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New types of insulin and the concept of physiologic insulin replacement provide more options for people with diabetes. Insulin is now available in rapid-acting, short-acting, intermediate-acting, or long-acting forms. It is also available in pens and pumps. Physiologic insulin replacement means attempting to mimic the body's natural secretion of insulin, which occurs primarily after a meal.

Importance: Continuous glucose monitoring (CGM) provides real-time assessment of glucose levels and may be beneficial in reducing hypoglycemia in older adults with type 1 diabetes.Objective: To determine whether CGM is effective in reducing hypoglycemia compared with standard blood glucose monitoring (BGM) in older adults with type 1 diabetes.Design, Setting, and Participants: Randomized clinical trial conducted at 22 endocrinology practices in the United States among 203 adults at least 60 years of age with type 1 diabetes.Interventions: Participants were randomly assigned in a 1:1 ratio to use CGM (n = 103) or standard BGM (n = 100).Main Outcomes and Measures: The primary outcome was CGM-measured percentage of time that sensor glucose values were less than 70 mg/dL during 6 months of follow-up. There were 31 prespecified secondary outcomes, including additional CGM metrics for hypoglycemia, hyperglycemia, and glucose control; hemoglobin A1c (HbA1c); and cognition and patient-reported outcomes, with adjustment for multiple comparisons to control for false-discovery rate.Results: Of the 203 participants (median age, 68 [interquartile range {IQR}, 65-71] years; median type 1 diabetes duration, 36 [IQR, 25-48] years; 52% female; 53% insulin pump use; mean HbA1c, 7.5% [SD, 0.9%]), 83% used CGM at least 6 days per week during month 6. Median time with glucose levels less than 70 mg/dL was 5.1% (73 minutes per day) at baseline and 2.7% (39 minutes per day) during follow-up in the CGM group vs 4.7% (68 minutes per day) and 4.9% (70 minutes per day), respectively, in the standard BGM group (adjusted treatment difference, -1.9% (-27 minutes per day); 95% CI, -2.8% to -1.1% [-40 to -16 minutes per day]; P <.001). Of the 31 prespecified secondary end points, there were statistically significant differences for all 9 CGM metrics, 6 of 7 HbA1c outcomes, and none of the 15 cognitive and patient-reported outcomes. Mean HbA1c decreased in the CGM group compared with the standard BGM group (adjusted group difference, -0.3%; 95% CI, -0.4% to -0.1%; P <.001). The most commonly reported adverse events using CGM and standard BGM, respectively, were severe hypoglycemia (1 and 10), fractures (5 and 1), falls (4 and 3), and emergency department visits (6 and 8).Conclusions and Relevance: Among adults aged 60 years or older with type 1 diabetes, continuous glucose monitoring compared with standard blood glucose monitoring resulted in a small but statistically significant improvement in hypoglycemia over 6 months. Further research is needed to understand the long-term clinical benefit.Trial Registration: ClinicalTrials.gov Identifier: NCT03240432. [ABSTRACT FROM AUTHOR]

The article discusses the additional markers of risk for diabetic microvascular complications that have not been captured so far in the Diabetes Control and Complications Trial, besides the standard hemoglobin A1c. Recent evidence has also pointed to the contribution of blood pressure and lipids in the pathogenesis of diabetic microvascular complications.

The continued practice of sliding scale insulin (SSI) administration in academic medical centers and community hospitals for hyperglycemia management is condemned. SSI is considered obsolete and detrimental, and the need to manage hyperglycemia with basal insulin, prandial (mealtime) insulin and correction-dose insulin is emphasized.

