implementation science approaches.
Summary
Telehealth platforms have been shown to be both feasible and effective for health care delivery in diabetes, although there are many caveats that require tailoring to the institution, clinician, and patient population. Research in diabetes telehealth should focus next on how to increase access to patients who are known to be marginalized from traditional models of health care.
In The Lancet, Juan P Frias and colleagues report positive results in a phase 2 trial evaluating the safety and efficacy of co-administered cagrilintide and semaglutide (CagriSema) for type 2 ...diabetes,1 approximately 2 years after a phase 1b study showed early efficacy in the treatment of obesity.2 The role of a gut–brain axis in energy balance has been intensely studied since the 1994 discovery of leptin as a hormone produced by adipose tissue in response to feeding.3 In the years that followed, many investigations led to the current understanding of energy regulation to include signalling in the liver and endocrine pancreas through both classic incretins (eg, glucose-dependent insulinotropic polypeptide and glucagon-like peptide-1 GLP-1) and the unique hormone co-secreted with insulin (amylin). The pathway from obesity to type 2 diabetes is generally understood as chronic inflammation in adipose tissue depots that lead to insulin resistance, causing excess insulin secretion eventually leading to β-cell failure.11 Indeed, those cases where the two conditions do not overlap probably reflects variability in natural history (due in part to environmental factors) as well as imprecision in available diagnostics, rather than a true failure of our present understanding of energy and glucose regulation.12 There are some caveats to note in Frias and colleagues' phase 2 study1 beyond the limitation inherent in the small study size. CMA report grants paid to her institution from the US National Institutes of Health and Patient-Centered Outcomes Research Institute related to obesity; grants paid to her institution from Novo Nordisk and GI Dynamics related to drugs and devices for the treatment of obesity (not including the drugs tested in this study); consulting fees from Curavit Clinical Research and Cowen and Company related to treatment of obesity; advisory board payments from Abbott Nutrition, Nutrisystem, Pursuit By You, Riverview School, and Tivity Health related to nutrition, Allergan, Altimmune, Currax Pharmaceuticals, Jazz Pharmaceuticals, L-Nutra, NeuroBo Pharmaceuticals, Novo Nordisk, Pain Script Corporation, Rhythm Pharmaceutical, Xeno Biosciences, and Zafgen related to drugs for the treatment of obesity (not including the drugs tested in this study), Echosens North America and EnteroMedics related to devices for the treatment of obesity, and EPG Communication Holdings, Real Appeal, Form Health, and ReShape Lifesciences related to obesity; has stock options in Gelesis, a company that has developed a device that mimics bariatric surgery, and Xeno Biosciences, a company involved in phase 1 research to develop a device for delivering oxygen to the lower gut; and is Treasurer for the World Obesity Federation. MEM reports grants paid to her institution from Lilly related to designing care models for treating diabetes in the setting of cancer (ended in 2022) and Dexcom related to the use of continuous glucose monitoring in the hospital setting; scientific advisory board fees from Everlyhealth related to diagnostic services to individuals with endocrine disorders (ended in January, 2023); and is Chair of the Clinical Guidelines Committee for the Endocrine Society (unpaid).
Objective:
To formulate clinical practice guidelines for the pharmacological management of obesity.
Participants:
An Endocrine Society-appointed Task Force of experts, a methodologist, and a medical ...writer. This guideline was co-sponsored by the European Society of Endocrinology and The Obesity Society.
Evidence:
This evidence-based guideline was developed using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system to describe the strength of recommendations and the quality of evidence.
Consensus Process:
One group meeting, several conference calls, and e-mail communications enabled consensus. Committees and members of the Endocrine Society, the European Society of Endocrinology, and The Obesity Society reviewed and commented on preliminary drafts of these guidelines. Two systematic reviews were conducted to summarize some of the supporting evidence.
Conclusions:
Weight loss is a pathway to health improvement for patients with obesity-associated risk factors and comorbidities. Medications approved for chronic weight management can be useful adjuncts to lifestyle change for patients who have been unsuccessful with diet and exercise alone. Many medications commonly prescribed for diabetes, depression, and other chronic diseases have weight effects, either to promote weight gain or produce weight loss. Knowledgeable prescribing of medications, choosing whenever possible those with favorable weight profiles, can aid in the prevention and management of obesity and thus improve health.
