2008 Clinical Practice Guidelines - Canadian Diabetes Association

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2008 CLINICAL PRACTICE GUIDELINES S90 18. Robertson RP. Islet transplantation as a treatment for diabetes – a work in progress. N Engl J Med. 2004;350:694-705. 19. Hering BJ, Kandaswamy R,Ansite JD, et al. Single-donor, marginal-dose islet transplantation in patients with type 1 diabetes. JAMA. 2005;293:830-835. 20. Markmann JF, Deng S, Huang X, et al. Insulin independence following isolated islet transplantation and single islet infusions. Ann Surg. 2003;237:741-749. 21. Ryan EA, Paty BW, Senior PA, et al. Five-year follow-up after clinical islet transplantation. Diabetes. 2005;54:2060-2069. 22. Shapiro AM, Ricordi C, Hering BJ, et al. International trial of the Edmonton protocol for islet transplantation. N Engl J Med. 2006;355:1318-1330. 23. Close NC, Hering BJ, Eggerman TL. Results from the inaugural year of the Collaborative Islet Transplant Registry. Transplant Proc. 2005;37:1305-1308. 24. Hirshberg B, Rother KI, Digon BJ 3rd, et al. Benefits and risks of solitary islet transplantation for type 1 diabetes using steroid-sparing immunosuppression: the National Institutes of Health experience. Diabetes Care. 2003;26:3288-3295. 25. Lehmann R,Weber M, Berthold P, et al. Successful simultaneous islet-kidney transplantation using a steroid-free immunosuppression: two-year follow-up. Am J Transplant. 2004;4: 1117-1123. 26. Toso C, Baertschiger R, Morel P, et al. Sequential kidney/islet transplantation: efficacy and safety assessment of a steroid-free immunosuppression protocol. Am J Transplant. 2006;6:1049- 1058. 27. Ryan EA, Shandro T, Green K, et al. Assessment of the severity of hypoglycemia and glycemic lability in type 1 diabetes subjects undergoing islet transplantation. Diabetes. 2004;53: 955-962. 28. Paty BW, Senior PA, Lakey JR, et al. Assessment of glycemic control after islet transplantation using the continuous glucose monitor in insulin-independent versus insulin-requiring type 1 diabetes subjects. Diabetes Technol Ther. 2006;8:165-173. 29. Rother KI, Harlan DM. Challenges facing islet transplantation for the treatment of type 1 diabetes mellitus. J Clin Invest. 2004;114:877-883. 30. Senior PA, Zeman M, Paty BW, et al. Changes in renal function after clinical islet transplantation: four-year observational study. Am J Transplant. 2007;7:91-98. 31. Fiorina P, Folli F, Bertuzzi F, et al. Long-term beneficial effect of islet transplantation on diabetic macro-/microangiopathy in type 1 diabetic kidney-transplanted patients. Diabetes Care. 2003;26:1129-1136. 32. Fiorina P, Gremizzi C, Maffi P, et al. Islet transplantation is associated with an improvement of cardiovascular function in type 1 diabetic kidney transplant patients. Diabetes Care. 2005; 28:1358-1365. 33. Fiorina P, Folli F, Zerbini G, et al. Islet transplantation is associated with improvement of renal function among uremic patients with type I diabetes mellitus and kidney transplants. J Am Soc Nephrol. 2003;14:2150-2158. 34. Johnson JA, Kotovych M, Ryan EA, et al. Reduced fear of hypoglycemia in successful islet transplantation. Diabetes Care. 2004;27:624-625. 35. Poggioli R, Faradji RN, Ponte G, et al. Quality of life after islet transplantation. Am J Transplant. 2006;6:371-378. 36. Humar A, Kandaswamy R, Granger D, et al. Decreased surgical risks of pancreas transplantation in the modern era. Ann Surg. 2000;231:269-275. 37. Ryan EA, Paty BW, Senior PA, et al. Risks and side effects of islet transplantation. Curr Diab Rep. 2004;4:304-309.
