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link. In a large cohort of women from New York City, the biological activity of elevated insulin-like growth factor-I levels was demonstrated to have only a modest negative impact on the incidence of colorectal cancer (Ma J et al. JNCI 2004). Could Treatment Play a Role? Turning to the recent controversy surrounding the use of insulin glargine as a driver of increased cancer incidence, Jay S. Skyler, MD, MACP, University of Miami, Miller School of Medicine, Miami, FL, explained the origin of and media reaction to the proposed theory that insulin glargine may be a carcinogen. The controversy began in 2009 with an analysis of a German database that suggested that patients who were using higher doses of insulin glargine had an increased risk for cancers of all types but only when adjusted for dose (Figure 2). Figure 2. Hazard Ratios for Risk of All Forms of Cancer.
Glargine Aspart Lispro
The Diabetic Foot Wound
David G. Armstrong, DPM, MD, PhD, University of Arizona College of Medicine, Tucson, AZ, presented the 2010 Roger Pecoraro Lecture at the American Diabetes Association 70th Annual Scientific Sessions, where he discussed management strategies for the treatment of the diabetic foot wound. Every 30 seconds, a lower limb is lost due to complications of diabetes [www.diabeticfootonline. com]. According to the Nord-Trondelag Health Study, foot ulcer history is associated with a 38% increased risk of death among diabetics after adjusting for lifestyle and demographic factors [Iverson MM et al. Scandinavian J Public Health 2008]. Dr. Armstrong recommends the team approach to diabetic foot wound management in order to reduce the incidence of amputation. In a study that evaluated 1708 procedures over a period of 32 months, patients who received the team approach to treatment were 61.0% less likely to undergo amputation versus 28.9% in the control group (p<0.0001) [Armstrong DG et al. ADA 2010]. An effective amputation prevention team should include the ability to perform certain tasks, such as site-appropriate culture techniques, vascular assessment and revascularization, neurological evaluation, wound assessment and infection staging/ grading, site-specific bedside and intraoperative incision and debridement, culture- and patient-appropriate antibiotic therapy implementation, and postoperative monitoring with a focus on reulceration and infection risk reduction [Fitzgerald et al. EPlasty 2009; Armstrong DG et al. JVS 2010]. There are also many advances being made in the area of wound care that may optimize the management of diabetic foot ulcers. Among them is vacuum-assisted closure (VAC) therapy. This therapy provides several healing advantages, such as promotion of flap and graft survival, removal of interstitial fluid and infectious material, and uniform wound closure through the use of negative pressure [Saxena et al. Plast Reconstr Surg 2004]. VAC therapy resulted in fewer surgical procedures and dressing changes compared with standard moist wound therapy (p<0.0001 for both) [Apelqvist J et al. Am J Surg 2008]. Receptor activator of nuclear factor kappa B ligand (RANK-L), osteoprotegerin (OPG), and intranasal calcitonin may also facilitate healing in diabetic foot ulcers. RANK-L and OPG play a key role in bone remodeling and resorption. Dysregulation of RANK-L or OPG may result in bone loss. Upregulation of RANK-L may occur in the
Adjustment None Age, gender Age, gender, dose Multiple covariates
Higher risk
0.6
0.8 1.0 1.2 Hazard ratio (95% CI) vs. human insulin
1.4
Hemkens et al. Diabetologia 2009.
Copyright 2009 European Association for the Study of Diabetes. All rights reserved.
This conclusion resulted in several high-profile news articles [Hemkens et al. Diabetologia 2009]. This finding prompted the Diabetologia editors to request a confirmatory analysis based on unrelated datasets from the United Kingdom, Scotland, and Sweden. The resultant submissions from these public health databases were in general agreement that the association between insulin glargine and cancer was unfounded. As concluded by Dr. Skyler, “The press headline ‘Glargine causes cancer’ is unsubstantiated, unwarranted, and unproven.” For additional details and the ADA consensus statement regarding the controversy, see Giovannucci E et al. Diabetes Care 2010;33:1674-1685.
Highlights from the American Diabetes Association 70th Annual Scientific Sessions
37
Table of Contents for the Digital Edition of MD Conference Express
MD Conference Express
Contents
Real-Time Continuous Glucose Monitoring and Diabetes Treatment
The Globalization of Diabetes
Treat the Individual, Tend to the Population
Microvascular Outcomes from the ACCORD Trial
Diabetic Retinopathy in the ACCORD Trial
Results from the STAR 3 Study
Findings from HELP PD
Insights from the BARI 2D Trial
Effect of Atorvastatin on Beta Cell Function
Caffeine Supplementation Reduces Exercise Induced Hypoglycemia
Cardiometabolic Risk
Point of Care Devides
Newer Insulins
Diabetes, Glycemia and Cardiovascular Disease: Is it Time to Rethink the Regulatory Approach?
Diabetes and Cancer: ADA Consensus Statement
The Diabetic Foot Wound
HEALTHY Study - Middle School-Based Intervention to Reduce Diabetes Risk
MD Conference Express
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