Diabetes

Talking points that Repertoire readers can share with their physician customers.

Editor’s note: Diabetes affects more than 25 percent of Americans aged 65 or older, and its prevalence is projected to increase two-fold for all U.S. adults (ages 18-79) by 2050 if current trends continue.

Cardiovascular disease and diabetes

Cardiovascular disease is the leading cause of morbidity and mortality for people with diabetes. The 2020 Standards of Medical Care in Diabetes, published in December 2019 by the American Diabetes Association, offers recommendations for screening, testing and treating people with diabetes to reduce the occurrence of cardiovascular disease. The recommendations have been individualized based on patients’ risk, including the presence of atherosclerotic cardiovascular disease (ASCVD) or ASCVD risk factors, diabetic kidney disease or heart failure.

The Standards say that in asymptomatic patients, routine screening for coronary artery disease is not recommended, as it does not improve outcomes as long as ASCVD risk factors are treated. However, providers should consider investigating for coronary artery disease in the presence of atypical cardiac symptoms (e.g., unexplained dyspnea, chest discomfort); signs or symptoms of associated vascular disease, including transient ischemic attack or stroke; or electrocardiogram abnormalities (e.g., Q waves).

The Standards of Care is available online at https:///care.diabetesjournals.org, and is published as a supplement to the January 2020 issue of “Diabetes Care.”

Diabetes and heart failure

Diabetes is an independent risk factor and is associated with the development of heart failure over time, conclude researchers at Mayo Clinic, who reported their findings in January 2020 “Mayo Clinic Proceedings.” Approximately 21% (22 of 116) of patients with diabetes mellitus developed heart failure over a 10-year period, which is significantly elevated when compared with patients without diabetes (12% [24 of 232]). In the study, researchers say they have also shown that participants with diabetes – even in the absence of diastolic dysfunction (that is, abnormal pumping of the heart) – are more likely than those without diabetes to develop heart failure. Future research should be focused on whether aggressive management of risk factors such as BMI and glucose and cholesterol levels will decrease the development of heart failure in patients with diabetes.

The elderly and type 1 diabetes

People with type 1 diabetes are living longer. Hence the American Diabetes Association has added a subsection focusing on special considerations for older adults with type 1 diabetes in the 2020 Standards of Medical Care in Diabetes. Some points for doctors and their patients to keep in mind:

In order to avoid diabetic ketoacidosis, older adults with type 1 diabetes need some form of basal insulin even when they are unable to ingest meals. Insulin may be delivered through insulin pump or injections.
Continuous glucose monitoring (CGM) is approved for use by Medicare and can play a critical role in improving A1C, reducing glycemic variability, and reducing risk of hypoglycemia.
Administration of insulin may become more difficult as complications, cognitive impairment, and functional impairment arise in older people with type 1 diabetes. This increases the importance of caregivers in the lives of these patients.
Many older patients with type 1 diabetes require placement in long-term care settings. Unfortunately, these patients may encounter providers who are unfamiliar with insulin pumps or CGM. Some providers may be unaware of the distinction between type 1 and type 2 diabetes. In these instances, the patient or the patient’s family may be more familiar with diabetes management than the providers.
Education of relevant support staff and providers in rehabilitation and LTC settings regarding insulin dosing and use of pumps and CGM is recommended as part of general diabetes education.

The Standards of Care is available online at https:///care.diabetesjournals.org, and is published as a supplement to the January 2020 issue of Diabetes Care.

Young people and types 1 and 2 diabetes

The incidence of type 1 and type 2 diabetes among young people in the United States is on the rise, and has been since at least 2002, especially among racial and ethnic minority populations, according to the Centers for Disease Control and Prevention.

From 2002 to 2012, type 1 and type 2 diabetes incidence increased 1.4% and 7.1%, respectively, among U.S. youths. To assess recent trends in incidence of diabetes in youths (defined as persons under age 20), researchers analyzed 2002–2015 data from the SEARCH for Diabetes in Youth Study, a U.S. population-based registry study with surveillance of 69.5 million youths in five states. Among all youths, the incidence of type 1 diabetes increased from 19.5 per 100,000 in 2002–2003 to 22.3 in 2014–2015. Among persons aged 10–19 years, type 2 diabetes incidence increased from 9.0 per 100,000 in 2002–2003 to 13.8 in 2014–2015. For both type 1 and type 2 diabetes, the rates of increase were generally higher among racial/ethnic minority populations than among whites.

Diabetes is a chronic disease that requires lifelong treatment and management, point out CDC researchers. Better understanding of the number of new cases of diabetes among youths helps in planning for healthcare needs and resources.