Complementary and Alternative Medicine in the Management of Diabetes Canadian Diabetes Association Clinical Practice Guidelines Expert Committee The initial draft of this chapter was prepared by Jeannette Goguen MD MEd FRCPC KEY MESSAGES • Up to 30% of patients with diabetes use complementary and alternative medicine (CAM) for various indications. • Most CAM studies have small sample sizes and are of short duration, and therefore may have missed harmful side effects. • Certain CAM in common use for disorders other than diabetes can result in side effects and drug interactions. INTRODUCTION Complementary and alternative medicine (CAM) has been defined as “medicine that does not conform to the standards of the medical community, is not widely taught in North American medical schools and is not available in North American hospitals” (1). It involves the use of herbal medications as well as dietary supplements, including minerals, vitamins and other micronutrients.When used in a traditional system (e.g. Chinese,Tibetan,Ayurvedic), an herb is often only one of a number of interventions, which could also include acupuncture, yoga and multiple other herbs. MANAGEMENT CAM in the management of diabetes has been included in these guidelines, as it includes potential new therapeutic agents, and because studies have suggested that up to 30% of patients with diabetes use CAM for multiple indications (2), leading to potential side effects, drug interactions and increased cost to the patient. In 1 Canadian study in predominantly Caucasian subjects, the most commonly used alternative trace element for glycemic control was chromium (6%), followed by magnesium (2.2%) and vanadium (1%) (2). Herbs were rarely used. There are several issues unique to CAM that have implications in the assessment of the evidence for its use: trials are typically of short duration, with small sample sizes and unique patient populations that may not be generalizable (3); publications are often difficult to access, with only 10% referenced in MEDLINE (4); and there is a lack of standardization and purity of available compounds, including their contamination with regular medications and toxic compounds (5). The following herbs have been shown to improve glycemic control in adults with type 2 diabetes: Aloe vera (6,7); Ipomoea batatas (caiapo) (8); Coccinia indica (9); Ganoderma lucidum (10); Gymnema sylvestre (11); Ocimum tenuiflorum (holy basil or tulsi) (12); Salacia reticulata (13); pinitol (14); touchi (15); and Pterocarpus marsupium (vijayasar) (16). However, as all of the studies were small and of short duration, it is premature to recommend the use of these agents. The following herbs have been shown to be ineffective for glycemic control in adults with type 2 diabetes: Syzgium cumini (17); Tinospora crispa (18); French maritime pine bark (19); garlic (20); and soy phytoestrogens (21).The following dietary supplements have been shown to be ineffective: coenzyme Q10 (22) and vitamin E (23-26). Glucosamine sulfate, used to treat osteoarthritis, does not affect glycemic control (27). The following herbs have conflicting evidence with regards to glycemic control in adults with type 2 diabetes: Cinnamomum cassia (Chinese cinnamon) (28-31); Momordica charantia (bitter melon or bitter gourd) (32,33); Trigonella foenum-graecum (fenugreek) (34,35); and ginseng (36,37).The following dietary supplements have conflicting evidence: chromium (38-46); vanadium (47); magnesium (48-52); lipoic acid (53); vitamin C (52,54); and carnitine (55,56). Studies have examined the combinations of herbs as used by traditional practitioners. These studies included Tibetan traditional medicine (57), Chinese plants (58,59) and Ayurvedic pancreas extract (60). Methodological concerns make the results of these studies difficult to interpret. COMPLICATIONS It is important to consider potential harm from the use of CAM. Most studies were of small sample size and short duration, and thus may have missed harmful side effects.The use of Tinospora crispa was associated with markedly elevated liver enzymes in 2 patients and should be avoided (18).Alternative medications should not be used in pregnancy – some are abortificants (e.g. Momordica charantia) (61).As well, there are case reports of severe hypoglycemia with the use of bitter melon in children (61). Impurities of substances are another concern. Contamination with regular medications and with heavy metals has been documented in several publications (5). Finally, certain CAM in common use for disorders other than diabetes can result in side effects and drug interactions. Agents that have been associated with elevations in blood pressure include the following: ginseng, licorice, yohimbine S91 MANAGEMENT
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2008 Clinical Practice Guidelines - Canadian Diabetes Association

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