Importance: The majority of individuals with type 1 diabetes do not meet recommended glycemic targets.Objective: To evaluate the effects of continuous glucose monitoring in adults with type 1 diabetes treated with multiple daily insulin injections.Design, Setting, and Participants: Open-label crossover randomized clinical trial conducted in 15 diabetes outpatient clinics in Sweden between February 24, 2014, and June 1, 2016 that included 161 individuals with type 1 diabetes and hemoglobin A1c (HbA1c) of at least 7.5% (58 mmol/mol) treated with multiple daily insulin injections.Interventions: Participants were randomized to receive treatment using a continuous glucose monitoring system or conventional treatment for 26 weeks, separated by a washout period of 17 weeks.Main Outcomes and Measures: Difference in HbA1c between weeks 26 and 69 for the 2 treatments. Adverse events including severe hypoglycemia were also studied.Results: Among 161 randomized participants, mean age was 43.7 years, 45.3% were women, and mean HbA1c was 8.6% (70 mmol/mol). A total of 142 participants had follow-up data in both treatment periods. Mean HbA1c was 7.92% (63 mmol/mol) during continuous glucose monitoring use and 8.35% (68 mmol/mol) during conventional treatment (mean difference, -0.43% [95% CI, -0.57% to -0.29%] or -4.7 [-6.3 to -3.1 mmol/mol]; P < .001). Of 19 secondary end points comprising psychosocial and various glycemic measures, 6 met the hierarchical testing criteria of statistical significance, favoring continuous glucose monitoring compared with conventional treatment. Five patients in the conventional treatment group and 1 patient in the continuous glucose monitoring group had severe hypoglycemia. During washout when patients used conventional therapy, 7 patients had severe hypoglycemia.Conclusions and Relevance: Among patients with inadequately controlled type 1 diabetes treated with multiple daily insulin injections, the use of continuous glucose monitoring compared with conventional treatment for 26 weeks resulted in lower HbA1c. Further research is needed to assess clinical outcomes and longer-term adverse effects.Trial Registration: clinicaltrials.gov Identifier: NCT02092051. [ABSTRACT FROM AUTHOR]

This JAMA Insights Clinical Update reviews indications and timing of insulin therapy for management of type 2 diabetes, emphasizing the likely benefit of its use as first-line therapy in patients with HbA1c levels less than 9.0%. [ABSTRACT FROM AUTHOR]

The article presents a study on the effectiveness of sertraline for prevention of depression recurrence in diabetes melliltus (DM) in the U.S. Using a random, double-blind, and controlled trial, it examines the prevalence of depression and recurrent problems among patients with DM that could adversely affect the medical prognosis.

The article reports on the physiologic actions of the enteric hormone glucagon-like peptide 1 (GLP-1) that can lower blood glucose levels and treat type 2 diabetes. Topics discussed include the clinical use of exenatide in the U.S. and Europe to lower glycated hemoglobin and reduce body weight, some factors hindering the use of GLP-1 receptor agonists (GLP-1RA) in clinical practice and an overview of research which generated interest in the use of GLP-1RA as diabetes drugs.

The article discusses the authors' views about the cost effectiveness of medications and the use of synthetic human insulin as a treatment for patient with type 2 diabetes, and it mentions pharmacy prices for long-acting and short-acting insulin analogues such as glargine, detemir, and lispro. It states that synthetic human insulin products such as neutral protamine Hagedorn, which are less expensive than insulin analogues, are prescribed less frequently.

The article discusses the costs of various insulin preparations. Details on human insulin and insulin analog are presented. It is suggested that although there has been an increase in usage of the latter, there is little clinical evidence showing its advantages over the former in type 2 diabetes. According to the author, some patients may be better served by lower-cost preparations. Topics include neutral protamine Hagedorn (NPH) insulin and the timing of insulin dosages.

A letter to the editor is presented in response to the article "Reexamining Metrics for Glucose Control," by Katya Rubinow and Irl Hirsch, in a 2011 issue.

The authors focus on the variability of HbA1c values for glucose control. They stated that the varying HbA1c values cannot detect correct levels of mean blood glucose (MBG) as medications like dapsone, erythropoeitin alter HbA1c values. They le provide alternatives to measuring MBG like the use of fructosamine or glycated albumin which are used for the diagnosis and treatment of diabetes. They add that fructosamine does not associate with fasting plasma glucose and glycated albumin is not available in the U.S.

The authors argue that more markers are needed to identify risk for diabetic microvascular complications. They explain the use of hemoglobin A1c (HbA1c) as a marker for the development of diabetes complications. They describe the influence of proinflammatory gene expression, proinflammatory proteins monocyte chemotactic protein-1 and inducible nitric oxide synthase on HbA1c values. The authors further argue that physicians should recognize the need for more research on microvascular complications risks.

The authors discuss the problem of diabetes in the U.S. and the relationship between time-average mean levels of glycemia and diabetic complications. The use of self-monitored blood glucose (SMBG) is also considered. The article focuses on two studies in the same issue, one by Saudek et al and the other by Monnier et al. The authors suggest that additional work is needed to determine the best pharmacologic strategies for minimizing glycemic variability and the increased free radical production it causes. They also advocate the wider use of real-time continuous glucose monitoring in clinical practice.

Describes two cases of pulmonary edema associated with the use of troglitazone. Medical histories of the patients; Weight gain and fluid retention during troglitazone therapy; Cardiovascular events; Contraindication of the therapy.