Real-world outcomes of treatment with insulin glargine 300 U/mL versus standard-of-care in people with uncontrolled type 2 diabetes mellitus

Objective: To compare real-world outcomes with newer (insulin glargine 300 U/mL; Gla-300) versus standard of care (SoC) basal insulins (BIs) in the REACH (insulin-naïve; NCT02967224) and REGAIN (basal insulin-treated; NCT02967211) studies in participants with uncontrolled type 2 diabetes (T2DM) in Europe and Brazil.Methods: In these open-label, parallel-group, pragmatic studies, patients (HbA_1c > 7.0%) were randomized to Gla-300 or SoC BI for a 6-month treatment period (to demonstrate non-inferiority of Gla-300 vs SoC BIs for HbA_1c change [non-inferiority margin 0.3%]) and a 6-month extension period (continuing with their assigned treatment). Insulin titration/other medication changes were at investigator/patient discretion post-randomization.Results: Overall, 703 patients were randomized to treatment in REACH (Gla-300, n = 352; SoC, n = 351) and 609 (Gla-300, n = 305, SoC, n = 304) in REGAIN. The primary outcome, non-inferiority of Gla-300 versus SoC for HbA_1c change from baseline to month 6, was met in REACH (least squares [LS] mean difference 0.12% [95% CI -0.046 to 0.281]) but not REGAIN (LS mean difference 0.17% [0.015-0.329]); no between-treatment difference in HbA_1c change was shown after 12 months in either study. BI dose increased minimally from baseline to 12 months in REACH (Gla-300, +0.17 U/kg; SoC, +0.15 U/kg) and REGAIN (Gla-300, +0.11 U/kg; SoC, +0.07 U/kg). Hypoglycemia incidence was low and similar between treatment arms in both studies.Conclusions: In both REACH and REGAIN, no differences in glycemic control or hypoglycemia outcomes with Gla-300 versus SoC BIs were seen over 12 months. However, the suboptimal insulin titration in REACH and REGAIN limits comparisons of outcomes between treatment arms and suggests that more titration instruction/support may be required for patients to fully derive the benefits from newer basal insulin formulations.

Similar glycaemic control and less hypoglycaemia during active titration after insulin initiation with glargine 300 units/mL and degludec 100 units/mL: A subanalysis of the BRIGHT study

AIM

To further investigate glycaemic control and hypoglycaemia in BRIGHT, focusing on the titration period.

MATERIALS AND METHODS

BRIGHT was a multicentre, open-label, randomized, active-controlled, two-arm, parallel-group, 24-week study in insulin-naïve patients with uncontrolled type 2 diabetes initiated on glargine 300 U/mL (Gla-300) (N = 466) or degludec (IDeg-100) (N = 463). Predefined efficacy and safety outcomes were investigated during the initial 12-week titration period. In addition, patients' characteristics and clinical outcomes were assessed descriptively, stratified by confirmed (≤3.9 mmol/L) hypoglycaemia incidence during the initial titration period.

RESULTS

At week 12, HbA1c was comparable between Gla-300 (7.32%) and IDeg-100 (7.23%), with similar least squares (LS) mean reductions from baseline (-1.37% and - 1.39%, respectively; LS mean difference of 0.02; 95% confidence interval: -0.08 to 0.12). Patients who experienced hypoglycaemia during the initial titration period had numerically greater HbA1c reductions by week 12 than patients who did not (-1.46% vs. -1.28%), and higher incidence of anytime (24 hours; 73.3% vs. 35.7%) and nocturnal (00:00-06:00 hours; 30.0% vs. 11.9%) hypoglycaemia between weeks 13-24.

CONCLUSIONS

The use of Gla-300 resulted in similar glycaemic control as IDeg-100 during the initial 12-week titration period of the BRIGHT study, when less anytime (24 hours) hypoglycaemia with Gla-300 versus IDeg-100 has been reported. Experiencing hypoglycaemia shortly after initiating Gla-300 or IDeg-100 may be associated with hypoglycaemia incidence in the longer term, potentially impacting glycaemic management.

Insulintherapie bei Diabetes mellitus Typ 2: patientenzentriert, rechtzeitig, nutzen-risiko-bilanziert; Standortbestimmung 2019 nach dem ADA/EASD-Konsensus 2018

Erhöhte Blutzucker- und Fettsäurespiegel schädigen die residuale B-Zell-Regeneration und -Funktion (Glukolipotoxizität) und vermindern die Insulinempfindlichkeit von Muskulatur, Fettgewebe, Leber und Endothel der Gefäßwand. Chronische Hyperglykämie triggert in einem komplexen circulus vitiosus proatherogene und inflammatorische Prozesse, die die Morbidität und Mortalität erhöhen. Die rechtzeitige nutzen-risiko-basierte Therapie mit Insulin schützt nachhaltig die B-Zellen und kann die Progression des Diabetes wesentlich verzögern. Damit verbunden ist eine signifikante Senkung der Inzidenz diabetesbezogener Komplikationen. Langzeitstudien mit intensivierter Glykämiekontrolle und Insulin haben zu der Empfehlung geführt, den HbA1c-Wert von Anfang an unter 6,5–7,0 % zu halten, unter Vermeidung von Hypoglykämien. Die Zielkorridore für Blutzucker und HbA1c-Wert sollten an die individuelle Lebenssituation, eine realistische Einschätzung der Nutzen-Risiko-Bilanz und die Möglichkeiten des Patienten angepasst werden. Langwirksame Basalinsuline ermöglichen einen einfachen Einstieg in die Diabeteskontrolle zu jedem Zeitpunkt der Entgleisung. Dies gilt, wenn Metformin, orale duale oder Triple-Therapien und GLP-1-Rezeptoragonisten nicht länger ausreichen, um die Zielkorridore für Blutzucker und HbA1c-Wert einzuhalten. Rechtzeitiger Einsatz von Insulin ist besonders indiziert für Subtypen mit schwerem Insulinmangel, Patienten mit diabetesbezogenen Komplikationen sowie Individuen mit chronischen Infekten und/oder Sarkopenie. Rechtzeitiger Einsatz von Insulin ist effektiver, sicherer und auch kostengünstiger, da dies hilft, Polypharmazie zu vermeiden.

Treatment intensification strategies after initial metformin therapy in adult patients with type-2 diabetes: results of the DPV and DIVE registries

AIMS

Our study aimed to analyse treatment strategies after failure of initial metformin mono-therapy in adult patients with type-2 diabetes (T2DM).

METHODS

The DIVE and DPV databases were combined and 16,681 adult patients with T2DM and metformin mono-therapy identified. Patients were analysed depending on whether metformin was continued (MET), or whether it was combined with other oral antidiabetics (OAD), with GLP-1 antagonists (GLP-1) or with basal insulin (BOT/BOT plus). Metabolic control, body weight and hypoglycaemia, micro- and macro-vascular events were compared within 1 year.

RESULTS

A total of 11,911 (71%) participants continued MET until the end of the observation period, 3334 (20.0%) were intensified using OAD, 579 (3%) started on GLP-1, and 857 (5%) were initiated on BOT/BOTplus. Predictors of OAD and BOT/BOTplus therapy were elevated HbA1c, longer diabetes duration and the presence of micro- and macro-vascular diseases, while GLP-1 therapy was predicted by younger age, female sex, higher body weight and shorter diabetes duration. Micro- and macro-vascular diseases were negative predictors of GLP-1 therapy. Effects on HbA1c were highest in the BOT/BOTplus and OAD group, while GLP-1 treatment had the best effect on body weight.

CONCLUSIONS

BOT/BOTplus and OAD show good HbA1c reduction even in patients with longer diabetes duration and in older patients. GLP-1 therapy is effective concerning weight loss in overweight patients and is more often used in females and patients with shorter diabetes duration. Interestingly, despite several studies showing positive effects on micro- and macro-vascular outcomes, prevalent macro-vascular diseases are no predictors of GLP-1 use.

