Cardio Metabolic Health Congress – Official Blog

New “Fingerprint” of Inflammation Identified in Obesity-Associated T2DM

Researchers at Boston University School of Medicine have identified a new “fingerprint” of inflammation that may be able to predict which patients with obesity may also develop type 2 diabetes. Specifically, inflammatory proteins known as Th17 cells, which are associated with autoimmune conditions, were identified as major contributors to inflammation and hyperglycemia. Although research has already shown inflammation promotes obesity-related type 2 diabetes and related complications, anti-inflammatory drugs have had limited success in treatment. Thus, the findings may provide better insight into the relationship between inflammation and obesity-related type 2 diabetes.

Read more on the study published in the journal Obesity  here.

Lixisenatide Proves Safety in ELIXA While Liraglutide Shows Greater HbA1c Reduction Compared with SGLT-2 Inhibitors

CV outcomes data from the ELIXA trial have been published in the New England Journal of Medicine for the as-yet FDA unapproved GLP-1 agonist lixisenatide, and have shown no increase or decrease in the rate of major cardiovascular events in patients with acute coronary syndrome. Read more here.

Meanwhile, findings from a recent meta-analysis have shown that among people with type 2 diabetes the GLP-1 agonist liraglutide provided greater HbA1c reductions compared with SGLT-2 inhibitors. Comprising the meta-analysis were 17 randomized controlled trials that included patients with type 2 diabetes inadequately controlled with metformin alone or in combination with sulfonylurea, DPP-4 inhibitors, or thiazolidinedione. Liraglutide was also associated with an improved likelihood of achieving glycemic goals compared with SGLT-2 inhibitors. Read more from a press release on the meta-analysis here.

Pfeffer MA et al. Lixisenatide in patients with type 2 diabetes and acute coronary syndrome. N Engl J Med. 2015;373:2247-2257.

Lorenzi M et al. Liraglutide vs SGLT-2 inhibitors in people with type 2 diabetes: a network meta-analysis. Presented at 23rd World Diabetes Congress, Vancouver, BC, Canada; 30 November – 4 December 2015. Abstract number 0226-P.

Lack of Sleep Reduces Insulin Sensitivity, May Increase Risk of Diabetes

Results of a recent study co-authored by CMHC Chair Robert Eckel, MD, showed that a lack of adequate sleep in healthy study participants led to a reduction in insulin sensitivity of approximately 20%, which may increase their risk of developing diabetes over time. Further, eating during the biological night may alter the way the body responds to the food and impairing insulin sensitivity. Although increasing sleep from 5 hours per night to 9 hours per night for 3 days restored oral insulin sensitivity, the same increase in sleep for 5 days was insufficient to restore intravenous insulin sensitivity. “We did a study last year showing weight gain is caused by a lack of sleep and now we find that there could also be a risk of diabetes,” Dr. Eckel said. “While the exact mechanisms are unknown, it’s clear that a lack of sleep causes metabolic stress.”

Read perspective on the study here and the full study here.

Eckel et al. Morning circadian misalignment during short sleep duration impacts insulin sensitivity. Current Biology. http://dx.doi.org/10.1016/j.cub.2015.10.011.

Are Newest Screening Recommendations for Type 2 Diabetes Falling Short?

In an update to their 2008 recommendations, the US Preventive Services Task Force (USPSTF) is calling for screening of overweight and obese adults between 40 and 70 years of age for abnormal blood glucose levels and type 2 diabetes. The recommendation applies to individuals being seen in primary care settings with no symptoms of type 2 diabetes as a component of cardiovascular risk assessment. Adults who are shown to have elevated glucose levels should be referred for intensive behavioral counseling, emphasizing a healthy diet and regular physical activity. Read more

Education of Youth Is Key to Promoting Wellness and Alleviating the Obesity Epidemic

Results of a recent study found that among children and young adults with a BMI at the 85th percentile or higher, cardiometabolic risk factors including low HDL-C, high systolic and diastolic blood pressures, and high triglyceride and glycated hemoglobin levels increased with the severity of obesity. Commenting on the study, CMHC faculty member Caroline Apovian, MD pointed out the prevalence of severe obesity in children between 2 and 19 years of age has increased at an alarming rate, from 4% to 6% for the block of years from 1999 to 2004 and 2011 to 2012. However, she said, educating the young, even those as young as preschool age, is key in combating obesity and promoting wellness, citing the Si! Program in Madrid, Spain as a successful example. Read more

USPSTF Recommends ABPM to Confirm Hypertension Diagnosis and Yearly Screening for Higher Risk Groups

In an update to their 2007 reaffirmation recommendation statement, the US Preventive Services Task Force (USPSTF) finalized Grade A recommendations for blood pressure screening of adults. The use of ambulatory blood pressure management (ABPM) is recommended to confirm a diagnosis of hypertension outside of the clinical setting before treatment begins. (The exception to this recommendation is for cases in which therapy should begin immediately.) Further, adults 40 years of age and older and those at higher risk should undergo screening every year after a normal blood pressure finding; others can be screened every 3 to 5 years.

In response to public comments that were received after the draft version of the recommendation statement was released in December 2014, the USPSTF acknowledges there are barriers to implementing their recommendation of utilizing ABPM due to availability and affordability. In response, their final recommendation is “to include home blood pressure monitoring (HBPM) as an alternative method for confirmation of a diagnosis of hypertension when ABPM is not feasible.”

To learn more, plan to attend the Hypertension and Cardio-Renal Syndrome session at the 10th Annual CMHC on Friday, October 23, and read more on the USPSTF recommendations here.

