Fasting for lab tests isn't good for patients with diabetes

Fasting before getting your blood drawn for cholesterol tests is common practice, but new research from Michigan State University shows it is a contributing factor of low blood sugar, or hypoglycemia, in patients who take diabetes medications.

08 dec 2018--The study, published in the International Journal of Endocrinology, shows that people with diabetes are more likely to experience FEEHD—fasting-evoked en route hypoglycemia in diabetes—than they would if they hadn't fasted. The "en route" comes from patients who have an episode while driving to a lab for blood work.
Saleh Aldasouqi, an endocrinologist in the College of Human Medicine, explained that eating before a lab test does not alter the results of the pivotal components of the cholesterol test as previously thought. In fact, fasting for these tests can incite hypoglycemia in patients with diabetes.
"Hypoglycemia is an overlooked problem that we see from time-to-time in patients with diabetes who show up for lab tests after skipping breakfast," Aldasouqi said. "Patients continue taking their diabetes medication but don't eat anything, resulting in low blood sugar levels that cause them to have a hypoglycemic event while driving to or from the lab, putting themselves and others at risk. Our new motto is 'Feed not FEEHD', to remind patients of this danger and get them to eat."
Hypoglycemia happens when blood sugar levels drop below 70 mg/dl and can cause faintness, confusion and even a loss of consciousness. Severe hypoglycemia can cause acute harm to the patient or others, especially if it causes falls or motor vehicle accidents.
Aldasouqi said that routine fasting is based off guidelines from the 1970s and newer studies show it may not be necessary anymore. Canada and Europe have already changed their guidelines and no longer require fasting for lipid tests, the most commonly ordered fasting labs. Similar U.S. guidelines have not yet become mainstream. In view of the risk of FEEHD, Aldasouqi hopes for diabetes organizations to take a lead in disseminating these emerging changes on lipid testing.
The study showed proper education about fasting and diabetes also is lacking. Only 35 percent of patients surveyed indicated having received any FEEHD prevention instructions from their doctor prior to their lab visit.
"We encourage patients who receive orders for a lab test to ask their doctor if fasting is really necessary, and if so, how they should handle their diabetes medications during the fasting period to account for the changes in their blood sugar levels," Aldasouqi said. "FEEHD is overlooked in clinical practice, and we aim to bring this problem to light and further educate doctors and patients about the consequences of fasting while on diabetes medications."
The study involved 525 patients with diabetes and was conducted at two endocrinology practices in Michigan. Patients completed a two-page survey and were excluded if data was missing or they reported no fasting labs in the previous 12 months. Aldasouqi plans to conduct a larger, population-based study to determine the prevalence of FEEHD in the general population.

More information: Saleh Aldasouqi et al, Fasting-Evoked En Route Hypoglycemia in Diabetes (FEEHD): An Overlooked Form of Hypoglycemia in Clinical Practice, International Journal of Endocrinology (2018). DOI: 10.1155/2018/1528437


Provided by Michigan State University

53 million Americans might have diabetes by 2025, according to new study

Population Health Management is an authoritative peer-reviewed journal published bimonthly in print and online that reflects the expanding scope of health care management and quality. Credit: (c) 2012 Mary Ann Liebert Inc., publishers

The Diabetes 2025 Model for the U.S. projects a continuous and dramatic increase in the diabetes epidemic and makes it possible to estimate the potential effects of society-wide changes in lifestyle and healthcare delivery systems. 

18 may 2012--Predictions for individual states and population subgroups are highlighted in an article published in Population Health Management, a peer-reviewed journal from Mary Ann Liebert, Inc., publishers. The article is available free on the Population Health Management website at http://www.liebertpub.com/pop.
"Diabetes is now a national security issue as it threatens all aspects of our nation's well-being," says Journal Editor-in-Chief David B. Nash, MD, MBA, Dean, Jefferson School of Population Health (Philadelphia, PA).
Based on their Diabetes 2025 Model, William Rowley, MD and Clement Bezold, PhD, Institute for Alternative Futures (Alexandria, VA), project that diabetes (mainly type 2 diabetes) will affect 53.1 million Americans by 2025, an increase of 64% from 2010. Their model can also be used to estimate the benefit of changes in lifestyle and specific interventions in reducing the burden of diabetes, according to the article "Creating Public Awareness: State 2025 Diabetes Forecasts."
Provided by Mary Ann Liebert, Inc.