Type 2 diabetes in older patients: an analysis of the DPV and DIVE databases

BACKGROUND

The clinical profile differs between old and young patients with type 2 diabetes mellitus (T2DM). We explored, based on a large real-world database, patient and disease characteristics and actual treatment patterns by age.

METHODS

The analysis was based on the DIVE and DPV registries of patients with T2DM. Patients were analyzed by age groups 50-59 (middle-young), 60-69 (young-old), 70-79 (middle-old), 80-89 (old), and 90 years or more (oldest-old).

RESULTS

A total of 396,719 patients were analyzed, of which 17.7% were 50-59 years, 27.7% 60-69 years, 34.3% 70-79 years, 18.3% 80-89 years and 2.0% at least 90 years. We found that (a) T2DM in old and oldest-old patients was characterized much less by the presence of metabolic risk factors such as hypertension, obesity, dyslipidemia and smoking than in younger patients; (b) the HbA1c was much lower in oldest-old than in middle-young patients (7.2 ± 1.6% versus 8.0 ± 2.2%; p < 0.001), but it was associated with higher proportions of patients with severe hypoglycemia (7.0 versus 1.6%; p < 0.001); (c) this was potentially associated with the higher and increasing rates of insulin use in older patients (from 17.6% to 37.6%, p < 0.001) and the particular comorbidity profile of these patients, for example, chronic kidney disease (CKD); (d) patients with late diabetes onset had lower HbA1c values, lower bodyweight and less cardiovascular risk factors; (e) patients with a longer diabetes duration had a considerable increase in macrovascular and even more microvascular complications.

CONCLUSION

In very old patients there is a need for frequent careful routine assessment and a tailored pharmacotherapy in which patient safety is much more important than blood-glucose-lowering efficacy.

Titration of insulin glargine 100 U/mL when added to oral antidiabetic drugs in patients with type 2 diabetes: results of the TOP-1 real-world study

AIMS

Adequate insulin titration is crucial for optimal glycaemic control in type 2 diabetes (T2D). We aimed to explore the factors and outcomes associated with titration of glargine 100 U/mL (Gla-100) in patients uncontrolled on oral antidiabetic drugs (OAD) and initiating insulin therapy.

METHODS

Patients from the Titration and Optimization (TOP)-1 registry were stratified by the magnitude of Gla-100 up-titration during the first month (no [< 1 Units (U)/day (d)], minimal [≥ 1 and < 5 U/d], moderate [≥ 5 and ≤ 8 U/d] and strong [> 8 U/d]). The primary endpoint was a fasting blood glucose (FBG) ≤ 110 mg/dL on ≥ 2 occasions and/or individual HbA1c target by 12 months.

RESULTS

Of 2308 patients, 905, 715, 409 and 279 underwent no, minimal, moderate and strong titration, respectively. Age decreased across increasing titration groups (p = 0.02) while body mass index (BMI) (p < 0.0001), FBG (p < 0.0001), and HbA1c (p < 0.0001) increased. At 12 months, the proportions of patients achieving the primary endpoint were comparable across groups (66.1% overall), though a smaller proportion of no titration patients met both their individual HbA1c target and FBG ≤ 110 mg/dL compared to moderate and strong titration patients (20.1% vs. 27.2% and 26.2%, p = 0.033 and 0.023, respectively). HbA1c was also comparable, though FBG was higher in the no titration group (126.2 vs. 122.6, 121.5 and 120.9 mg/dL, p < 0.02). A similar, small reduction in body weight occurred in all groups; hypoglycaemia rates were comparable across groups.

CONCLUSIONS

In real-world, titration of Gla-100 during the first month appears to coincide with a number of baseline factors. Insulin dose to meet HbA1c and FBG targets remains suboptimal in the majority of T2D patients.

P6271The effect of semaglutide once weekly on MACE and blood pressure by race and ethnicity: SUSTAIN 6 post hoc analysis

Background

In SUSTAIN 6, subcutaneous semaglutide once weekly added to standard of care significantly reduced major adverse cardiovascular events (MACE: non-fatal myocardial infarction, non-fatal stroke or death) vs placebo over 2 years in T2D subjects.

Purpose

Assess the effect of semaglutide vs placebo on MACE and blood pressure (BP) by race and ethnicity in a post hoc analysis of SUSTAIN 6.

Methods

Subjects were randomised to semaglutide 0.5 mg, 1.0 mg or volume-matched placebo. Data for the two semaglutide-dose groups were pooled and compared to the pooled placebo groups. Time-to-event data were analysed with a Cox proportional hazards model. Changes from baseline to week 104 were analysed using analysis of covariance. The interaction between treatment and subgroup was added to the models.

Results

Overall, 3,297 patients received treatment. Subgroups included Caucasian, Asian, Black/African American, Other (race), and Hispanic, non-Hispanic (ethnicity). Mean baseline characteristics were similar across subgroups (age 64.7 years, HbA1c 8.7%, diabetes duration 14.2 years). Time to composite MACE and individual components were improved with semaglutide across all subgroups. Semaglutide affected BP similarly across race and ethnicity, except for systolic BP in Black/African American subjects (Table).

Race Ethnicity Caucasian Asian Black/African American Other Interaction p-value Hispanic Non-Hispanic Interaction p-value Semaglutide (n) 1,384 121 108 35 256 1,392 Placebo (n) 1,352 152 113 32 254 1,395 MACE and individual outcomes   MACE HR [95% CI] 0.76 [0.58; 1.00] 0.58 [0.25; 1.34] 0.72 [0.23; 2.28] 0.46 [0.08; 2.50] 0.8793 0.67 [0.33; 1.36] 0.74 [0.57; 0.96] 0.7978   CV death HR [95% CI] 0.98 [0.63; 1.50] 0.32 [0.04; 2.85] 1.01 [0.06; 16.20] n/a† 0.8089 0.79 [0.31; 2.00] 1.00 [0.63; 1.59] 0.6521   Non-fatal MI HR [95% CI] 0.69 [0.45; 1.07] 0.97 [0.36; 2.60] 1.37 [0.31; 6.12] 0.31 [0.03; 3.00] 0.6637 0.65 [0.18; 2.31] 0.74 [0.50; 1.10] 0.8562   Non-fatal stroke HR [95% CI] 0.70 [0.42; 1.16] 0.31 [0.04; 2.77] n/a‡ n/a‡ 0.9176 0.73 [0.16; 3.27] 0.60 [0.36; 0.99] 0.7995 Blood pressure at week 104   Systolic BP* ETD (mmHg) [95% CI] −1.92 [−3.09; −0.74] −4.98 [−8.61; 1.35] 4.47 [0.15; 8.79] −11.02 [−18.45; −3.60] 0.0008 −3.22 [−5.93; −0.51] −1.81 [−2.98; −0.64] 0.3489   Diastolic BP* ETD (mmHg) [95% CI] 0.36 [−0.32; 1.04] −1.31 [−3.43; 0.80] −0.07 [−2.56; 2.43] −3.41 [−7.73; 0.92] 0.1871 −0.18 [−1.75; 1.39] 0.16 [−0.52; 0.83] 0.6981 *Treatment difference between semaglutide and placebo (pooled 0.5 and 1.0 mg values for each treatment group) at week 104. †No events in the placebo group; ‡No events in the semaglutide group. BP, blood pressure; CI, confidence interval; ETD, estimated treatment difference; HR, hazard ratio; MACE, major adverse cardiovascular event; MI, myocardial infarction.

Conclusion

Overall there was no evidence of a differential effect of semaglutide on risk reduction in MACE and its components and on BP across race and ethnicity subgroups in this post hoc analysis.

