Volume 8, Number 3, May-June 2008

POPULAR
TOPICEDITORIALWill the NICE guidelines on diabetes in pregnancy improve outcomes?
Anne Dornhorst

Br J Diabetes Vasc Dis 2008;8:107-110.

REVIEWClinical aspects of the management of HIV lipodystrophy
Anthony S Wierzbicki, Scott D Purdon, Timothy C Hardman, Ranjababu Kulasegaram, Barry S Peters

Chronic complications of human immunodeficiency virus (HIV) and highly active retroviral therapy have become increasingly relevant as life expectancy for HIV patients has improved and the affected population ages. HIV-associated lipodystrophy syndrome is characterised by an abnormal fat distribution syndrome associated with metabolic disturbances including insulin resistance, and deranged glucose and lipid metabolism. It is associated with increased risks of progression to type 2 diabetes and cardiovascular disease.
Lipodystrophy is a clinical diagnosis and mostly subjective as standardised diagnostic criteria have not yet been defined. Several therapeutic interventions have been investigated including lifestyle therapy, vitamin supplements, switching antiretroviral therapy and specific therapies for insulin resistance and hyperlipidaemia. Current management options for HIV associated lipodystrophy are limited and are mostly based on avoidance of risk factors and switching of antiretroviral drugs. Therapies to improve insulin resistance have been tried but they are frequently ineffective as are lipid-lowering drugs. Interest in anabolic agents has been resurrected and new clinical data suggest that HIV-associated lipodystrophy growth hormone releasing factor therapy may have a beneficial role in the treatment of HIV-associated lipodystrophy. However, there still remains a need for robust prospective cohort studies and well designed intervention trials to resolve the aetiology and define the best treatment for this complication of HIV disease and its treatment.

Br J Diabetes Vasc Dis 2008;8:113-119.

POPULAR
TOPICREVIEWThe role of omega-3 fatty acids in cardiovascular disease, hypertriglyceridaemia and diabetes mellitus
Narayanan Kandasamy, Franklin Joseph, Niru Goenka

It has been suggested that omega-3 fatty acids confer benefit in patients with known coronary heart disease by significantly reducing all-cause mortality and the risk of sudden death caused by cardiac arrhythmias. This may be as a result of the triglyceride-lowering effect of omega-3 fatty acids at high doses. Much of the evidence in favour of omega-3 in cardiovascular disease relates to studies which looked at the effects of increased intake from dietary sources. Oily fish (such as salmon and tuna), flaxseed, canola oil and walnuts, are all rich dietary sources of omega-3 fatty acids. Firm evidence for pharmacological supplementation exists in a few secondary prevention studies and recent National Institute for Health and Clinical Excellence guidance only recommends pharmacological omega-3 supplements to patients within three months of a myocardial infarction, to be continued for up to four years, assuming dietary intake is insufficient. There is currently little evidence for specific benefits of omega-3 supplementation in patients with diabetes.

Br J Diabetes Vasc Dis 2008;8:121-128.

ACHIEVING BEST PRACTICEHIV-associated lipodystrophy - a new metabolic syndrome
Lukman Hakeem, Ian W Campbell, Diptendu Nath Bhattacharyya

Human immunodeficiency virus (HIV) associated lipodystrophy may affect up to half or even more HIV-infected patients receiving antiretroviral therapy. However, a simple practical definition for this condition is still lacking. Features of lipoatrophy and lipohypertrophy may be seen in this condition. Intrinsic host factors and disease status, as well as treatment duration and type, probably play key roles in the aetiology. Several metabolic abnormalities such as dyslipidaemia and insulin resistance have been commonly reported in these patients. Most attempts to improve or reverse abnormal fat distribution have so far only shown modest success. Therefore, choosing optimal antiretroviral therapy is vital. There are too few reasons to support widespread use of rosiglitazone and metformin in these patients except on an individual basis. However, lipid lowering agents should be considered in the treatment of severe hypertriglyceridaemia and elevated low-density lipoprotein-cholesterol or a combination of both as lipid abnormalities are commonly seen in these patients. Advances in plastic surgery are attractive treatment options as they give immediate results.

Br J Diabetes Vasc Dis 2008;8:129-134.

POPULAR
TOPICACHIEVING BEST PRACTICEIs non-dipping of nocturnal blood pressure in type 2 diabetes associated with increased incidence of microalbuminuria?
Alison J Heggie, Karen A Adamson, Riccardo E Marioni, Paul L Padfield, Mark WJ Strachan

Microalbuminuria has been associated with non-dipping of nocturnal blood pressure (BP) in people with type 2 diabetes, but the mechanism of this association is unclear. We aimed to identify the development of microalbuminuria in patients with nocturnal non-dipping of BP and type 2 diabetes. Data were examined from 150 people with type 2 diabetes who had undergone ambulatory BP monitoring, non-dippers were defined as those with a systolic nocturnal BP dip less than 10% of the daytime BP.
The development of microalbuminuria, over five years of follow-up, in dippers and non-dippers was not significantly different. Non-dippers who were microalbuminuric at baseline were more likely to have a higher body mass index (p=0.01) and to be male (p<0.01).
This lack of a difference may be due to the initial exclusion of microalbuminuric patients, who may be genetically predetermined to develop microalbuminuria. Further prospective trials are required to investigate this relationship.

Br J Diabetes Vasc Dis 2008;8:136-139.

ACHIEVING BEST PRACTICEThe MERCURY I open-label extension study – subgroup analysis in patients with diabetes
Herbert Schuster, Mike K Palmer, Marc Ditmarsh for the MERCURY I Study Group

Background: The MERCURY I open-label extension study provides safety and efficacy data on hypercholesterolaemic patients with type 2 diabetes treated with rosuvastatin for up to three years.
Methods: A total of 2,492 hypercholesterolaemic patients, including 665 (26.7%) with type 2 diabetes, on rosuvastatin 10 mg or 20 mg were followed for a mean of 672 days in an open-label extension study during which the dose could be increased to 20 or 40 mg to reach the 1998 European low-density lipoprotein- cholesterol (LDL-C) target of < 3.0 mmol/L (< 115 mg/dL).
Results: Most diabetic and non-diabetic patients started (85.4% and 88.7%) and finished (78.3% and 77.6%) on rosuvastatin 10 mg. Adverse event (9.8% and 12.3%) and treatment discontinuation (2.2% and 3.5%) rates were similar in diabetic and non-diabetic patients. No myopathy or rhabdomyolysis was observed. Mean serum creatinine decreased in both subgroups. Proteinuria was reported as an adverse event in five (0.7%) diabetic patients and eight (0.4%) non-diabetic patients. Fasting plasma glucose did not change markedly in either subgroup. LDL-C decreased by 51.1% and 47.4% in diabetic and non-diabetic patients, respectively, with 92.4% and 90.3% reaching target LDL-C.
Conclusion: Long-term rosuvastatin treatment is effective and well tolerated in diabetic patients.

Br J Diabetes Vasc Dis 2008;8:142-147.

CASE REPORTDevelopment of new onset and extensive xanthelasma in HIV hyperlipidaemia
Adrian J Park, Graham Ball, Michael D Feher

Br J Diabetes Vasc Dis 2008;8:149-150.

POPULAR
TOPICMEETING REPORTMetformin: a practical guide to optimising outcomes
Round-table discussion held in Edinburgh, December 2007

UK and international guidelines recommend metformin as part of a management programme for type 2 diabetes, but its introduction and continued use can sometimes pose problems. This round-table offers practical guidance to facilitate and optimise metformin therapy.

Br J Diabetes Vasc Dis 2008;8:153-156.