Screening for high blood pressure in adults: US Preventive Services Task Force Recommendation Statement. Ann Intern Med. Published online 13 October 2015 doi:10.7326/M15-2223.

Bariatric Surgery Appears to Cure Half of Patients with T2DM for at Least 5 Years

In a study of obese patients with type 2 diabetes, bariatric surgery was found to be more effective than medical treatment in the long-term control of the disease (for at least 5 years). The study consisted of 60 patients randomized to either medical treatment or surgery (Roux-en-Y gastric bypass or biliopancreatic diversion). The primary endpoint was the rate of diabetes remission at 2 years (defined as HbA1c of 6.5% or less and a fasting glucose concentration of 5.6 mmol/L or less) without active pharmacologic treatment for 1 year. Patients were followed up for 5 years. Among 38 patients who underwent surgery, 19 (50%) maintained diabetes remission at 5 years compared with none of the 15 medically treated patients. The study authors advise continued monitoring of glycemic control because of a potential relapse for hyperglycemia.

Read the complete study here in The Lancet. To learn more from one of the study authors, Dr. Francesco Rubino, be sure to attend the 10th Annual CMHC where he will co-present “Long-Term and Metabolic Effects of Bariatric Surgery” on Friday, October 23, from 3:25 – 4:05 pm with Dr. Lee M. Kaplan.

Elevated Blood Pressure Increases Risk of Type 2 Diabetes

Results of a recent study published in the Journal of the American College of Cardiology are lending weight to the widely believed hypothesis that hypertension is an independent risk factor for type 2 diabetes. The study, an analysis of electronic health records and a meta-analysis, consisted of 4.1 million adults without diabetes and cardiovascular disease. The objective was to evaluate the association between usual blood pressure and risk of diabetes.

Each 20 mmHg increase in systolic blood pressure and 10 mmHg increase in diastolic blood pressure was associated with a 58% and a 52% higher risk of new-onset diabetes. The strength of that association per 20 mmHg higher SBP decreased with age and increasing body mass index. According to the study authors, “Elevated blood pressure is associated with chronic inflammation and endothelial dysfunction, both of which appear to be mediators of diabetes risk. There is, therefore, a biological rationale to suspect that elevated blood pressure may cause new-onset diabetes.” Read more

FDA Grants Approval for Two New Insulin Therapies

Two new insulin formulations were recently granted FDA approval: Tresiba® (insulin degludec), a long-acting insulin analog that can be administered once daily any time of day, and Ryzodeg®, a combination of insulin degludec and rapid-acting insulin aspart that is taken once or twice per day with any main meal. Both are indicated for adults with type 1 and 2 diabetes.

The approvals add to a growing list of insulin options for patients with diabetes. Toujeo® (insulin glargine U300) was approved earlier this year and Afrezza®, the only inhaled insulin available in the US, reached pharmacies in February. Learn more about these newest options and how they can help you customize your patients’ insulin regimens at the 10th Annual CMHC. On Friday, October 23, Dr. Matthew Riddle will chair the symposium, “Paving the Way to Patient Acceptance, Adherence and Satisfaction: The Role of Next-Generation Insulin Therapies,” and Dr. Anne Peters will chair “The Evolution of Insulin Therapy: New Developments in Treatment, Technology, and Methods of Administration” on Saturday, October 24. Read more

SGLT-2 Inhibitor Empagliflozin Significantly Reduces CV Risk and Mortality in CV Outcomes Trial

Results of the EMPA-REG OUTCOME trial have shown that the SGLT2-inhibitor empagliflozin significantly reduced the risk of myocardial infarction, stroke, and CV death, as well as death from any cause, in more than 7000 adults with type 2 diabetes at high CV risk. Patients in the study were given either low- or high-dose empagliflozin or placebo in combination with standard treatment (eg, glucose-lowering, lipid-lowering, and antihypertensive agents).

Expert analysis of the trial indicates the most impressive findings are the early and profound reductions both in all-cause and CV mortality as well as hospitalization for heart failure. Further speculation by Dr. James Stein, of the University of Wisconsin Medical School, points to the treatment of metabolic syndrome for these dramatic results rather than simply an effect on glycemic control. “Unclear what the mechanism is, but I suspect it is not just the lower blood sugar levels. Since waist circumference and blood pressure went down and HDL-C went up, it appears to be treating the metabolic syndrome, perhaps by reducing insulin resistance.”

Empagliflozin was approved by the FDA last year and is the first glucose-lowering agent to demonstrate CV risk reduction in a CV outcomes trial. Earlier this year, the TECOS findings were released providing reassurance on the cardiovascular safety of the DPP-4 inhibitor, sitagliptin. Previous studies (SAVOR-TIMI 53 and EXAMINE) have associated DPP-4 inhibitors with increased risk of heart failure causing some concern.

The 10th Annual CMHC provides the perfect venue to keep up to date on these and other important developments. To provide expert perspective and answer questions on the cardiovascular implications of type 2 diabetes therapies, CMHC is hosting a CME symposium titled “A Closer Look at CV Outcomes for Type 2 Diabetes Therapies: Implications for Patient Care” on Thursday, October 22. Jay S. Skyler, MD will chair, accompanied by faculty Deepak L. Bhatt, MD, MPH, Jennifer B. Green, MD, and Darren K. McGuire, MD, MHSc.

Read details of the complete EMPA-REG OUTCOME study in NEJM here and more interpretation here.