BMJ: Flu jag timing matters

From BMJ May 2019: Minerva BMJ 2019;365:1993

A review in Science indicates that vaccines for mumps, whooping cough and yellow fever lose their effectiveness more quickly than those for measles, diptheria, tetanus and flu.

The flu vaccine at best only protects about 60% of the people given it in any given year. Its effectiveness also declines after just a few months. If you are first in the queue to get it towards the end of September, much of its effects will be lost by January and February which are the peak months for flu infection.

My comment: Maybe you should plan to get the jag any time from mid November to mid December  if you are very keen on getting maximum effectiveness to prevent flu?

 

BMJ: Flozin effects in type one diabetes

 Adapted from BMJ 13 April19 Efficacy and safety of dual SGLT 1/2 inhibitor sotagliflozin in type one diabetes Musso G, Gambino R. Cassader M, Pascheta E. BMJ 2019:365:1328

Flozins are increasingly used for patients with “double diabetes” in practice. The authors of this study searched for randomised controlled trials for the drug Sotagliflozin to find out how effective they were and what safety issues were apparent. Over three thousand patient responses were studied. There were six trials that were of moderate to good quality and they ran between four weeks and a year. The relative pluses and minus are listed.

lowered HbA1c by  0.34% (small)

reduced fasting and post meal blood sugars

reduced daily total, basal and meal insulins

reduced time in target blood sugar range

reduced body weight by 3%

reduced systolic blood pressure by 3 mmHg

reduced protein in the urine

reduced the number of hypoglycaemic events

reduced the number of severe hypoglycaemic events

On the other hand these factors were increased:

Ketoacidosis increased by a factor of x 2 to x 8 depending on the study looked at

genital tract infections increased by a factor of x 2 to x 4.5

diarrhea increased up to x 2

volume depletion events increased by up to x 4

Patients got better blood sugar results from the higher dose of 400mg Sotagliflozin compared to the 200mg dose without increasing the risk of adverse events.

Most DKA episodes occurred as the drug was being started and patients cut their insulin dose too much, in anticipation of reduced blood sugars.

My comment: The risk of DKA in type twos is not very common but is a known effect of flozins, so it is not that surprising that this is increased in type ones too. The reduction in hypoglycaemia events and severity is a new finding and suggests an increasing role for flozins in type one management.

 

 

 

Vitamin D shown to improve blood sugar control in gestational diabetes

From Ojo O et al. The effect of vitamin D supplementation in women with gestational diabetes mellitus. A systemic review and meta-analysis of randomised controlled trials. Int J Environ Res Public Health. 2019:16(10)

A meta-analysis has indicated that various factors relevant to improved blood sugar control are likely to be improved by vitamin D supplementation in  a total of 173 women with gestational diabetes.

Fasting blood glucose decreased by a mean of 0.46 mmol/L

Glycated haemoglobin decreased by a mean of 0.37%

Serum insulin reduced by a mean of 4.10 uIU/mL.

 My comment: Although the improvements are small, vitamin D supplements are inexpensive, easy to take and do not have the side effects of other medications.

 

 

Lower cholesterol may not better if you have neuropathy

From Jende JME et al. Peripheral nerve damage in patients with type 2 diabetes. JAMA Netw Open. 2019;2(5);e194798

In type two patients who had diabetic neuropathy affecting the legs, low total cholesterol and low density lipoprotein cholesterol had more nerve lesions, impaired nerve conduction and more pain and disability than those with higher cholesterol levels.

Almost all type two diabetics will be advised to take statins to keep the cholesterol level down as this is generally accepted as improving the outlook for cardiac and circulatory conditions.

One hundred participants with type two diabetes were tested using magnetic resonance neurography. 64 had diabetic neuropathy and 36 did not.

My comment: Although this was not discussed in the abstract, I wonder whether those people with more advanced complications were being more intensively treated all round and thus had more/higher doses of statins, and so the relationship between low cholesterol and neuropathy severity was simple association, or whether there is a causative factor here. I am aware that statin neuropathy is believed to exist.

Higher blood pressure is linked to LESS cognitive decline

From Streit S et al. Ann Fam Med 1 March 2019 and reported by Sarfaroj Khan UK Clinical Digest 13 March 2019

In my GP career treatment of blood pressure for the general population has become more intensive as time has gone on. This hasn’t always resulted in better long term outcomes overall. Indeed, the target systolic blood pressure, the upper measurement, has been moved from 130 to 140 in the last few years because of this.

A Dutch study of over a thousand patients over the age of 75 showed that those with a systolic blood pressure under 130 showed more cognitive decline than those with a blood pressure over 150 when they had mental functioning tests a year later.

Those with higher blood pressures had no loss of daily functioning or quality of life.

As aggressive blood pressure control in those with diabetes is standard treatment, it is worth knowing this. Perhaps further studies in this subgroup of patients would be worth doing. I have seen reports of impaired kidney function when blood pressure levels are “optimal” but low too.

Another study regarding blood pressure management reported in the British Journal of Sports Medicine indicates that blood pressure reduction of almost 9mm Hg in hypertensive patients when regular structured exercise is undertaken. This is of a degree similar to most anti-hypertensive medications. (Reported in BMJ 5 Jan 2019)

 

 

Eating carbs last gives lower blood sugar spikes

From IDDT newsletter December 2018

A report in BMJ Open Diabetes Research and Care Sept 2017 shows that in type two diabetes, eating sugar and starch later in the meal halved the blood sugar spike after the meal compared with those who ate the sugar and starch first.

This study was done on 16 people who ate test meals of protein, vegetables, bread and orange juice. Those who were instructed to eat the bread and juice last also had 40% lower post meal glucose levels compared to those who ate all of the meal components in a mixed fashion.

My comment: This is a small study but easily reproducible with yourself and your blood glucose meter. If you do wish to eat sugar and starch best have these last, unless you are treating a hypo.

 

 

More fat = more kidney failure

From BMJ 12th January 2019

Chang AR et al The CKD Prognosis Consortium BMJ 2019;364:k5301

Between 1970 and 2017 a huge number of people were assessed for fatness using body mass index, waist circumference and waist to height ratio. The outcome was that the fatter you get, the more your kidney function declines. This was true whether you started off  with normal or impaired kidney function.

The lowest kidney disease was seen in those with a BMI of 20 and this barely changed till a BMI of 25 was reached. After this was a linear progression. By the time your BMI is 40, you have double the risk of kidney function impairment.

The results were adjusted for age, sex, race and current smoking.

My comment: This is a new risk factor for obesity as far as I know.