Abstract
Context
While individuals with diabetes appear to be at similar risk for SARS-CoV-2 infection to those without diabetes, they are more likely to suffer severe consequences, including death. ...Diabetic ketoacidosis (DKA) is a common and potentially lethal acute complication of diabetes arising from a relative insulin deficiency, which occurs more often in those with type 1 diabetes and in the setting of moderate to severe illness. Early reports indicate that among patients with pre-existing diabetes, DKA may be a common complication of severe COVID-19 and a poor prognostic sign.
Case Description
This clinical perspective explores the key elements of caring for individuals with DKA during the COVID-19 pandemic through 2 cases. Topics addressed include diagnosis, triage, and the fundamental principles of treatment with a focus on the importance of characterizing DKA severity and medical complexity to determine the best approach.
Conclusions
As discussed, some tenets of DKA management may require flexibility in the setting of COVID-19 due to important public health goals, such as preventing transmission to highest risk individuals, reducing healthcare worker exposure to infected patients, and preserving personal protective equipment. Evidence for alternative treatment strategies is explored, with special attention placed on treatment options that may be more relevant during the pandemic, including use of subcutaneous insulin therapy. Finally, DKA is often a preventable condition. We include evidence-based strategies and guidance designed to empower clinicians and patients to avoid this serious complication when possible.
The most common cause of death among adults with diabetes is cardiovascular disease (CVD). In this concise review on pathogenesis of CVD in diabetes, the 4 common conditions, atherosclerosis, ...microangiopathy, diabetic cardiomyopathy, and cardiac autonomic neuropathy, are explored and illustrated to be caused by interrelated pathogenetic factors. Each of these diagnoses can present alone or, commonly, along with others due to overlapping pathophysiology. Although the spectrum of physiologic abnormalities that characterize the diabetes milieu is broad and go beyond hyperglycemia, the authors highlight the most relevant evidence supporting the current knowledge of potent factors that contribute to CVD in diabetes.
Abstract
Objective
The objective is to formulate clinical practice guidelines for the treatment of diabetes in older adults.
Conclusions
Diabetes, particularly type 2, is becoming more prevalent in ...the general population, especially in individuals over the age of 65 years. The underlying pathophysiology of the disease in these patients is exacerbated by the direct effects of aging on metabolic regulation. Similarly, aging effects interact with diabetes to accelerate the progression of many common diabetes complications. Each section in this guideline covers all aspects of the etiology and available evidence, primarily from controlled trials, on therapeutic options and outcomes in this population. The goal is to give guidance to practicing health care providers that will benefit patients with diabetes (both type 1 and type 2), paying particular attention to avoiding unnecessary and/or harmful adverse effects.
Screening, treatment, and management of diabetes mellitus and complications in older patients.
Abstract
The pandemic of COVID-19 has presented new challenges to hospital personnel providing care for infected patients with diabetes who represent more than 20% of critically ill patients in ...intensive care units. Appropriate glycemic management contributes to a reduction in adverse clinical outcomes in acute illness but also requires intensive patient interactions for bedside glucose monitoring, intravenous and subcutaneous insulin administration, as well as rapid intervention for hypoglycemia events. These tasks are required at a time when minimizing patient interactions is recommended as a way of avoiding prolonged exposure to COVID-19 by health care personnel who often practice in settings with limited supplies of personal protective equipment. The purpose of this manuscript is to provide guidance for clinicians for reconciling recommended standards of care for infected hospitalized patients with diabetes while also addressing the daily realities of an overwhelmed health care system in many areas of the country. The use of modified protocols for insulin administration, bedside glucose monitoring, and medications such as glucocorticoids and hydroxychloroquine that may affect glycemic control are discussed. Continuous glucose monitoring systems have been proposed as an option for reducing time spent with patients, but there are important issues that need to be addressed if these are used in hospitalized patients. On-site and remote glucose management teams have potential to provide guidance in areas where there are shortages of personnel who have expertise in inpatient glycemic management.