Acknowledgement/Funding

Novo Nordisk A/S

Trends in BMI, Glycemic Control and Obesity-Associated Comorbidities After Explantation of the Duodenal-Jejunal Bypass Liner (DJBL)

BACKGROUND

A novel-approach for treatment of obesity and diabetes mellitus type 2 (T2DM) is represented by the endoscopic duodenal-jejunal bypass liner (DJBL). Recent data from the German DJBL registry provide evidence for substantial efficacy of the DJBL during the implantation period in obese patients with T2DM. However, little is known about the trends of glycemic control, BMI, and comorbidities after explantation of the DJBL, which have been investigated in the registry in this report.

METHODS

Patients were selected from the registry if they had a dataset at implantation, explantation, and at least one time point after explantation of the DJBL (n = 77). We also investigated a subgroup of patients with available data at least 1 year (-2 weeks) after explantation of the DJBL (n = 32).

RESULTS

For a mean BMI at implantation and a mean follow-up period, an increase of BMI of 2.1 kg/m² (CI 0.8-3.2; p = 0.013) had to be expected (for HbA1c 0.3% (CI - 0.0-0.7; p = n.s.), respectively). In the subgroup analysis, HbA1c and BMI increased after explantation of the DJBL but stayed significantly below baseline levels. Meanwhile, the mean number of antidiabetic drugs slightly increased. There was deterioration seen for blood pressure and LDL cholesterol over the postexplantation period to approximately baseline levels (or higher).

CONCLUSION

With this data, we show that improvement of HbA1c and BMI can be partly maintained over a time of nearly 1-year postexplantation of the DJBL. However, for HbA1c, this may be biased by intensified medical treatment and effects deteriorated with time after explantation. These results suggest that implantation of the DJBL needs to be integrated in a long-term weight management program as most of other interventions in obese patients with T2DM.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02731859.

Clinical Impact of the TCF7L2 Gene rs7903146 Type 2 Diabetes Mellitus Risk Polymorphism in Women with Gestational Diabetes Mellitus: Impaired Glycemic Control and Increased Need of Insulin Therapy

Background The single nucleotide polymorphism in TCF7L2 rs7903146 is associated with an increased risk of type 2 diabetes mellitus and gestational diabetes mellitus. Mechanisms by which this mutation acts, and its impact on the clinical course of the diseases remain unclear. Here we investigated the clinical impact of the T risk allele in women with gestational diabetes mellitus.

Methods We genotyped the C/T polymorphism in 164 Caucasian women with GDM (German n=114; Greek n=50). The impact of the T allele on the results of the 75g oral-glucose-tolerance-test, and on the required therapy (diet/lifestyle or insulin) was investigated.

Results During oral-glucose-tolerance-test, women harboring the T allele displayed significantly higher glucose values at 60 min (p=0.034) and were more likely to require insulin therapy even after adjusting for confounders, such as BMI and age.

Conclusion These results provide evidence that the T risk allele in TCF7L2 rs7903146 is associated with failure in early postprandial glycemic control and requirement of insulin therapy in women with gestational diabetes mellitus, even after adjusting for confounding factors such BMI and age.

Predictors of treatment response in type-2 diabetes patients initiating basal-supported oral therapy with insulin glargine 100 U/mL: A sub-analysis of the Titration and OPtimisation (TOP) registry

The aim of this study was to identify predictors of long-term response to the initiation of basal-supported oral therapy (BOT) with insulin glargine (IGlar-100). Patients from the observational TOP registry were grouped based on those who had achieved (responders) and those who had not achieved (non-responders) their HBA1c target and/or FBG ≤110 mg/dL 12 months after IGlar-100 initiation. Independent predictors of treatment response were identified by regression analysis. Data for 2444 patients were analysed (responders, n = 1610; non-responders, n = 834). Although the IGlar-100 dose increase over 12 months was larger for non-responders (+12.83 vs +9.46 U/d; P < 0.0001), the corresponding decrease in HbA1c was smaller (-0.88% vs -1.57%). Independent predictors of response included lower BMI (OR, 0.97; 95% CI, 0.95-1.00), lower FBG (OR, 0.98; 95% CI, 0.97-0.98) and HbA1c values at baseline (OR, 0.24; 95% CI, 0.18-0.31), a less ambitious HbA1c target (OR, 5.07; 95% CI, 3.37-7.63) and bedtime administration of IGlar-100 (OR, 1.55; 95% CI, 1.12-2.14). In conclusion, HbA1c was the clinically most significant baseline characteristic predictive of response to BOT. This may suggest an advantage of IGlar-100 initiation prior to excessive hyperglycaemia escalation.

[Outcome studies on SGLT-2 inhibitors]

BACKGROUND

Inhibitors of sodium-glucose cotransporters type 2 (SGLT-2) are a class of oral antidiabetic drugs with a novel specific mode of action in the kidneys.

OBJECTIVE

The effects of SGLT-2 inhibitors on cardiovascular (CV) and renal endpoints in outcome trials with type 2 diabetes patients.

MATERIAL AND METHODS

Differential analysis and interpretation of the results of outcome trials with the SGLT-2 inhibitors empagliflozin, canagliflozin and dapagliflozin in type 2 diabetes mellitus.

RESULTS

In the EMPA-REG OUTCOME trial, empagliflozin demonstrated a significant reduction in major cardiac adverse events (MACE), hospitalization for heart failure (HHI), renal endpoints, CV and total mortality vs. placebo in >7000 patients with type 2 diabetes and established CV disease over 3.1 years. In the CANVAS program, canagliflozin demonstrated a significant reduction of MACE, HHI and renal endpoints vs. placebo in >10,000 patients with type 2 diabetes and high CV risk over 2.4 years. In the CREDENCE trial, canagliflozin demonstrated a significant reduction of a combined renal endpoint and CV endpoints vs. placebo in >4000 patients with type 2 diabetes and established kidney disease with albuminuria over 2.6 years. In the DECLARE-TIMI 58 trial, dapagliflozin demonstrated a significant reduction in a combined endpoint of CV death and HHI vs. placebo in >17,000 patients with type 2 diabetes and established CV disease or with multiple CV risk factors over 3.1 years.

CONCLUSION

Outcome trials with SGLT-2 inhibitors have collectively demonstrated cardioprotective and nephroprotective effects in patients with type 2 diabetes and high CV risk. The use of SGLT-2 inhibitors is recommended in current guidelines and consensus statements as primary combination partners for metformin in patients with type 2 diabetes and established CV disease, high CV risk, heart failure or kidney disease.

Neue Therapieoptionen mit kontinuierlich gemessenen Glukosedaten – Empfehlungen für die Praxis

Kontinuierliches Glukosemonitoring (Continuous Glucose Monitoring – CGM) ist heute fest in Konsensusempfehlungen und Leitlinien zur Verbesserung der glykämischen Kontrolle bei Menschen mit insulinpflichtigem Diabetes mellitus verankert. In der täglichen Praxis werden im Besonderen HbA1c, Glukosevariabilität und Hypoglykämien durch die Nutzung von CGM positiv beeinflusst. Der Stellenwert von CGM bei Therapieentscheidungen wächst und birgt weitere vielfältige Potenziale. Dieser Übersichtsartikel stellt dar, welche Therapieoptionen auf der Basis von CGM-Daten bestehen, wie das ambulante Glukoseprofil und Trendpfeile Therapieentscheidungen beeinflussen können und welche Schulungskonzepte für Patienten angeboten werden. Auch werden zukünftige Felder für die Anwendung von CGM erörtert und diskutiert.

