Russell Drummond

Seeing double: the low carb diet

A 38 year old white Scottish man with mild learning difficulties (able to read and write but not to maintain employment) presented with a three day history of diplopia and agitation, after seven days of presumed viral gastroenteritis. On admission, he was agitated, mildly confused, tachycardic (115 beats/min, regular) and tachypnoeic (18 breaths/min). There were no chest signs or peripheral oedema. He had complete bilateral sixth cranial nerve palsies and horizontal nystagmus, with dilated, slowly reacting pupils. Limb movements were clumsy, with moderate cerebellar signs and dysdiadochokinesis, but no tremor. He was clinically jaundiced. Electrocardiography showed inferolateral T wave inversion. His heart size was at the upper limit of normal on chest radiography. On specific questioning, he gave a history of lifelong avoidance of alcohol, but of 34 kg weight loss over the preceding three months. This information was corroborated by his parents and practice nurse. At an initial weight of 127 kg (body mass index 42.4), he had received “healthy eating” advice from his practice nurse, who described him as her “star patient.” His weight had rapidly fallen—from 123 kg at four weeks, to 110 kg at eight weeks, 104 kg at 11 weeks, and finally 93 kg (body mass index 31) on admission. More recently, pursuing greater weight loss, he had eliminated all bread, cereals, and fats, on a diet considered “starvation” by his parents, without nutritional supplements. ### 1 What is the most likely diagnosis? #### Short answer Concurrent agitation and cerebellar signs suggest Wernicke’s encephalopathy as the most likely …

Cardiovascular safety and DPP-4 inhibitors

Following the rosiglitazone controversy there is a requirement from the licensing agencies that new antidiabetic drugs must be shown not to increase cardiovascular risk during phase 3 development. This includes studying patients with high cardiovascular risk, who were previously excluded from phase 3 studies. All of the currently available dipeptidyl peptidase (DPP)‐4 inhibitors (sitagliptin, vildagliptin, saxagliptin, linagliptin) have satisfied these safety criteria, with the suggestion that there might be some cardiovascular benefit with this class. Large randomised‐controlled trials are ongoing to assess safety as well as potential benefit. The results of these randomised‐controlled trials will influence the long‐term use of DPP‐4 inhibitors and their place in treatment guidelines. Copyright

Physicians’ real-world experience with IDegLira: results of a European survey

Objective This study aimed to build on the current clinical findings and investigate physicians’ experiences and level of satisfaction in using insulin degludec/liraglutide (IDegLira) to treat patients with type 2 diabetes (T2D). Research design and methods This multicountry, European online survey included respondents from primary (n=132) and secondary (n=103) care and examined physicians’ use, confidence and satisfaction with IDegLira. To standardize responses, 24 of 28 questions pertained to an ‘average patient’ with T2D who has no major comorbidities, aged 35–70 years, with average cognitive ability/normal mental status and body mass index ≥25 kg/m2. Results The majority (70%) of respondents prescribe IDegLira in the same visit they first mention it, with uncontrolled glycated hemoglobin (HbA1c) (44%) and weight gain (22%) being the most common reasons. On average, physicians reported that patients weighed 95 kg and the HbA1c level was 9.0% at initiation. Physicians also reported the average HbA1c target set was 7.1%; 76% of patients achieved their target. On average, patients achieved their HbA1c target in <6 months, and the average dose of IDegLira in patients in glycemic control was 28 dose steps. Respondents were more satisfied with IDegLira than basal-bolus therapy across all parameters assessed, including reaching HbA1c targets (59%), number of injections (77%) and avoiding weight gain (84%). Correspondingly, 77% of physicians reported that IDegLira had more potential to improve patient motivation compared with basal-bolus to reach target blood glucose levels. Conclusions Real-world experience of IDegLira is consistent with previous trials/studies, with no major differences between primary and secondary care. Importantly, the majority of respondents were more/much more satisfied with IDegLira than with basal-bolus therapy.

Cardiovascular safety and GLP-1 receptor agonists

Owing to the situation that exists following the rosiglitazone controversy aligned with the high cardiovascular risk profile that underlies type 2 diabetes mellitus, there is a requirement from the licensing agencies that new antidiabetic drugs must be shown not to increase cardiovascular risk during phase 3 development. This includes studying patients with high cardiovascular risk, who were previously excluded from phase 2 studies.