International Diabetes Federation 2003

Insulin pump usage is lower in the UK than in the US
Thousands of patients in Europe do not have access to, or use, insulin pump therapy, reported Dr Pinget (Centre Hospitalier Universitaire, Strasbourg) at the IDF. Only 1.3% of patients with diabetes in the UK and 1.2% of patients in Italy use insulin pumps compared with about 10% of Americans. Interestingly though, the survey also found that more than half of healthcare professionals with type 1 diabetes use an insulin pump to treat their own disease.

‘Insulin pump technology brings considerable advantages to diabetes patients, allowing them to return to a more normal life. That thousands of European patients are unaware of, or being denied access to, them is a tragedy’, said Dr David Kerr (Royal Bournemouth Hospital).

Dr Eric Renard (Centre Hospitalier Universitaire) welcomed the launch of CGMS System Gold, a new type of glucose sensor which can collect up to 288 glucose readings a day. He explained that this continuous glucose monitoring system could provide ‘physicians and patients with 72 times more information’ than blood samples using four daily finger stick measurements.

Morag McLaren (Business Manager, Medtronic Minimed) commented that in the UK, pumps had received favourable NICE recommendations in Feb 2003 but funding was still being refused by many PCTs. ‘Our objective is that everybody that could benefit from an insulin pump and meets the NICE selection criteria can get a pump. At present, patients are missing out on this opportunity’, she said.

Is insulin detemir worth it?
Insulin detemir was a hot topic at the IDF. Mads Krogsgaard Thomsen, Professor of Pharmacology and Executive Vice President and CSO of Novo Nordisk chaired the meeting. He began the session with the figure of 0.5 billion euros… which is how much Novo Nordisk spent on research and development last year. As one of the newest basal insulin analogues around, is insulin detemir worth the pennies that have been pumped into it?

Research to date is affirmative. The aim of insulin therapy is to mimic the normal physiological response, and according to Dr Peter Kurtzhals, Senior Vice President of Novo Nordisk, insulin detemir does this more successfully than any other basal

insulin analogue on the market. The consequence is ‘smooth, long-lasting absorption, more predictable glycaemic control and a 20% reduction in hypoglycaemic episodes’, said Dr Kurtzhals. ‘Insulin detemir lowers weight in people with type 1 and type 2 diabetes – this was unexpected and our most consistent finding’, continued Dr Kurtzhals.

Dr Tim Heise, CEO of Profil, Germany discussed a single centre, parallel group, double-blind study of 54 people with type 1 diabetes. ‘Results showed that insulin detemir is associated with significantly less within-patient variability (in terms of fasting blood glucose levels) in comparison to other insulins’, said Dr Heise.

Diabetes workshops encourage active learning
A symposium was held on Monday 25th August at the IDF on how to organise diabetes education on a large scale. Dr Margalit Goldfracht from Clalit Health Services, Israel, spoke about a scheme for educating primary care providers. As a learning tool ‘lectures are good as they are cost effective and easy to organise’, said Dr Goldfracht. However, information disseminated is not remembered as well as if workshops are used.

‘Workshops are better as it is active learning, so there is good assimilation of knowledge and skills’, continued Dr Goldfracht. Judging by the success of the education programme that Dr Goldfracht was involved in, the answer is a combination of both. Since the programme was established, Israeli healthcare professionals have been increasingly testing HbA_1c, and a reduction in complications has been reported.

Building for the future – satellite meeting of the IDF
The sixth international conference of PCDE Europe was an official satellite of IDF 2003. It took place in the Hopital Européen Georges Pompidou, Paris on 23–24 August 2003.

Rhys Williams (UK), who gave the keynote lecture, spoke about healthcare systems across Europe, emphasising the effectiveness of structured care and that primary care should not adopt a passive role. He noted that access, motivation, communication and adherence were the cornerstones of a good service.

Torsten Lauritzen (Denmark) presented an analysis of the research evidence relating to control of blood pressure, blood glucose and lipids in type 2 diabetes.

Hilary Hearnshaw (UK) reported findings from Eurobstacle, a multicentre study on obstacles to healthcare. She explained that international collaboration was needed to identify ways of dealing with the obstacles.

Timo Saaristo (Finland) described a screening programme for high risk groups linked with an electronic management and quality improvement system.

On the second day, Mary Banotti (Ireland), who is a member of the European parliament with responsibility for securing funding for diabetes management, encouraged people to fight for the needs of people with diabetes in face of competition from groups representing other diseases.

Speaking for the WHO, Gojka Roglic (Geneva) emphasised the need for more research, information and training in relation to diabetes. She said that funds were available for research and education but highlighted the growing problem of pre-diabetes and obesity.