Comparative Dose Accuracy of Durable and Patch Insulin Pumps Under Laboratory Conditions

Background: Recent studies demonstrate variable results of the accuracy with which patch pumps infuse insulin. Aim of this evaluation was to measure dose accuracies of the patch pump mylife™ OmniPod^® (OP) in comparison with the durable insulin pump MiniMed^® 640G (MM) simulating real-life clinical situations under laboratory conditions. Methods: Thirty-two OP and 15 MM were tested using insulin aspart at five different boluses (0.5, 1, 5, 10, and 15 international units [IU]) and three basal rates (0.2, 0.6, and 1.8 IU/h) at different time points during a 70 h investigation period. Owing to malfunctions only 22 OP and 11 MM could be analyzed. Dose accuracy was measured by an experimental setting based on IEC 60601-2-24:2012 with determination of weight differences of insulin collection tubes before and after experiments using a precision scale. A maximal tolerance of ±5% for boluses and basal rates was considered adequate according to IEC 60601-2-24:2012. Results: For the five boluses, the percentages of measurement results within the ±5% accuracy threshold were as follows: OP (18.6%, 26.5%, 89.0%, 96.0%, and 96.0%); MM (21.7%, 44.1%, 88.1%, 98.3%, and 100.0%). Both pumps were more accurate at higher bolus volumes (5, 10, and 15 IU), later bolus periods, and if the accuracy threshold was lowered to <10%, <15%, or >15%. For the three basal rates, the percentages within the ±5% accuracy threshold were as follows: OP (66.7%, 22.7%, and 16.7%); MM (14.3%, 0.0%, and 0.0%). Conclusion: This study demonstrates low accuracy for basal rates and single bolus deliveries at low insulin doses for both pump models. Clinicians should be aware of this variability when initiating insulin pump therapy especially in insulin-sensitive patients with low insulin dose requirements.

Characteristics of Patients with Type-1 or Type-2 Diabetes Receiving Insulin Glargine U300: An Analysis of 7268 Patients Based on the DPV and DIVE Registries

INTRODUCTION

Insulin glargine 300 U/ml (U300) was registered based on the EDITION clinical trial program. The aim of this database analysis was to describe the profile of adult U300 recipients with type-1 (T1DM) or type-2 diabetes (T2DM).

METHODS

The analysis was based on data from the German DIVE/DPV registries. Patients were sampled in May (DIVE) and in March 2018 (DPV) and divided into those who commenced U300 within the 1st year (early adopters) or 2nd year (late adopters). Patients were further compared to patients receiving U100 during the same time period.

RESULTS

Among 581,519 adult patients contained in the databases, 7268 with either T1 or T2DM received U300 and 22,050 U100. Baseline characteristics of U300 and U100 recipients did not differ substantially in both types of diabetes. Patients with T2DM had many risk factors and comorbidities. The median HbA1c (both T1DM and T2DM, 8.1% for U300 and 7.9 and 8.3% for U100) and fasting blood glucose values were similar at baseline. Severe hypoglycemia was less prevalent in T2DM and among recipients of U300 (3.1 vs. 3.9%), whereas in T1DM the rate was higher (10.6 vs. 10.1%). There were minor, but clinically probably irrelevant, differences in age and BMI for T1DM and T2DM between the first and second years. Patients with T2DM being initiated in the second year had a higher HbA1c value (8.6 vs. 8.3%) than those initiated during the first year. Patients in clinical practice showed substantially higher HbA1c values in both T1DM and T2DM, and doses used were lower than those reported from the EDITION trial program. U300 patients had a longer diabetes duration (T1 and T2DM), a higher BMI and received higher basal insulin doses (T1 and T2DM) compared to U100. While HbA1c was comparable, the rate of severe hypoglycemia under U300 was reduced in T2DM but not T1DM with or without adjustment for differences in baseline characteristics in T2DM.

CONCLUSION

The data confirm the clinical profile documented for U300 in the EDITION studies during the first years of its registration. In an unselected patient population, there was a lesser rate of severe hypoglycemia but at a comparable HbA1c.

FUNDING

German Centre for Diabetes Research (DZD) (01GI1106), the European Foundation for the Study of Diabetes (EFSD) and the German Diabetes Society (DDG). The DIVE registry (organized as Diabetes Agenda 2010 GmbH, Berlin, Germany) received funding from Sanofi, AstraZeneca, Bayer, and Abbott and was conducted under the auspices of diabetesDE.

Types of diabetes are not limited to age groups: type 1 diabetes in adults and type 2 diabetes in children and adolescents

Based on data from the national diabetes registry DPV (Diabetes patient documentation), the diabetes registry of North Rhine-Westphalia and surveys conducted at hospitals and practices in Baden-Württemberg and Saxony, this study estimates the incidence and prevalence of type 1 diabetes in over-18-year-old adults and type 2 diabetes in 11- to 18-year-old children and adolescents. The national incidence of type 1 diabetes in adults was 6.1 per 100,000 person-years from 2014 to 2016, with slightly lower figures for women compared to men. Annually, around 4,150 adults develop type 1 diabetes. In 2016, the prevalence of type 1 diabetes was estimated at 493 per 100,000 persons and was lower in women at 445 per 100,000 people than in men at 544 per 100,000. Based on this data, there were around 341,000 adults with type 1 diabetes in 2016. For 11- to 18-year-old children and adolescents, the national incidence of type 2 diabetes was 2.8 per 100,000 person-years between 2014 and 2016 and higher for girls than for boys. Annually, around 175 adolescents in this age group develop type 2 diabetes. The incidence estimates for Saxony were higher (4.3 per 100,000 person-years). The prevalence of type 2 diabetes between 2014 and 2016 for 11- to 18-year-old children and adolescents was estimated between 12 and 18 cases per 100,000 persons. During this period, there were about 950 children and adolescents of this age group with type 2 diabetes in Germany.

Reductions in insulin resistance are mediated primarily via weight loss in subjects with type 2 diabetes on semaglutide

CONTEXT

Semaglutide, a once-weekly glucagon-like peptide 1 (GLP-1) analog approved for use in patients with type 2 diabetes (T2D), demonstrated superior body weight (BW) reductions and decreased insulin resistance (IR) vs comparators across the SUSTAIN 1-3 clinical trials.

OBJECTIVE

To investigate the relationship between IR and BW across the SUSTAIN 1-3 trials.

DESIGN

Post hoc analysis of the SUSTAIN 1-3 trials.

SETTING

311 sites in 30 countries. Patients or Other Participants: 2,432 subjects with T2D.

INTERVENTIONS

Semaglutide 0.5 or 1.0 mg, placebo or active comparator (sitagliptin 100 mg, exenatide extended release 2.0 mg).

MAIN OUTCOME MEASURE

To assess the extent of the effect on IR that is mediated (indirect effect) and not mediated (direct effect) by the effect on BW.

RESULTS

Across SUSTAIN 1-3, mean BW was significantly reduced with semaglutide 0.5 mg (3.7-4.3 kg; p<0.0001) and semaglutide 1.0 mg (4.5-6.1 kg; p<0.0001) vs comparators (1.0-1.9 kg). There were significantly greater reductions in IR with semaglutide 0.5 mg (27-36%) and semaglutide 1.0 mg (32-46%) vs comparators (17-28%). Greater reductions in BW were generally associated with greater decreases in IR. The effect on IR was primarily mediated by weight loss (70-80% and 34-94%, respectively, for semaglutide 0.5 mg and 1.0 mg vs comparator).

CONCLUSIONS

Semaglutide consistently reduced BW and IR in subjects with T2D in SUSTAIN 1-3. In this analysis, IR improvement was positively associated with, and primarily mediated by, the effect of semaglutide on BW.

Patient and disease characteristics of type-2 diabetes patients with or without chronic kidney disease: an analysis of the German DPV and DIVE databases

BACKGROUND

To evaluate the characteristics of type 2 diabetes (T2DM) patients with or without chronic kidney disease (CKD) in Germany.

