Clinical Briefs
By Louis Kuritzky, MD, Clinical Assistant Professor, University of Florida, Gainesville. Dr. Kuritzky is a consultant for Sucampo Pharmaceuticals, Takeda, Boehringer Ingelheim; and is a consultant and on the speaker's bureau for Novo Nordisk, Lilly, Daiichi Sankyo, Forest Pharmaceuticals, Cephalon, Novartis, and Sanofi Aventis.
Bariatric surgery for obese diabetic subjects
Source: Keating CL, et al. Cost-efficacy of surgically induced weight loss for the management of type 2 diabetes: A randomized controlled trial. Diabetes Care 2009;32:580-584.
Weight management issues continue to be problematic for persons with type 2 diabetes. Success attainable with exercise, diet, and pharmacotherapy has great limitations. Surgical approaches provide prompt, dramatic results; indeed, the metabolic responses to gastric bypass surgical procedures occur more rapidly and intensively than can be attributed to simple weight loss.
Since management of diabetes and its consequences incurs a substantial burden on health care systems, it is conceivable that not only is a surgical approach metabolically beneficial, but it might also be cost-effective.
A randomized controlled trial in Australia of obese persons (n = 60) compared surgical therapy with conventional diabetes management (diet, exercise, and pharmacotherapy). The conventional treatment arm received much more intensive support than that seen in typical clinical practice, thus making the challenge for the surgical intervention (laparoscopic adjustable gastric banding) to demonstrate superiority even more difficult.
In the first 6 months of this 2-year study, costs were 7-fold greater in the surgical group than conventional treatment; cost differentials progressively declined with time, such that costs were equal in both groups in the last 6 months of the trial. In these newly diagnosed diabetics, surgical treatment was associated with 18 additional cases of remission of diabetes, at a cost of AUD$16,600 (US$13,000) per case. These data support surgical therapy as a cost-effective intervention for obesity in type 2 diabetes.
Microalbuminuria and venous thromboembolism
Source: Mahmoodi BK, et al. Micro-albuminuria and risk of venous thromboembolism. JAMA 2009;301:1790-1797.
Current laboratory standards indicate that normal urinary albumin excretion (UAE) should not exceed 30 mg/24 hours in healthy persons. Acute stressors (e.g., fever, significant physical exertion, acute illness) can transiently induce UAE above these limits and require reevaluation. Sustained increases in UAE between 30-300 mg/24 hours are designated microalbuminuria, which is separated from macroalbuminuria (frank nephropathy) by prognostic distinctions: Microalbuminuria can often be halted or even reversed, whereas frank nephropathy typically progresses to end-stage renal disease (although it may be slowed with pharmacotherapy).
Numerous data sets have consistently shown a relationship between abnormal UAE and arterial vascular disease, specifically coronary artery disease and ischemic stroke. In essence, it appears that the same vasculopathy manifest in the glomerulus as increased UAE heralds vasculopathy elsewhere in the arterial vascular tree.
The Prevention of Renal and Vascular End-state Disease trial is an ongoing study of all adult residents of Groningen, Netherlands (n = 85,421). A cohort from this population (n = 8592) was followed for 8.6 years. Venous thromboembolism (pulmonary embolus and/or DVT) was twice as common in persons with microalbuminuria as without. Indeed, there was a linear relationship of increased DVT risk with increasing levels of albuminuria. This study expands the pathologic associations of increased UAE to the venous side of the circulation.
CRP: A link between sleep apnea and CV adversity
Source: Lui MM, et al. C-reactive protein is associated with obstructive sleep apnea independent of visceral obesity. Chest 2009;135:950-956.
The link between obstructive sleep apnea (OSA) and cardiovascular (CV) adversity is strong and consistent. The primary putative mechanism leading to adverse CV events is the hyperactivation of the sympathetic nervous system routinely identified in persons with OSA; higher levels of sympathetic tone appears to be the compensatory response to progressive increases in apnea and hypopnea. Confirming this association are the reductions in blood pressure, arrhythmia, and catecholamine levels seen with successful interventions such as CPAP.
Yet, there may be other etiologic factors. Lui et al studied non-obese men (n = 111) who had sleep apnea to investigate whether OSAindependent of visceral adiposity seen in obese individualsis associated with increased levels of CRP.
The mean CRP level was significantly higher in persons with moderate-to-severe OSA than in men with no/mild OSA (1.32 vs 0.54). These data suggest that OSA is associated with higher levels of CRP, independent of visceral adiposity. Because the data were determined solely in men, a similar relationship cannot be presumed in women. Interestingly, a pediatric trial found reductions in CRP subsequent to tonsillectomy, but CRP results of OSA treatment in adults have been conflicting.
Weight management issues continue to be problematic for persons with type 2 diabetes.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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