Adult patients with diabetes or newly recognized hyperglycemia account for over 30% of noncritically ill hospitalized patients. These patients are at increased risk for adverse clinical outcomes in ...the absence of defined approaches to glycemic management.
To review and update the 2012 Management of Hyperglycemia in Hospitalized Patients in Non-Critical Care Settings: An Endocrine Society Clinical Practice Guideline and to address emerging areas specific to the target population of noncritically ill hospitalized patients with diabetes or newly recognized or stress-induced hyperglycemia.
A multidisciplinary panel of clinician experts, together with a patient representative and experts in systematic reviews and guideline development, identified and prioritized 10 clinical questions related to inpatient management of patients with diabetes and/or hyperglycemia. The systematic reviews queried electronic databases for studies relevant to the selected questions. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology was used to assess the certainty of evidence and make recommendations.
The panel agreed on 10 frequently encountered areas specific to glycemic management in the hospital for which 15 recommendations were made. The guideline includes conditional recommendations for hospital use of emerging diabetes technologies including continuous glucose monitoring and insulin pump therapy; insulin regimens for prandial insulin dosing, glucocorticoid, and enteral nutrition-associated hyperglycemia; and use of noninsulin therapies. Recommendations were also made for issues relating to preoperative glycemic measures, appropriate use of correctional insulin, and diabetes self-management education in the hospital. A conditional recommendation was made against preoperative use of caloric beverages in patients with diabetes.
The recommendations are based on the consideration of important outcomes, practicality, feasibility, and patient values and preferences. These recommendations can be used to inform system improvement and clinical practice for this frequently encountered inpatient population.
An appropriate balance between proinflammatory (Th17 and Th1) and anti-inflammatory (regulatory T cells Tregs and Th2) subsets of T cells is critical to maintain homeostasis and avoid inflammatory ...disease. Type 2 diabetes (T2D) is a chronic inflammatory disease promoted by changes in immune cell function. Recent work indicates T cells are important mediators of inflammation in a mouse model of T2D. These studies identified an elevation in the Th17 and Th1 subsets with a decrease in the Treg subset, which culminates in inflammation and insulin resistance. Based on these data, we tested the hypothesis that T cells in T2D patients are skewed toward proinflammatory subsets. Our data show that blood from T2D patients has increased circulating Th17 cells and elevated activation of Th17 signature genes. Importantly, T cells required culture with monocytes to maintain Th17 signatures, and fresh ex vivo T cells from T2D patients appeared to be poised for IL-17 production. T cells from T2D patients also have increased production of IFN-γ, but produce healthy levels of IL-4. In contrast, T2D patients had decreased percentages of CD4(+) Tregs. These data indicate that T cells in T2D patients are naturally skewed toward proinflammatory subsets that likely promote chronic inflammation in T2D through elevated cytokine production. Potential therapies targeted toward resetting this balance need to be approached with caution due to the reciprocal relationship between Th17 cells and Tregs. Understanding the unique aspects of T2D T cells is essential to predict outcomes of such treatments.
Patients with type 2 diabetes (T2D) have disease-associated changes in B-cell function, but the role these changes play in disease pathogenesis is not well established. Data herein show B cells from ...obese mice produce a proinflammatory cytokine profile compared with B cells from lean mice. Complementary in vivo studies show that obese B cell–null mice have decreased systemic inflammation, inflammatory B- and T-cell cytokines, adipose tissue inflammation, and insulin resistance (IR) compared with obese WT mice. Reduced inflammation in obese/insulin resistant B cell–null mice associates with an increased percentage of anti-inflammatory regulatory T cells (Tregs). This increase contrasts with the sharply decreased percentage of Tregs in obese compared with lean WT mice and suggests that B cells may be critical regulators of T-cell functions previously shown to play important roles in IR. We demonstrate that B cells from T2D (but not non-T2D) subjects support proinflammatory T-cell function in obesity/T2D through contact-dependent mechanisms. In contrast, human monocytes increase proinflammatory T-cell cytokines in both T2D and non-T2D analyses. These data support the conclusion that B cells are critical regulators of inflammation in T2D due to their direct ability to promote proinflammatory T-cell function and secrete a proinflammatory cytokine profile. Thus, B cells are potential therapeutic targets for T2D.
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