METHODS

Using combined DPV/DIVE registry data, the analysis included patients with T2DM at least ≥ 18 years old who had an estimated glomerular filtration rate (eGFR) value available. CKD was defined as an eGFR < 60 mL/min/1.73 m2 or eGFR ≥ 60 mL/min/1.73 m2 and albuminuria (≥ 30 mg/g). Median values of the most recent treatment year per patient are reported.

RESULTS

Among 343,675 patients with T2DM 171,930 had CKD. Patients with CKD had a median eGFR of 48.9 mL/min/1.73 m2 and 51.2% had a urinary albumin level ≥ 30 mg/g. They were older, had a longer diabetes duration and a higher proportion was females compared to patients without CKD (all p < 0.001). More than half of CKD patients (53.5%) were receiving long-acting insulin-based therapy versus around 39.1% of those without (p < 0.001). CKD patients also had a higher rate of hypertension (79.4% vs 72.0%; p < 0.001). The most common antihypertensive drugs among CKD patients were renin-angiotensin-aldosteron system inhibitors (angiotensin converting enzyme inhibitors 33.8%, angiotensin receptor blockers 14.2%) and diuretics (40.2%). CKD patients had a higher rate of dyslipidemia (88.4% vs 86.3%) with higher triglyceride levels (157.9 vs 151.0 mg/dL) and lower HDL-C levels (men: 40.0 vs 42.0 mg/dL; women: 46.4 vs 50.0 mg/dL) (all p < 0.001) and a higher rate of hyperkalemia (> 5.5 mmol/L: 3.7% vs. 1.0%). Comorbidities were more common among CKD patients (p < 0.001).

CONCLUSION

The results illustrate the prevalence and morbidity burden associated with diabetic kidney disease in patients with T2DM in Germany. The data call for more attention to the presence of chronic kidney disease in patients with diabetes, should trigger intensified risk factor control up and beyond the control of blood glucose and HbA1c in these patients. They may also serve as a trigger for future investigations into this patient population asking for new treatment options to be developed.

Local, collaborative, stepped and personalised care management for older people with chronic diseases (LoChro): study protocol of a randomised comparative effectiveness trial

Background

Multimorbid older adults suffering from a long-term health condition like depression, diabetes mellitus type 2, dementia or frailty are at high risk of losing their autonomy. Disability and multimorbidity in the older population are associated with social inequality and lead to soaring costs. Our local, collaborative, stepped and personalised care management for older people with chronic diseases (LoChro-Care) aims at improving outcomes for older multimorbid patients with chronic conditions whose social and medical care must be improved.

Methods

The study will evaluate the effects of LoChro-Care on functional health, depressive symptoms and satisfaction with care, resource utilisation as well as health costs in older persons with long-term conditions. The trial will compare the effectiveness of LoChro-Care and usual care in a cross-sectoral setting from hospital to community care. We will recruit 606 older adults (65+) admitted to local hospital inpatient or outpatient departments who are at risk of loss of independence. Half of them will be randomised to receive the LoChro-Care intervention, comprising seven to 16 contacts with chronic care managers (CCM) within 12 months. The hypothesis that LoChro-Care will result in better patient-centred outcomes will be tested through mixed-method process and outcome evaluation and valid measures completed at baseline and at 12 and 18 months. Cost-effectiveness analyses from the healthcare perspective will include incremental cost-effectiveness ratios.

Discussion

The trial will provide evidence about the effectiveness of local, collaborative, stepped and personalised care management for multimorbid patients with more than one functional impairment or chronic condition. Positive results will be a first step towards the implementation of a systematic cross-sectoral chronic care management to facilitate the appropriate use of available medical and nursing services and to enhance self-management of older people.

Trial registration

German Clinical Trials Register (DRKS): DRKS00013904; Trial registration date: 02. February 2018.

Titration and optimization trial for the initiation of insulin glargine 100 U/mL in patients with inadequately controlled type 2 diabetes on oral antidiabetic drugs

For patients with type 2 diabetes mellitus (T2DM) and inadequate glycaemic control, addition of basal insulin is recommended, but titration and optimization of basal insulin therapy in primary care is not well understood. We conducted an observational trial in 2470 patients with T2DM who initiated insulin glargine 100 U/L (Gla-100) on top of oral antidiabetic drugs. Physicians were free to choose either a "Davies," "Fritsche" or "individual" titration algorithm. We found that fasting blood glucose (FBG) and glycated haemoglobin (HbA1c) levels were effectively reduced by Gla-100; 65.9% of patients achieved the primary endpoint (FBG ≤6.1 mmol/L (110 mg/dL) or an individual HbA1c target). There were no significant differences in efficacy and safety between the algorithms used. The mean FBG decreased by 3.2 mmol/L (59 mg/dL) over 12 months, while the mean HbA1c decreased by 15.3 mmol/mol (1.4%)%. From a starting dose of 11.7 U/d, the Gla-100 dosage was 22.8 U/d at 12 months, with similar values in each group. Rates of hypoglycaemia were low and did not differ by titration algorithm. We conclude that Gla-100 was effective at reducing FBG and HbA1c, independent of the titration algorithm, but observed that algorithms were inconsistently applied in clinical practice.

Stem cells in the treatment of diabetes mellitus - Focus on mesenchymal stem cells

Diabetes mellitus type 1 and type 2 have become a global epidemic with dramatically increasing incidences. Poorly controlled diabetes is associated with severe life-threatening complications. Beside traditional treatment with insulin and oral anti-diabetic drugs, clinicians try to improve patient's care by cell therapies using embryonic stem cells (ESC), induced pluripotent stem cells (iPSC) and adult mesenchymal stem cells (MSC). ESC display a virtually unlimited plasticity, including the differentiation into insulin producing β-cells, but they raise ethical concerns and bear, like iPSC, the risk of tumours. IPSC may further inherit somatic mutations and remaining somatic transcriptional memory upon incomplete re-programming, but allow the generation of patient/disease-specific cell lines. MSC avoid such issues but have not been successfully differentiated into β-cells. Instead, MSC and their pericyte phenotypes outside the bone marrow have been recognized to secrete numerous immunomodulatory and tissue regenerative factors. On this account, the term 'medicinal signaling cells' has been proposed to define the new conception of a 'drug store' for injured tissues and to stay with the MSC nomenclature. This review presents the biological background and the resulting clinical potential and limitations of ESC, iPSC and MSC, and summarizes the current status quo of cell therapeutic concepts and trials.

Addition of a single short-acting insulin bolus to basal insulin-supported oral therapy: a systematic review of data on the basal-plus regimen

We summarize here clinical and trial data on a once-daily administration of a single bolus to the meal with the largest expected postprandial glucose excursion (basal-plus), and comment on its clinical utility in the treatment of type 2 diabetes. A PubMed search of data published until September 2018 was taken into consideration and PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines were followed. Eighteen reports representing 15 studies were identified (age: 18-80 years; 50-890 patients; follow-up: 8 days to 60 weeks). Data suggest basal-plus is efficacious for improving glycemic control, with a low incidence of (severe) hypoglycemia and minor increases in bodyweight. The timing of short-acting insulin administration and use of different monitoring/titration approaches appear to have minimal impact. When compared with premixed insulin, basal-plus results in largely comparable outcomes. Compared with basal-bolus, it may result in non-inferior glycemic improvements with less weight gain, less hypoglycemia and fewer daily injections. A basal insulin/glucagon-like peptide-1 receptor agonist fixed ratio combination may offer several advantages over the basal-plus regimen, at the cost of gastrointestinal side effects. We conclude that the stepwise introduction of short-acting insulin via the basal-plus strategy represents a viable alternative to a full basal-bolus regimen and may help to overcome barriers associated with multiple injections and anticipated complexity of the insulin regimen.

Patient and disease characteristics of adult patients with type 1 diabetes in Germany: an analysis of the DPV and DIVE databases

BACKGROUND

An understanding of the current status of patients with type 1 diabetes mellitus (T1DM) can help to provide appropriate treatment.