Guidelines Revised for Management of Type 2 Diabetes Mellitus

November 30, 2007 — The American Diabetes Association and the European Association for the Study of Diabetes have issued a consensus statement on the management of hyperglycemia in type 2 diabetes mellitus. This consensus algorithm for the initiation and update regarding the thiazolidinediones was published in the November 27 Online First issue of Diabetologia.
"New information suggests additional hazards associated with the use of either thiazolidinedione, and rosiglitazone in particular may result in an increased frequency of myocardial infarctions," write David M. Nathan, MD, from the Diabetes Center, Massachusetts General Hospital, Harvard Medical School, in Boston, Massachusetts , and colleagues. "We therefore recommend greater caution in using the thiazolidinediones, especially in patients at risk of, or with, CHF [congestive heart failure]."
Approximately 1 year ago, the American Diabetes Association and the European Association for the Study of Diabetes commissioned development of an evidence-based, consensus algorithm for the management of type 2 diabetes mellitus, which was designed to help clinicians choose the most appropriate treatment regimens from the expanding armamentarium of available drugs.
The guidelines authors note that newly approved medications and new data from clinical trials and other studies should be considered in the management of type 2 diabetes, thereby warranting an update of the algorithm. The present update mainly focuses on recent understanding of the advantages and disadvantages of the thiazolidinediones.
The guidelines also now include the dipeptidylpeptidase-4 inhibitor sitagliptin as a management option in the revised algorithm, noting that this agent was not yet approved by the US Food and Drug Administration (FDA) when the original algorithm was issued. Comments concerning sitagliptin are that expected percentage decrease in hemoglobin A1c (HbA1c) levels is 0.5% to 0.8%. Advantages of sitagliptin are that it is weight neutral, but disadvantages are that there is scant clinical experience with the drug, and it is expensive.
The revised guidelines continue to support the major features of the original algorithm, including the need for tight glycemic control within, or as close to, the nondiabetic range without compromising safety; beginning lifestyle interventions and treatment with metformin at the time of diagnosis; rapidly adding medications and changing to new regimens when target glycemia is not reached; and adding insulin treatment for patients not achieving target HbA1c levels.
"We are mindful of the importance of not changing this consensus guideline in the absence of definitive or compelling new data," the guidelines authors write. "Future updates are planned to consider further revisions of the algorithm, guided by the evidence base and clinical experience with the newer classes of glucose-lowering medications."
In the original consensus algorithm, the thiazolidinediones, insulin, and sulfonylurea were 3 possible options that should be added to metformin and lifestyle intervention if target HbA1c levels (< 7%) were not achieved. However, recent meta-analyses, including 1 performed by the maker (GlaxoSmithKline) and 1 by regulatory authorities, have highlighted the potential risk for myocardial infarction associated with the use of rosiglitazone (30% - 40% relative increase in risk for myocardial infarctions). Although the underlying data are not thought to be conclusive, clinicians are still warned to use extra caution when considering use of rosiglitazone.
However, another recent meta-analysis, reviewing virtually the same data, showed that neither rosiglitazone nor pioglitazone was associated with a significantly increased risk for cardiovascular death.
The Rosiglitazone Evaluated for Cardiac Outcomes and Regulation of Glycaemia in Diabetes (RECORD) study was designed specifically to evaluate cardiovascular outcomes associated with rosiglitazone therapy. Although an interim analysis of RECORD showed an increased risk for CHF associated with rosiglitazone (hazard ratio [HR], 2.15; 95% confidence interval [CI], 1.30 - 3.57), no statistically significant effects of rosiglitazone on myocardial infarction were observed (HR, 1.17; 95% CI, 0.75 - 1.82).
A meta-analysis of clinical trial data concerning the risk for cardiovascular disease associated with use of pioglitazone actually suggested that this drug may have a protective effect. However, both pioglitazone and rosiglitazone have been linked to an increased risk (approximately double) for fluid retention and CHF, which has resulted in a stronger black box warning in the prescribing information for the thiazolidinediones.
Especially in women, both pioglitazone and rosiglitazone have been associated with increased risk for fractures, mostly in the distal extremities (forearm, hand, wrist, foot, ankle, fibula, or tibia), where osteoporotic fractures do not typically occur.
"At this time, we do not view as definitive the clinical trial data regarding increased or decreased risk of myocardial infarctions with rosiglitazone or pioglitazone, respectively," the guidelines authors conclude. "Nor do we think that the increased risk of CHF or fractures with either of the available thiazolidinediones is of a magnitude to warrant their removal as one of the possible second-step medications in our algorithm, given that they cause hypoglycaemia less frequently than other second-step drugs. On the other hand, we do believe that the weight of the new information outlined above should prompt clinicians to consider more carefully whether to use this class of drugs vs insulin or sulfonylureas as the second step in the algorithm."
The guidelines further note that there may be clinically important differences between pioglitazone and rosiglitazone and that maintaining both thiazolidinediones in the current algorithm represents a balance between the need for multiple options to treat a challenging and progressively serious disease such as diabetes and the recent unfavorable data.
Some of the guidelines authors have disclosed various financial relationships with the University of North Carolina, Sanofi-Aventis, GlaxoSmithKline (maker of rosiglitazone), Pfizer, Amylin, Bristol-Myers Squibb, Hoffman-LaRoche, Eli Lilly, NovoNordisk, Merck (maker of sitagliptin), Novartis, AstraZeneca, Merck Sharp & Dohme, Roche, Servier, Boehringer Ingelheim, Takeda (maker of pioglitazone), Johnson & Johnson, and Smiths Medical.
Diabetologia. Published online November 27, 2007.

