Primary care-led weight management for remission of type 2 diabetes

Type 2 diabetes is a chronic disorder that requires lifelong treatment. The investigators in this report aimed to assess whether intensive weight management within routine primary care would achieve remission of type 2 diabetes.

Patients aged 20–65 years, diagnosed within the past six years who were not taking insulin were involved. Two hundred and ninety-eight such patients were recruited from 49 primary care practices in Scotland and England. One hundred and forty-nine were allocated to receive a weight management programme delivered by practice dietitians or trained nurses. The other 149 received standard best practice care. At 12 months 24% of the intervention group had lost 15kg or more versus none in the control group. Diabetes remission, defined as glycated haemoglobin of less than 48mmol/mol, occurred in 46% of the patients in intervention group and in 4% of the control group.

The investigators concluded that their findings show that, at 12 months, almost half of participants achieved remission to a non-diabetic state and off antidiabetic drugs. Remission of type 2 diabetes is a practical target for primary care.

Lancet 2018; 391:541–51

Continuous glucose monitoring (CGM)

Interstitial glucose levels, which are closely related to blood glucose levels, can be measured by a sensor inserted subcutaneously. The sensor is linked to a handheld receiver. This enables the subject to deal with epsiodes of hypo- or hyperglycaemia.

This issue is comprehensively reviewed in this paper. Historically there has been concern about the accuracy of these devices. However, the currently available CGM devices have an accuracy approaching 10% when the CGM result is compared with a simultaneous capillary blood glucose treatment.

The authors of the review conclude that CGM in type 1 diabetes improves HbA1C and hypoglycaemia. However, the evidence is less robust for type 2 diabetes. It is noted that the Australian Government has recently agreed to fund CGM for type 1 diabetes in patients under the age of 21 years.

Internal Medicine Journal. 2018; 48:499–508

A role for hydrocortisone therapy in septic shock?

Two studies and an accompanying editorial in a recent NEJM review this important topic.

In one, 3,658 patients were randomised to receive hydrocortisone or placebo in addition to standard ICU care. The researchers noted a significant reduction in the need for mechanical ventilation. However, 90-day mortality was not reduced in the steroid cohort.

In the second study 1,241 patients were randomised to receive hydrocortisone plus fludrocortisone or placebo. The number of ventilation-free days was similar in the two groups. The 90-day mortality was significantly less in the steroid-treated group.

An editorial reviewer noted the different outcomes and speculated that these might be accounted for by differences in the severity of illness between the two studies.

NEJM 2018; 378:797–808 & 2018;378:809–18 & 2018; 378:860–861

‍