METHODS

This was a retrospective analysis of the DIabetes Versorgungs-Evaluation (DIVE) and the Diabetes-Patienten-Verlaufsdokumentation (DPV) databases for Germany.

RESULTS

The analysis included 56,250 people with T1DM (54.2% male), a median age of 36.8 years, and a median diabetes duration of 12.4 years. 15.3% were obese (body mass index ≥ 30kg/m²). Long-acting insulin analogs were used by 53.3%, short-acting analogs by 72.1%, and oral antidiabetic drugs by 4.7%. Patients had a median glycosylated hemoglobin (HbA1c) of 7.8%. There was a drop in HbA1c and an increase in the rate of hypertension, oral antidiabetic drug use, and in the rate of severe hypoglycemia (all p < 0.01) with age. Flash glucose monitoring (FGM) showed the best glucose values with fewer complications compared to other monitoring systems. HbA1c and FBG were lower in patients using a pump versus multiple daily injections (MDIs; 7.7 versus 7.9% and 7.8 versus 8.7 mmol/l; all adjusted p < 0.01). Patients had a lower risk of at least one severe hypoglycemic or DKA episode during the most recent treatment year with pump treatment compared to MDI (9.4% versus 10.5% and 4.7% versus 6.1%, both adjusted p < 0.01).

CONCLUSION

The data demonstrated less-than-optimal glycemic control in the young, an increasing metabolic pattern in T1DM with increasing age, a benefit of FGM to improve HbA1c control and adverse effects, as well as benefits of pump treatment over MDIs.

HbA1c target achievement in the elderly: results of the Titration and Optimization trial for initiation of insulin glargine 100 U/mL in patients with type 2 diabetes poorly controlled on oral antidiabetic drugs

OBJECTIVES

To identify real-world, age-related trends in the use of insulin glargine 100 U/mL (Gla-100) as part of basal-supported oral therapy (BOT).

RESEARCH DESIGN AND METHODS

The prospective, observational Titration and Optimization registry enrolled patients with poorly controlled type 2 diabetes mellitus initiated on Gla-100 BOT. The primary outcome was the proportion of patients with capillary fasting blood glucose (FBG) ≤110 mg/dL on ≥2 occasions and/or who met their individual HbA1c target within 12 months.

RESULTS

2462 patients were analyzed (<65 years: n=1122; 65-74 years: n=771; ≥75 years: n=569). Diabetes duration (6.8, 8.9, and 11.2 years, p<0.0001) and proportion of women (40.7%, 47.9%, and 55.7%, p<0.0001) increased with age. Baseline HbA1c was highest in <65-year-olds (8.6% vs 8.4% and 8.5%, p<0.0001). Gla-100 up-titration until 12 months was highest in <65-year-olds (+11.6 U/day), compared with 65-74 (+10.2 U/day) and ≥75 years (+8.8; p<0.0001) but similar by units per kilogram, as was the decrease in FBG (<65: -64.1 mg/dL; 65-74: -56.1 mg/dL; ≥75: -53.4 mg/dL) and HbA1c (<65: -1.47%; 65-74: -1.31%; ≥75: -1.22%, p<0.0001). At 12 months, 65.9% of participants met the primary endpoint, with no significant difference between age groups. The proportion achieving their individual HbA1c target was lower for <65-year-olds (46.0% vs 54.3% and 54.7%; p<0.02). Symptomatic hypoglycemia incidence was more common in the ≥75-year-old group (3.4% vs 1.4% and 1.4%; p=0.0126).

CONCLUSIONS

BOT with Gla-100 results in similar improvements of glycemic values with low risk of hypoglycemia across age groups. Given the link between HbA1c and long-term cardiovascular risk, ensuring appropriately stringent target-setting, intensification of basal insulin and making sure hypoglycemia is avoided is of paramount importance.

TRIAL REGISTRATION NUMBER

Database: https://awbdb.bfarm.de; Identifier: 1641; Date of registration: September 23, 2013.

Regional differences in type 2 diabetes treatment and outcomes in Germany-An analysis of the German DPV and DIVE registries

AIMS

On the basis of the Diabetes Versorgungs-Evaluation (DIVE) and Diabetes-Patienten-Verlaufsdokumentation (DPV) datasets, we aimed to explore the impact of differences in treatment modalities on outcomes in Germany and put these into a global context.

METHODS

The 2014 to 2016 DIVE and DPV databases were combined, and a total of 127 838 patients 18 years and older was analysed with respect to demographics, cardiovascular risk factors, comorbidities, treatments, and outcomes, separately for each German state. Estimates were expressed as adjusted least squares means together with 95% confidence intervals.

RESULTS

Saarland dataset recorded the lowest mean HbA_1c (6.7%; 6.6%-6.8%; 50 mmol/mol, 49-51 mmol/mol), Saxony-Anhalt showed the highest (8.3%; 8.2%-8.3%; 67 mmol/mol, 66-67 mmol/mol). The highest percentage of hypoglycaemic events was reported in Mecklenburg-West Pomerania (MWP) (4.7%; 3.9%-5.7%), the lowest in Thuringia (0.9%; 0.2%-3.4%). Metformin and sulfonylurea accounted for 36.4% to 53.3% of anti-diabetic treatments across states; other antihyperglycaemic drugs such as DPP-4 inhibitors, SGLT2 inhibitors, and GLP-1 analogues were used most often in MWP (40.0%; 37.8%-42.1%) and least in Rhineland-Palatinate (13.6%; 13.0%-14.2%). Treatment with insulin (alone or in combination) was reported most often in MWP (78.2%; 76.4%-80.0%) and least in Thuringia (26.0%; 20.1%-32.9%).

CONCLUSIONS

Federal states in Germany are heterogeneous concerning diabetes treatment and associated outcomes. These data should stimulate further discussion about how optimal diabetes care can be implemented in all areas of Germany, to achieve good treatment outcomes in all federal states.

Efficacy and safety of dapagliflozin or dapagliflozin plus saxagliptin versus glimepiride as add-on to metformin in patients with type 2 diabetes

OBJECTIVE

To compare the efficacy and safety of dapagliflozin and dapagliflozin plus saxagliptin vs glimepiride as add-on to metformin in patients with type 2 diabetes.

RESEARCH DESIGN AND METHODS

This 52-week, multicentre, double-blind, active-controlled study (NCT02471404) randomized (1:1:1) patients (n = 939; HbA1c 7.5%-10.5%) on metformin monotherapy (≥1500 mg/day) to add-on dapagliflozin 10 mg, dapagliflozin 10 mg plus saxagliptin 5 mg, or glimepiride 1 to 6 mg (titrated). The primary efficacy end point was change in HbA1c from baseline to Week 52.

RESULTS

Baseline mean age, diabetes duration and HbA1c were 58.4 years, 7.0 years and 8.3%, respectively. Adjusted mean HbA1c change from baseline was -1.20% with dapagliflozin plus saxagliptin and -0.82% with dapagliflozin, vs -0.99% with glimepiride (mean dose at Week 52, 4.6 mg). Changes in body weight (-3.2 kg and -3.5 kg vs +1.8 kg) and systolic blood pressure (SBP; -6.4 mm Hg and -5.6 mm Hg vs -1.6 mm Hg) were significantly greater with dapagliflozin plus saxagliptin and dapagliflozin than with glimepiride. FPG decreased significantly with dapagliflozin plus saxagliptin compared with glimepiride (-2.1 mmol/L vs -1.5 mmol/L) and was similar with dapagliflozin (-1.6 mmol/L) compared with glimepiride. Confirmed incidence of hypoglycaemia was lower with dapagliflozin regimens than with glimepiride (0 and 1 vs 13 patients) and fewer patients required rescue. Genital infections were more frequent with dapagliflozin; other AE profiles were similar.