Novo says NovoRapid approved for the elderly

Thu Sep 20, 4:29 AM ET
Denmark's Novo Nordisk said on Thursday the European Commission had approved its rapid-acting insulin NovoRapid for treatment of diabetes in the elderly and in people with kidney or liver impairment.
The world's biggest maker of insulin said in a statement that NovoRapid had now been established to be safe to use by all people from two years of age with types 1 or 2 diabetes.

Diabetes Linked to Higher Mortality After Acute Coronary Syndromes

Patients with acute coronary syndromes experience higher mortality if they also have diabetes, according to a JAMA study.
Researchers pooled data on some 62,000 patients with acute coronary syndromes who were participants in 11 independent randomized trials from 1997 to 2006. About 17% of the patients had diabetes.
After controlling for other factors, the researchers found that diabetes was independently linked with higher mortality 30 days after ST-segment elevation myocardial infarction (odds ratio, 1.40) and after unstable angina/non-STEMI (OR, 1.78). After 1 year, the risk for death in patients with diabetes who had UA/NSTEMI approached that of patients without diabetes who had STEMI (7.2% vs. 8.1%).
The authors conclude: "Despite modern therapies for [acute coronary syndromes], diabetes confers a significant adverse prognosis, which highlights the importance of aggressive strategies to manage this high-risk population with unstable ischemic heart disease."