Acting to improve insulin sensitivity
According to data presented at the IDF meeting in Paris, pioglitazone HCI (Actos) alone or in combination with metformin or sulphonylurea sustains improvements in blood glucose control and improves estimates of insulin sensitivity over the long term (52 weeks). Pioglitazone HCI not only improved fasting glucose levels but also improves postprandial glucose and postprandial lipid levels.

Takeda UK Ltd announced on September 2, 2003, that the European Commission has granted marketing authorisation for the use of Actos as oral monotherapy. It has been approved for doses up to 45 mg in people with type 2 diabetes, particularly in those who are overweight, inadequately controlled by diet and exercise and for whom metformin is inappropriate because of contraindications or intolerance.

Only a quarter of patients believe insulin will improve their condition
The problem of patient compliance reared its head again… this time at the IDF on 26th August. ‘No matter how good medications are, if the patient will not use them they are not effective’, said Professor Mark Peyrot from Loyola College, Baltimore, USA.

Data from the DAWN study was used; a total of 2061 adults with type 2 diabetes and 2750 physicians. It was found that 57% of patients were concerned about starting insulin and only 23% believed that using insulin would help them to manage their diabetes better. Over 40% of physicians stated that they preferred to delay insulin initiation until absolutely necessary.

The study found that attitudes to insulin differ substantially within and across countries. ‘Education of people with diabetes and healthcare professionals about why and when insulin treatment should be initiated may lead to fewer barriers, better adherence and improved glycaemic control’, said Professor Peyrot.

Rosuvastatin is highly effective in patients with metabolic syndrome
Rosuvastatinuni (Crestor) is significantly more effective at lowering LDL cholesterol than atorvastatin, simvastatin and pravastatin, according to new research presented at the IDF Congress in August. In addition, significantly more patients treated with rosuvastatin reached their European and US LDL cholesterol goals than the most commonly prescribed doses of other statins.

The MERCURY study investigated 1342 patients with elevated LDL cholesterol and the metabolic syndrome. Lead investigator of the group, Professor Steen Stender (Gentofte Hospital, Denmark) commented that the data showed that rosuvastatin was a ‘highly effective treatment for controlling the lipid risk factors of LDL cholesterol, HDL cholesterol and triglycerides’ in patients with metabolic syndrome.

The investigators also found that treatment with rosuvastatin led to beneficial changes in HDL cholesterol and triglyceride levels.

Helping children to understand diabetes
Roche Diagnostics have come up with an innovative way of helping children cope with their diabetes. The aim of the Accu-Chek art competition is to help children understand all aspects of living with diabetes and to allow them to express their feelings about the disease. It is hoped that the competition will help to improve care by treating the condition holistically.

‘The Accu-Chek Art Contest offers the opportunity for children to express themselves, through drawing or painting that helps parents, healthcare professionals and educators better understand how young people are feeling’, explained Shelia Knight, registered art therapist, Child and Family Therapy Service, UK.

The winners of the competition were announced at the IDF Congress.

Over 380 000 needle injuries a year in the US
The debate about the safe disposal of sharps continued at an IDF meeting. US healthcare workers sustain over 380 000 needle injuries every year, according to Jane Perry of the International Healthcare Worker Safety Centre, University of Virginia. Furthermore, a study by the UK Communicable Disease Surveillance Centre (2002) showed that 72% of blood exposures were caused by needles. Needlestick injuries represent a global problem in the transmission of HIV, hepatitis B and hepatitis C.

The US Needlestick Safety and Prevention Act was passed in November 2000, and represents ‘a benchmark towards a safer workplace’, said Jane Perry. EPINet, the Exposure Prevention Information Network is a standardised needlestick and blood exposure tracking system used by more than 1500 US hospitals to track sharps injuries. Jane Perry believes that there is a need to ‘more forward and create change through legislation in particular’.

Pregnant women should be screened for gestational diabetes
Universal screening of pregnant women for gestational diabetes should be mandatory, despite American Diabetes Association (ADA) recommendations to the contrary, says Dr Lois Jovnaovic of the Sansum Medical Research Institute, California. A continuum of even mild elevations in blood glucose of pregnant women with diabetes leads to increased anomalies of babies. ‘Because we are not able to absolutely normalise maternal glucose on a continuous basis, in human studies we see a rate of two to three times the anomaly rate of that seen in the general population’, said Dr Jovnaovic. Normal glycaemia before, during and between pregnancies of women with diabetes leads to the birth of healthy babies, and should be the priority of healthcare professionals.

Dr Jovnaovic has been involved in a programme in Santa Barbara which has succeeded in normalising the birth weight of babies born from women with diabetes, through intensified insulin delivery. ‘Our protocol has succeeded in saving the county system over $2000 per patient because of complications avoided in the mother and the infant’, said Dr Jovnaovic.