In episode 62, the eighth and final podcast in our tome on the treatment of type-2 diabetes, we talk about cholesterol and ASA. Statins have evidence of benefit, around 3-4% absolute risk reductions over 5 years, other drugs for cholesterol have little if any evidence of benefit, and there is evidence of no benefit from taking ASA. We come up with an overall synopsis; increase activity, eat good food, use metformin, then maybe sulfonylureas, thiazides/ACE inhibitors for BP, statins but don’t measure cholesterol, and no ASA. Both James and Mike collapse from exhaustion and leave the final word to Chris their producer.

Show Notes

1) Statin meta-analyses

Lancet 2008;371:117-25

Table of data

Another table of data

2) Fibric acid derivatives FIELD

Lancet 2005;366:1849-61

Fibrate meta-analysis

Arch Intern Med 2005;165:725-30

3) ASA – no benefit in diabetics

JAMA 2008;300:2134-41

BMJ 2008;337:a1840

Diabetes Care 2003;26:3264-72

In the 61st episode, the seventh podcast in our thesis on type-2 diabetes, we get off the topic of glucose and talk about STENO and blood pressure treatments. We decide the bottom line is control of blood pressure with low doses of thiazides and ACE inhibitors with no tolerance for side effects. Mike’s blood pressure goes up with some of James’ suggestions but high doses of reserpine, methyldopa and clonidine calm him down.

Show Notes

1) STENO

N Engl J Med 2008;358:580-91

2) Blood pressure trials UKPDS 38

BMJ 1998;317:703-13

HOT Trial

Lancet 1998;351:1755-62

Do ACEI/ARBs uniquely protect the kidney – No?

Lancet 2005;366:2026-33

ALLHAT

JAMA 2002;288:2981-97

Low doses of ACEI – most of the BP effect is from low doses

Cochrane Library

MICROHOPE

Lancet 2000;355:253-59

In episode 60, the sixth podcast in our saga on type-2 diabetes, we talk about what to do when metformin is not enough and get to the evidence surrounding other blood glucose lowering treatments. We fumble around in a pretty much evidence-free zone. James develops a bad case of hypoglycemia during the podcast because he hasn’t eaten since the start of the diabetes section of these podcasts; Mike comes to his aid by prescribing a low dose of a chocolate bar and eats the rest of it himself.

Show Notes

1) UKPDS (recent results)

NEJM 2008;359:1577-89

Table of results

2) Fluoxetine, orlistat, sibutramine for weight loss in type-2 diabetics

Arch Intern Med 2004;164:1395–404

3) Acarbose for impaired glucose tolerance

JAMA 2003;290:486-94

4) Glitazones meta-analyses

JAMA 2007;298:1180-8

JAMA 2007;298:1189-95

Table of results

5) Risks of an elevated A1c

Link to table

6) Long acting insulin analogues – no advantage

CMAJ 2009;180:385-97

In episode 59, the fifth podcast in our diatribe on type-2 diabetes, we finally get to the evidence surrounding specific treatments. The importance of lifestyle is discussed and then the rest of the time is spent talking about the who, what, why, where, and when’s of metformin. James asks lots of rhetorical questions and Mike tries to answer them in a grandiloquent way.

Show Notes

1) UKPDS (original trial)

Lancet 1998;352:854-65

2) UKPDS (recent results)

NEJM 2008;359:1577-89

3) Metformin’s contraindications should be contraindicated

CMAJ 2005;173:502-4

In episode 58, the fourth in our installment of podcasts on diabetes, we briefly talk about the evidence surrounding intensive glucose lowering (ACCORD, ADVANCE, VADT and UKPDS trials) – podcasts #9 and #38 did this in more detail. At the end of the podcast, Mike identifies many of James’ flaws, but does it with compassion and kindness; at least he says he does.

Show Notes

1) Does tight glycemic control burden patients with complex treatment programs, hypoglycemia, weight gain, and costs and offers uncertain benefits in return?

Ann Int Med 2009;150:803-8

2) ACCORD and ADVANCE studies

Click here for a synopsis of the results

N Engl J Med 2008 358:2545-2559

N Engl J Med 2008 358:2560-2572

Also listen to Episode 9: News Flash: Aggressive Blood Sugar Control Not All Sweet

3) VADT trial N Engl J Med 2009;360:129-39

Also listen to Episode 38: New trials you need to know about

4) Glucose lowering meta-analysis – do the results support the conclusions?