Mortality Rates Hold Steady for Women With Diabetes

ATLANTA, June 19 -- Mortality rates for men with diabetes -- but not for diabetic women -- have declined in tandem with the general population's drop in cardiovascular mortality.
A review of data from three large population-based cohorts showed no significant declines in either cardiovascular deaths or all-cause mortality among women with diabetes from the periods spanning 1971-1986 to 1988-2000, reported Edward W. Gregg, Ph.D., of the CDC, and colleagues,
"Our examination of U.S. adults with self-reported diabetes suggests that the well-documented reductions in mortality rates in the general U.S. adult population during the last 25 years have included men with diabetes, but their female diabetic peers have been left behind," the authors wrote online in the Annals of Internal Medicine, scheduled for print in the Aug. 7 issue.
Although the study was not designed to examine the reasons for the disparity, it may have to do with gender-based inequities in care, suggested cardiologist Nanette K. Wenger, M.D., of Emory in Atlanta, in an accompanying editorial.
"Are women with coronary heart disease and diabetes less likely to receive appropriate care?" Dr. Wenger asked. "The answer appears to be yes."
Several studies have shown that coronary heart disease is diagnosed at a later stage in women, that women receive fewer preventive measures than men, and that women less often receive guideline-based therapies during hospitalization or after discharge for an acute coronary event, she wrote.
The study by Dr. Gregg and colleagues tried to answer the question the question of whether the reported decline in all-cause mortality and cardiovascular disease mortality rates also applies to Americans with diabetes.
They compared three consecutive cohorts in the National Health and Nutrition Examination Surveys (NHANES I, II, and III), spanning the years 1971-75, 1976-1980, and 1988-1994, with mortality rates determined through 1986, 1992, and 2000, respectively.
The participants ranged in age from 35 to 74, and included adults both with and without self-reported diabetes.
The authors found that the age-adjusted all-cause mortality rate among men with diabetes declined from 42.6 per 1,000 annually in 1971-86, to 24.4 per 1,000 in 1988-2000 (P=0.03), for a rate ratio of 0.61 (95% CI 0.43 to 0.86). The slope of the decline was similar to that seen in non-diabetic men, which went from 19.0 per 1,000 in 1971-86, to 11.6 per 1,000 from 1988-2000 (rate ratio 0.68. 95% CI 0.57 to 0.81).
Similarly, cardiovascular disease mortality trends in diabetic men paralleled those of all-cause mortality, declining from 26.4 annual deaths per 1,000 in 1971-86, to 12.8 annual deaths per 1,000 in 1988-2000 (P=0.06).
When they looked at women with diabetes, however, they found that there was no decline in either all-cause mortality of cardiovascular disease mortality from 1971-1986 to 1988-2000.
The all-cause mortality rate for non-diabetic women went from 10.1 per 1,000 in NHANES I (1971-1986) to 7.7 in NHANES III (1988-2000). Similarly, the cardiovascular mortality rate among non-diabetic women went from 4.7 in the NHANES I cohort to 2.3 in the NHANESS III cohort.
Among diabetic women, all cause mortality rose from 18.4 per 1,000 from 1971-1986 to 25.9 from 1988-2000, and cardiovascular disease-related deaths went remained essentially unchanged, at 10.5 per 1,000 in NHANES I. to 9.4 per 1,000 in NHANES III.
In addition, the difference in the all-cause mortality rate between diabetic and non-diabetic women increased by more than two-fold, from a difference of 8.3 annual deaths per 1,000 in NHANES I, to 18.2 per 1,000 in NHANES III.
The authors wrote that the decrease in death rates of diabetic men may be attributable to better control of cardiovascular disease risk factors and to improvements in interventions.
"These national data reveal three key findings," Dr. Gregg and colleagues wrote. "1) Reductions in mortality occurred among diabetic men but not among diabetic women; 2) disparities in mortality rates between women with and without diabetes have worsened; and 3) the female-over-male advantage in mortality rates among the diabetic population has been eliminated."
They called for further research into gender inequities in care of patients with diabetes, and for improved public health efforts to lower mortality rates among diabetes patients in general, and women with diabetes in particular.
"We lack an evidence-based comprehensive strategy for improving cardiovascular outcomes in diabetic women," Dr. Wenger wrote in her editorial. "Until we do, a prudent clinical approach involves two steps. First, recognize that diabetic women are at excess risk of developing coronary heart disease. Second, take an aggressive, guideline-based approach to coronary heart disease risk factor management."
Dr. Gregg and colleagues noted that their study was limited by the fact that diabetes was assessed by self-report, and that the study had insufficient statistical power to examine the factors explaining mortality trends.
The study was supported by the CDC. The authors had no conflicts of interest to report.Additional source: Annals of Internal MedicineSource reference: Gregg EW et al. "Mortality Trends in Men and Women with Diabetes, 1971-2000." Ann Intern Med. 2007; 147, 3. Additional source: Annals of Internal MedicineSource reference: Wenger NK. "Heightened Cardiovascular Risk in Diabetic Women: Can the Tide be Turned?" Ann Intern Med. 2007; 147.

ASE: Perfusion Echo Picks Up CAD in Diabetic Patients

SEATTLE, June 19 -- Real-time perfusion imaging during dobutamine stress echocardiography can identify asymptomatic diabetic patients at risk of clinical events from occult coronary artery disease, researchers found.
Patients who had either myocardial perfusion defects or wall motion abnormalities had a significantly lower event-free survival (P<0.001 and P=0.004, respectively) compared with patients who had normal echo studies, Saritha Dodla, M.D., of the University of Nebraska in Omaha, reported at the American Society of Echocardiography meeting here.
Perfusion defects in the absence of wall-motion abnormalities also identified patients at risk of clinical events, Dr. Dodla and colleagues found.
"Conventional heart ultrasound evaluates wall motion abnormalities," said Dr. Dodla. "Real-time perfusion echocardiography looks at blood flow into the heart muscle, thereby increasing the accuracy of the stress test. We think this test is better than what is in clinical practice right now."
The researchers evaluated 149 consecutive patients with type I or type II diabetes who showed no symptoms of coronary artery disease. None of the patients had a history of CAD, coronary revascularization, chest pain, dyspnea, or resting segmental wall motion abnormalities on baseline echocardiography. All of the patients had a normal resting ejection fraction that averaged 58%.
Segmental myocardial perfusion and wall motion in three coronary-artery territories were analyzed at rest and during peak dobutamine stress. Myocardial perfusion and contrast-enhanced wall motion abnormalities were interpreted by means of a 17-segment model.
Abnormal perfusion was defined as a defect in contrast enhancement in two or more contiguous segments. Abnormal wall motion was defined as abnormalities in two contiguous segments.
The patients were followed for a median of 23 months for coronary events (nonfatal myocardial infarction, death, or the need for urgent revascularization).
Inducible perfusion defects were identified in 25 patients; 12 patients had inducible wall-motion abnormalities.
Patients with perfusion defects had an event-free survival of 72% versus 98% in patients with normal perfusion responses (P<0.001). The presence of wall-motion abnormalities was associated with a 67% event-free survival, compared with 96% among patients with normal wall motion (P=0.004).
Thirteen patients had abnormal perfusion but normal wall motion. Three of those patients had nonfatal myocardial infarctions during follow up.
"Real-time perfusion imaging during dobutamine stress testing is a promising technique to detect occult CAD in asymptomatic diabetic patients," Dr. Dodla concluded.
"Use of this technique during preoperative risk stratification will help identify patients at risk for perioperative cardiovascular complications. This method also can be used for primary prevention, enabling early detection of CAD and decreasing the risk of cardiovascular events."