Statins and diabetes

Several studies have reported a modestly increased risk of incident diabetes with statin use, which may be limited to those with diabetes risk factors, according to the 2020 Standards of Medical Care in Diabetes, published in December 2019 by the American Diabetes Association. However, an analysis of one of the initial studies suggested that although statin use was associated with diabetes risk, the reduction in cardiovascular events far outweighed the risk of incident diabetes even for patients at highest risk for diabetes. The absolute risk increase was small: Over five years of follow-up, 1.2% of participants on placebo developed diabetes, and 1.5% on rosuvastatin developed diabetes. A meta-analysis of 13 randomized statin trials with 91,140 participants showed that (on average) treatment of 255 patients with statins for four years resulted in one additional case of diabetes while simultaneously preventing 5.4 vascular events among those 255 patients.

Here’s the bottom line for patients, researchers concluded in a study published in October 2019 in the “British Journal of Clinical Pharmacology”: Clinicians should be aware of the association between statins and skin and soft-tissue infections (which are associated with diabetes), and, where appropriate, monitor blood glucose levels of statin users.

The financial cost of diabetes

The Centers for Medicare & Medicaid Services estimates that Medicare spent $42 billion more in the single year of 2016 on beneficiaries with diabetes than it would have spent if those beneficiaries did not have diabetes. Per beneficiary, Medicare spent an estimated $1,500 more on Part D prescription drugs, $3,100 more for hospital and facility services, and $2,700 more in physician and other clinical services for those with diabetes than those without diabetes. (Estimates based on fee-for-service, non-dual eligible, over-age-65 beneficiaries.)

Diabetes complications can snowball

Diabetes complications often share the same risk factors, and one complication can make other complications worse, says the Centers for Disease Control and Prevention. Some examples:

Heart disease and stroke: People with diabetes are two times more likely than people without diabetes to have heart disease or a stroke.
Blindness and other eye problems: Diabetes can lead to blood vessels in the retina, cataracts, glaucoma.
Kidney disease: High blood sugar levels can damage the kidneys and cause chronic kidney disease.
Nerve damage (neuropathy): Nerve damage most often affects the feet and legs but can also affect digestion, blood vessels, and heart.
Amputation: Diabetes-related damage to blood vessels and nerves, especially in the feet, can lead to serious, hard-to-treat infections. Amputation can be necessary to stop the spread of infection.
Gum disease: Gum disease can lead to tooth loss and increased blood sugar, making diabetes harder to manage. It can also increase the risk of type 2 diabetes.
Depression: Diabetes increases the risk of depression, and that risk grows as more diabetes-related health problems develop.
Gestational diabetes: Diagnosed during pregnancy, gestational diabetes can lead to preeclampsia (high blood pressure caused by pregnancy), injury from giving birth, and birth defects.

Complications usually develop over a long time without any symptoms. That’s why it’s so important for patients to make and keep doctor and dentist appointments, even if they feel fine.

Life insurance for people with diabetes

Half of Americans with diabetes lack an adequate amount of life insurance, or don’t have any life insurance at all, reports insurance company John Hancock. Many worry they won’t qualify for life insurance because they have diabetes, or that a life insurance policy would be unaffordable. John Hancock – in collaboration with Verily, an Alphabet company, and Onduo, a virtual “clinic” for people with type 2 diabetes – now offers a life insurance policy specifically for Americans with diabetes. Clients of John Hancock Aspire™ will receive a blood glucose monitoring device which, when used in conjunction with the Onduo app, provide insights into the user’s diabetes management. Onduo’s “virtual care team,” made up of dieticians, diabetes educators and doctors, offers personalized guidance and support regarding diet, activity, lifestyle habits and medication management. Those using Onduo to manage and improve their health can earn points to further boost their overall Vitality rewards and lower their premiums.

Bionic pancreas gets FDA “Breakthrough Device” designation

Beta Bionics Inc. (Boston, Massachusetts) received Breakthrough Device designation in December 2019 from the U.S. Food and Drug Administration for its automated bionic pancreas. The iLet Bionic Pancreas System is a pocket-sized, wearable device designed to autonomously control blood-sugar levels. The on-body wear is similar to that of an insulin pump. Unlike insulin pump therapy, however, the iLet system allows users to enter only their body weight for the iLet to initialize therapy. Immediately thereafter, the iLet begins controlling blood-sugar levels automatically, without requiring the user to count carbohydrates, set insulin delivery rates, or deliver bolus insulin for meals or corrections.

Smart insulin patch

UCLA bioengineers and colleagues at UNC School of Medicine and MIT have further developed a smart insulin-delivery patch that could one day monitor and manage glucose levels in people with diabetes and deliver the necessary insulin dosage. The adhesive patch, about the size of a quarter, is said to be simple to manufacture and intended for once-a-day use. The adhesive patch monitors blood sugar, or glucose. It has doses of insulin pre-loaded in tiny microneedles, less than one-millimeter in length, which deliver medicine quickly when the blood sugar levels reach a certain threshold. When blood sugar returns to normal, the patch’s insulin delivery also slows down. The researchers said the advantage is that it can help prevent overdosing of insulin, which can lead to hypoglycemia, seizures, coma or even death. A study, published in Nature Biomedical Engineering, describes research conducted on mice and pigs.