Lancet 2009; 373:1765-72

5) UKPDS data

BMJ 2000;320:1720-3

6)UKPDS – 10 year update (recent results)

NEJM 2008;359:1577-89

In episode 57, we continue yet again with the topic of type 2 diabetes. In this podcast, we talk about monitoring HbA1C, self-monitoring of blood glucose and, diabetes education in general. We hear Jillian Popel suggest not only is self-monitoring of glucose not really useful when it comes to overall glucose control, it in fact might be harmful. We also discuss what we think diabetes education should really focus upon. Finally, after 56 episodes, Mike and James actually agree on an issue, but it was just that all complaints about any of the content in the podcasts should be sent directly to Jillian.

Show Notes

1) Self-monitoring of blood glucose ESMON

BMJ 2008;336:1174-7

DiGEM

BMJ 2008;336:1177-80

2) Calculating cardiovascular risk for type 2 diabetics

UKPDS risk engine

3) Diabetes education – Cochrane reviews

Individual patient education for people with type 2 diabetes mellitus

Group based training for self-management strategies in people with type 2 diabetes mellitus

Episode 56 continues from where we left off last time with type 2 diabetes. In this podcast, we bring out the numbers and put the risks of diabetes into context by discussing the absolute cardiovascular risks associated with different levels of HbA1c. In addition, we talk about other things to look at in the evaluation of type 2 diabetes and Jillian Popel again joins us for the ride. She is quite shocked by what she hears about how “absolutely low” the renal risks associated with type 2 diabetics really are. She is also quite shocked by most of what Mike and James have to say in general, but that’s a whole other issue for another time.

Show Notes

1) Diabetes is NOT a CHD risk equivalent

Diabet Med 2009;26:142–8

2) Calculating cardiovascular risk for type 2 diabetics<

UKPDS risk engine

3) The risks associated with diabetes

Diabetes Care 2003;26:2353-8

Episode 55 starts off a “sweet” new topic – type 2 diabetes. In the first podcast on this topic we talk about the whole issue of the diagnosis of diabetes, how to make the diagnosis and to some degree what the diagnosis means.

Episode 54 finishes off the whole issue of CRP measurement by looking at the evidence we have about what happens to patients when they take drugs that lower CRP – glitazones, COX-2s, fibrates, vitamin E, niacin, ezetimibe, and statins. Other than statins and maybe niacin, it doesn’t look good – in contrast to Mike and James of course that is.

Show Notes

1) Drugs that lower CRP

Cardiovasc Drug Rev 2006;24:33-50

Chest 2004;125:1610-5

Atherosclerosis 2005;179:361-7

2)Drugs that lower CRP and their effect on outcome

Glitazones

JAMA 2007;298:1189-95

COX-2s

CMAJ 2002;166:1649-50

Fenofibrate

Lancet 2005;366;1849-61

Bezafibrate

Circulation 2000;102:21-7

Vitamin E

Lancet 2003;361:2017-23

JAMA 2007;297:842-57

Niacin

JAMA 1975;231:360-81

Ezetimibe

N Engl J Med 2008;358:1431-43

Statins

Lancet 2008;371:117-25

High dose statins – not treating to target

CMAJ2008;178(5):576-84

Episode 53 continues where we left with the whole CRP measurement or no measurement discussion. James and Mike start with the Reynolds Risk Score and show how even at the extremes of CRP, absolute risks only change by around +/- 2% or so. Far more interesting is that there are now 2 studies showing clearly that good estimates of cardiovascular risk can be made without knowing lab values like cholesterol and CRP. All you have to basically do is look at the patient. Mike looks at James and declares that James is at very high risk of annoying Mike – so he does, just to show the evidence is solid.

Show Notes

1) Reynolds Risk Score

www.reynoldsriskscore.org

2) CRP goes up as weight goes up

Diabetes Metab 2003;29:133-8

JAMA 1999;282:2131-5

3) Estimating cardiovascular risk estimates without knowing cholesterol or CRP

Lancet 2008;371:923–31

Eur J Card Prev RehabMay 2009