Diabetes Mellitus Linked to Depressive Symptoms in Well-Functioning Older Adults

June 13, 2007 — Diabetes mellitus is linked to depressive symptoms in well-functioning older adults, according to the results of the Health, Aging, and Body Composition (Health ABC) Study published in the June 11 issue of the Archives of Internal Medicine.
"Cross-sectional studies find an elevated prevalence of depression among subjects with diabetes mellitus (DM)," write Cinzia Maraldi, MD, from the University of Florida in Gainesville and colleagues from the Health ABC Study. "The causal mechanisms and temporal sequence of this association have not been clearly delineated. This study investigated the prospective relationship between DM and depressive symptoms."
The Health ABC Study was a cohort study of community-dwelling adults, aged 70 to 79 years, without baseline depressive symptoms who were living in the metropolitan areas of Memphis, Tennessee, and Pittsburgh, Pennsylvania. Incident depressed mood was defined as antidepressant use or presence of depressive symptoms (score ≥ 10 on a 10-item subset of the Center for Epidemiological Studies Depression Scale [CES-D]) at follow-up visits. Recurrent depressed mood was defined as presence of incident depressed mood at 2 consecutive annual clinic visits.
At baseline, the investigators evaluated glycosylated hemoglobin (HbA1c) level, DM status (absent, controlled [HbA1c level, < 7%], or uncontrolled [HbA1c level, ≥ 7%]), and DM-related comorbidities in 2522 participants. Depressive events risk was estimated from discrete time survival analysis. Mean duration of follow-up was 5.9 years.
During follow-up, participants with DM had a higher age-, sex-, race-, and site-adjusted incidence of depressed mood (23.5% vs 19.0%; P = .02) and of recurrent depressed mood (8.8% vs 4.3%; P < .001) than did those without DM. Although DM was associated with an increased risk for incident depressed mood (odds ratio [OR], 1.31; 95% confidence interval [CI], 1.07 - 1.61), adjustment for DM-related comorbidities reduced this increased risk (OR, 1.20; 95% CI, 0.97 - 1.48).
There was a stronger relationship between DM and recurrent depressed mood (OR, 1.91; 95% CI, 1.32 - 2.76), especially in participants with poor glycemic control.
"Among well-functioning older adults, DM is associated with increased risk of depressive symptoms," the authors write. "In particular, older adults with DM had an almost 2-fold increased risk of developing recurrent depressed mood. The increased risk of depressed mood was mainly observed among participants with DM and poor glycemic control, and HbA1c was an independent predictor of recurrent depressed mood among subjects with DM."
Study limitations include failure to record episodes of depressive symptoms between clinic visits that resolved during this period, CES-D capture of presence of depressed mood only in the past week, lack of data on depressive episodes before study entry, lack of data on the use of nonpharmacologic depression treatment, lack of data on information about change with time and about severity of DM complications, inability to completely rule out potential confounders, and narrow age range of the study inclusion criteria limiting the generalizability of the results.
"As the life expectancy of older Americans increases, DM is becoming a disease of older adults," the authors conclude. "Depression is among [the] key geriatric outcomes that strongly impact health-related quality of life of older adults but that are often underdiagnosed and undertreated. From this point of view, our results underline the importance of a clinical approach to the patient with DM that includes an appropriate screening for early detection and treatment of depressive symptoms."
The Intramural Research program of the National Institutes of Health, National Institute on Aging, and the National Heart, Lung, and Blood Institute supported this study. The authors have disclosed no relevant financial relationships.
Arch Intern Med. 2007;167:1137-1144.