CONCLUSIONS

Dapagliflozin, saxagliptin and metformin improved glycaemic control compared with glimepiride plus metformin; add-on of dapagliflozin alone showed efficacy similar to that of glimepiride. Both dapagliflozin regimens decreased body weight and SBP, with a lower incidence of hypoglycaemia compared with glimepiride.

17q12 Deletion Syndrome as a Rare Cause for Diabetes Mellitus Type MODY5

CONTEXT

Maturity-onset diabetes of the young type 5 (MODY5) is caused by mutations of the hepatocyte nuclear factor 1 homeobox β gene (HNF1B). Although clinical characteristics and therapeutic management of MODY5 are increasingly better defined, adequate consideration of the frequent association of MODY5 with 17q12 deletion syndrome is often missing.

EVIDENCE ACQUISITION

We report two cases of patients with 17q12 deletion syndrome who presented to our clinic. Furthermore, we reviewed the existing literature to improve systematic diagnostic and therapeutic approaches. A PubMed search using the terms 17q12 deletion syndrome, diabetes mellitus type MODY5, and/or HNF1B was performed.

EVIDENCE SYNTHESIS

Three hundred sixty-one cases of postnatal 17q12 deletion syndrome were assessed, and details on clinical manifestations, diagnostic approaches, and therapeutic management were reviewed and compared with the two cases at our clinic. Furthermore, data on pathogenic mechanisms and their clinical implications were evaluated.

CONCLUSION

The 17q12 deletion syndrome usually comprises MODY5, structural or functional abnormalities of the kidneys, and neurodevelopmental or neuropsychiatric disorders. A complete deletion of HNF1B can be found in about 50% of patients with MODY5. A wide variety of additional clinical features, including genital and brain malformations, has been reported. Because HNF1B deletions are virtually always part of a 17q12 deletion syndrome and common genetic analyses for evaluation of MODY5 are unable to detect the deletion of a 1.4-Mb chromosomal region, initial attention to the syndromal features at the stage of diagnosis is of considerable importance for establishing correct diagnosis, subsequent therapy, and interdisciplinary patient care.

Mesenchymal stem cell (MSC)-mediated survival of insulin producing pancreatic β-cells during cellular stress involves signalling via Akt and ERK1/2

Mesenchymal stem cells (MSC) are of interest for cell therapy since their secreted factors mediate immunomodulation and support tissue regeneration. This study investigated the direct humoral interactions between MSC and pancreatic β-cells using human telomerase-immortalized MSC (hMSC-TERT) and rat insulinoma-derived INS-1E β-cells. hMSC-TERT supported survival of cocultured INS-1E β-cells during cellular stress by alloxan (ALX) and streptozotocin (STZ), but not in response to IL-1β. Accordingly, hMSC-TERT had no effect on inflammatory cytokine-related signalling via NF-kB and p-JNK but maintained p-Akt and upregulated p-ERK1/2. Inhibition of either p-Akt or p-ERK1/2 did not abolish protection by hMSC-TERT but activated the respective non-inhibited pathway. This suggests that one pathway compensates for the other. Main results were confirmed in mouse islets except hMSC-TERT-mediated upregulation of p-ERK1/2. Therefore, MSC promote β-cell survival by preservation of p-Akt signalling and further involve p-ERK1/2 activation in certain conditions such as loss of p-Akt or insulinoma background.

Preventive medicine of von Hippel-Lindau disease-associated pancreatic neuroendocrine tumors

Pancreatic neuroendocrine tumors (PanNETs) are rare in von Hippel-Lindau disease (VHL) but cause serious morbidity and mortality. Management guidelines for VHL-PanNETs continue to be based on limited evidence, and survival data to guide surgical management are lacking. We established the European-American-Asian-VHL-PanNET-Registry to assess data for risks for metastases, survival and long-term outcomes to provide best management recommendations. Of 2330 VHL patients, 273 had a total of 484 PanNETs. Median age at diagnosis of PanNET was 35 years (range 10-75). Fifty-five (20%) patients had metastatic PanNETs. Metastatic PanNETs were significantly larger (median size 5 vs 2 cm; P < 0.001) and tumor volume doubling time (TVDT) was faster (22 vs 126 months; P = 0.001). All metastatic tumors were ≥2.8 cm. Codons 161 and 167 were hotspots for VHL germline mutations with enhanced risk for metastatic PanNETs. Multivariate prediction modeling disclosed maximum tumor diameter and TVDT as significant predictors for metastatic disease (positive and negative predictive values of 51% and 100% for diameter cut-off ≥2.8 cm, 44% and 91% for TVDT cut-off of ≤24 months). In 117 of 273 patients, PanNETs >1.5 cm in diameter were operated. Ten-year survival was significantly longer in operated vs non-operated patients, in particular for PanNETs <2.8 cm vs ≥2.8 cm (94% vs 85% by 10 years; P = 0.020; 80% vs 50% at 10 years; P = 0.030). This study demonstrates that patients with PanNET approaching the cut-off diameter of 2.8 cm should be operated. Mutations in exon 3, especially of codons 161/167 are at enhanced risk for metastatic PanNETs. Survival is significantly longer in operated non-metastatic VHL-PanNETs.

Efficacy and Safety of Dapagliflozin in Patients With Inadequately Controlled Type 1 Diabetes (the DEPICT-2 Study): 24-Week Results From a Randomized Controlled Trial

OBJECTIVE

This 24-week, double-blinded, phase 3 clinical trial (DEPICT-2; ClinicalTrials.gov, NCT02460978) evaluated efficacy and safety of dapagliflozin as adjunct therapy to adjustable insulin in patients with inadequately controlled type 1 diabetes (HbA_1c 7.5-10.5%).

RESEARCH DESIGN AND METHODS

Patients were randomized 1:1:1 to dapagliflozin 5 mg (n = 271), dapagliflozin 10 mg (n = 270), or placebo (n = 272) plus insulin. Insulin dose was adjusted by investigators according to self-monitored glucose readings, local guidance, and individual circumstances.

RESULTS

Baseline characteristics were balanced between treatment groups. At week 24, dapagliflozin significantly decreased HbA_1c (primary outcome; difference vs. placebo: dapagliflozin 5 mg -0.37% [95% CI -0.49, -0.26], dapagliflozin 10 mg -0.42% [-0.53, -0.30]), total daily insulin dose (-10.78% [-13.73, -7.72] and -11.08% [-14.04, -8.02], respectively), and body weight (-3.21% [-3.96, -2.45] and -3.74% [-4.49, -2.99], respectively) (P < 0.0001 for all). Mean interstitial glucose, amplitude of glucose excursion, and percent of readings within target glycemic range (>70 to ≤180 mg/dL) versus placebo were significantly improved. More patients receiving dapagliflozin achieved a reduction in HbA_1c ≥0.5% without severe hypoglycemia compared with placebo. Adverse events were reported for 72.7%, 67.0%, and 63.2% of patients receiving dapagliflozin 5 mg, dapagliflozin 10 mg, and placebo, respectively. Hypoglycemia, including severe hypoglycemia, was balanced between groups. There were more adjudicated definite diabetic ketoacidosis (DKA) events with dapagliflozin: 2.6%, 2.2%, and 0% for dapagliflozin 5 mg, dapagliflozin 10 mg, and placebo, respectively.

CONCLUSIONS

Dapagliflozin as adjunct therapy to adjustable insulin in patients with type 1 diabetes was well tolerated and improved glycemic control with no increase in hypoglycemia versus placebo but with more DKA events.

Comparative efficacy and safety of the duodenal-jejunal bypass liner in obese patients with type 2 diabetes mellitus: A case control study

AIMS

The duodenal-jejunal bypass liner (DJBL) is an endoscopic device mimicking surgical duodenal-jejunal bypass, and is indicated for the treatment of obesity-associated type 2 diabetes mellitus. This analysis was conducted to evaluate the efficacy and safety of the DJBL in comparison to lifestyle changes and antidiabetic drugs.

MATERIALS AND METHODS

To determine the efficacy and long-term safety of the DJBL, data concerning 235 obese patients with type 2 diabetes mellitus from the German DJBL registry were analysed. For comparison with standard treatment, propensity-score-matching with patients from the German DPV registry, including the matching parameters sex, age, diabetes duration, baseline BMI and baseline HbA1c, was applied. The final matched cohort consisted of 111 patients in the DJBL group and 222 matched control DPV patients.

RESULTS

Mean treatment time with the DJBL was 47.5 ± 12.2 weeks, mean BMI reduction was 5.0 kg/m² (P < .001) and mean HbA1c reduction was 1.3% (11.9 mmol/mol) (P < .001). Reduction of antidiabetic medications and improvements in other metabolic and cardiovascular risk parameters was observed. In comparison to the matched control group, mean reductions in HbA1c (-1.37% vs -0.51% [12.6 vs 3.2 mmol/mol]; P < .0001) and BMI (-3.02 kg/m² vs -0.39 kg/m² ; P < .0001) were significantly higher. Total cholesterol, LDL cholesterol and blood pressure were also significantly better.

CONCLUSION

This study provides the largest, so far, hypothesis-generating evidence for a putative positive risk/benefit ratio for treatment of obese patients with type 2 diabetes mellitus with the DJBL as an alternative treatment option for this patient population.

Ischemic Duodenal Ulceration after Transarterial Chemoembolization for Hepatocellular Carcinoma: A Case Report

Drug-eluting bead transarterial chemoembolization (DEB-TACE) is a well-established, minimally invasive interventional treatment for nonresectable hepatocellular carcinoma (HCC). Generally, TACE is regarded as safe and effective with a low complication rate. However, remote gastrointestinal ischemia due to the carryover of embolic material into visceral arteries is a rare but serious complication of TACE. In this report, we present a case of duodenal ulceration with contained perforation and severe necrotizing pancreatitis after TACE in a patient with nonresectable HCC and underlying hepatitis C virus associated with Child-Pugh stage B liver cirrhosis. This patient showed, for the first time, complete endoscopic and clinical recovery within 2 months of conservative treatment. Considering the high mortality rate from surgical intervention in all previously reported patients, the significant recovery potential demonstrated by our case suggests conservative treatment with antibiotics and parenteral nutrition combined with close clinical, radiological, and endoscopic monitoring should be considered in all clinically stable patients without signs of peritonism or septic sequelae.

Design of the Weight-loss Endoscopy Trial (WET): a multi-center, randomized, controlled trial comparing weight loss in endoscopically implanted duodenal-jejunal bypass liners vs. intragastric balloons vs. a sham procedure

Background

Obesity is a global problem leading to reduced life expectancy, cardiovascular diseases, diabetes and many types of cancer. Even people willing to accept treatment only achieve a mean weight loss of about 5 kg using commercial weight loss programs. Surgical interventions, e.g. sleeve gastrectomy or gastric bypass are effective but accompanied by risk of serious complications and side effects. Less invasive endoscopic procedures mainly comprise the intragastric balloon (IB) and the duodenal-jejunal bypass liner (DJBL). To date, a randomized comparison between these devices has not been undertaken or shown to be superior to a sham procedure.

Methods

We designed a multi-center, randomized, patient and assessor-blinded, controlled trial comparing weight loss in endoscopically implanted IB vs. DJBL vs. a sham procedure. A total of 150 patients with a BMI > 35 kg/m² or > 30 with obesity-related comorbidities and indication for proton pump inhibitors are randomized to receive either IB, DJBL or a sham gastroscopy (2:2:1 ratio). All participants undergo regular dietary consultation. The IB will be removed after 6 months, whereas the DJBL will be explanted after 12 months. All patients will receive gastroscopies at implantation and explantation of the devices or sedation without gastroscopy to maintain blinding. Main exclusion criteria are malignant diseases, peptic ulcer or previous bariatric intervention. Weight loss 12 months after explantation of the devices, changes in comorbidities, quality of life, complication rates and safety will be evaluated.

Discussion

This trial could help to identify the most effective and safest endoscopic device, thus determining the new standard procedure for endoscopic bariatric treatment.

Trial registration

16th January 2017. DRKS00011036. Funded by the German Research Foundation (DFG).

Comparative Characteristics of Patients with Type 2 Diabetes Mellitus Treated by Bariatric Surgery Versus Medical Treatment: a Multicentre Analysis of 277,862 Patients from the German/Austrian DPV Database

INTRODUCTION

Bariatric surgery is a well-established treatment option for serious obesity and concomitant type 2 diabetes mellitus (T2DM). In this analysis, we investigated predictors for bariatric surgery in everyday clinical practice.

MATERIALS AND METHODS

In the DPV-registry, patients with T2DM from Germany and Austria treated by bariatric surgery were compared to non-surgery controls by descriptive statistics and regression analysis.

RESULTS

Among 277,862 patients with T2DM, 0.07% underwent bariatric surgery. Surgery patients were predominantly female [61.20%], younger [median age (Q1;Q3) 54.74(47.40;61.61) vs. 70.04 (60.36;77.58) years] and had a longer diabetes duration [11.21 (7.15;17.93) vs. 8.36 (2.94;14.91) years]. They had a higher BMI [40.02 vs. 30.61 kg/m², adjusted p < 0.0001] and a slightly lower HbA1c [7.25 vs. 7.56%, adjusted p < 0.05]. There was a trend using more often insulin therapy (52.79 vs.50.08%, n.s.) with no difference in insulin dose/kg × day [0.56 vs. 0.58, n.s.]. Sleeve gastrectomy was performed most frequently, followed by Roux-en-Y gastric bypass, gastric banding, gastric balloon and others. A 2-year follow-up data in 29 patients demonstrated significant reductions in BMI [45.23 to 38.00 kg/m², p < 0.005] and HbA1c [7.98 to 6.98%, p < 0.005], and a trend for reduced insulin requirements [62.07 vs. 44.83%, n.s.].

CONCLUSION

Despite favourable 2-year outcomes, bariatric surgery is still used rarely in patients with T2DM and obesity. BMI rather than metabolic control seems to represent the major selector for or against bariatric surgery in T2DM.

Primary aldosteronism: key characteristics at diagnosis: a trend toward milder forms

OBJECTIVE

Primary aldosteronism (PA) is the most common endocrine form of arterial hypertension. The German Conn's Registry's purpose is to improve treatment outcomes of PA. We assessed whether key clinical, biochemical and epidemiological characteristics of newly diagnosed PA cases have changed over time, potentially indicating a different screening and referral practice in Germany evolving from 2008 to 2016.

DESIGN

The German Conn's Registry is a multicenter database prospectively analyzing morbidity and long-term outcome of patients with PA.

METHODS

Phenotypic changes between three year periods were calculated using Mann-Whitney U tests and Kruskal-Wallis tests for independent variables.

RESULTS

Over three time periods from 2008 to 2016, we noted a relative decrease of unilateral PA cases (67 vs 43%). Significantly more females were diagnosed with PA (33 vs 43%). Median daily defined drug doses decreased (3.1 vs 2.0) in the presence of unchanged SBP (150 vs 150 mmHg), plasma aldosterone (199 vs 173 ng/L) and PRC (3.2 vs 3.2 U/L). Median ARR values decreased (70 vs 47 ng/U) and median potassium levels at diagnosis (3.5 vs 3.7 mmol/L) increased as the percentage of normokalemic patients (25 vs 41%), indicating milder forms of PA.

CONCLUSIONS

Our results are in accordance with an increased screening intensity for PA. We identified a trend toward diagnosing milder forms, increasingly more females and less unilateral cases of PA.