Global Economic Burden of Diabetes in Adults: Projections From 2015 to 2030

Preventing and Treating Heart Failure with Sodium-Glucose Co-Transporter 2 Inhibitors

Heart failure is a common complication among patients with type 2 diabetes mellitus and is associated with significantly increased risks of subsequent morbidity and mortality. Until recently, therapies and strategies were lacking to attenuate this excess risk of heart failure in this population. Sodium-glucose co-transporter 2 (SGLT2) inhibitors represent a unique class of glucose-lowering therapies that have multisystem health benefits. Three large cardiovascular outcomes trials have demonstrated consistent reductions in heart failure events among patients with type 2 diabetes mellitus with, or at risk for, atherosclerotic cardiovascular disease. Another trial recently showed that an SGLT2 inhibitor, canagliflozin, also significantly reduced heart failure events among patients with type 2 diabetes mellitus and albuminuric chronic kidney disease. The SGLT2 inhibitor class represents an important new therapeutic approach for the prevention of heart failure in at-risk patients with type 2 diabetes mellitus, and is actively being studied for use in treating patients with heart failure (with or without type 2 diabetes mellitus). (Supplementary video "Preventing and Treating Heart Failure with Sodium-Glucose Co-Transporter 2 Inhibitors" is available online.).

Do Probiotics Improve the Health Status of Individuals with Diabetes Mellitus? A Review on Outcomes of Clinical Trials

Probiotics are now considered as an adjuvant and complementary therapeutic agent for several health complications, especially for metabolic and gastrointestinal disorders because of the influential impact of probiotic consumption on gut microbiota and immunity. Diabetes mellitus (DM) is fourth, in noncommunicable disease category, leading cause of mortality, morbidity, and economic crises in the world. Though several progressions are added in the medical field in recent decades, the treatment and management of diabetic-related health issues are still challenging. The present study summarizes the effects of probiotic supplementation on the health status of diabetic patients. The relevant information was collected from Scopus, PubMed, and Google Scholar. The detailed literature survey revealed that the consumption of probiotic supplementation significantly improved the overall health condition of diabetic patients. Especially, the probiotic intervention improved the fasting blood glucose, insulin sensitivity, and systemic inflammatory and antioxidant status in type 2 diabetic (T2D) patients. Moreover, improvement of gut microbial composition and prevention of bacterial translocation has also been observed in probiotic-supplemented T2D people. Some of the studies evidenced that the supplementation of probiotics can prevent and improve the gestational DM. Nevertheless, some of the studies reported negative results and limitations in the results of clinical trials. However, further studies are mandatory to develop a concrete probiotic-based adjuvant treatment procedure to treat DM.

Nanotechnology in Insulin Delivery for Management of Diabetes

Diabetes is a group of diseases characterized by hyperglycemia and originating from the deficiency or resistance to insulin, or both. Ultimately, the most effective treatment for patients with diabetes involves subcutaneous injections of insulin. However, this route of administration is often painful and inconvenient, as most patients will have to selfadminister it at least twice a day for the rest of their lives. Also, infection, insulin precipitation, and either lipoatrophy or lipohypertrophy are frequently observed at the site of injection. To date, several alternative routes of insulin administration have been explored, including nasal, pulmonary and oral. Although the delivery of insulin is an ideal route for diabetic patients, several limitations have to be overcome such as the rapid degradation of insulin in gastric fluid and low oral bioavailability. Numerous strategies have been carried out to improve these limited parameters such as the use of enzyme inhibitors, absorption enhancers, mucoadhesive polymers and chemical modification for receptor-mediated absorption. Also, insulin-loaded nanocarriers bypass several physiological barriers. This current review focuses on the various barriers existing in the delivery of insulin through the oral route and the strategies undertaken so far to overcome those obstacles using nanocarriers as a potential vehicle of insulin.

Risk scores for type 2 diabetes mellitus in Latin America: a systematic review of population-based studies

AIM

To summarize the evidence on diabetes risk scores for Latin American populations.

METHODS

A systematic review was conducted (CRD42019122306) looking for diagnostic and prognostic models for type 2 diabetes mellitus among randomly selected adults in Latin America. Five databases (LILACS, Scopus, MEDLINE, Embase and Global Health) were searched. type 2 diabetes mellitus was defined using at least one blood biomarker and the reports needed to include information on the development and/or validation of a multivariable regression model. Risk of bias was assessed using the PROBAST guidelines.

RESULTS

Of the 1500 reports identified, 11 were studied in detail and five were included in the qualitative analysis. Two reports were from Mexico, two from Peru and one from Brazil. The number of diabetes cases varied from 48 to 207 in the derivations models, and between 29 and 582 in the validation models. The most common predictors were age, waist circumference and family history of diabetes, and only one study used oral glucose tolerance test as the outcome. The discrimination performance across studies was ~ 70% (range: 66-72%) as per the area under the receiving-operator curve, the highest metric was always the negative predictive value. Sensitivity was always higher than specificity.

CONCLUSION

There is no evidence to support the use of one risk score throughout Latin America. The development, validation and implementation of risk scores should be a research and public health priority in Latin America to improve type 2 diabetes mellitus screening and prevention.

Performance of the UKPDS Outcomes Model 2 for Predicting Death and Cardiovascular Events in Patients with Type 2 Diabetes Mellitus from a German Population-Based Cohort

BACKGROUND AND OBJECTIVE

Accurate prediction of relevant outcomes is important for targeting therapies and to support health economic evaluations of healthcare interventions in patients with diabetes. The United Kingdom Prospective Diabetes Study (UKPDS) risk equations are some of the most frequently used risk equations. This study aims to analyze the calibration and discrimination of the updated UKPDS risk equations as implemented in the UKPDS Outcomes Model 2 (UKPDS-OM2) for predicting cardiovascular (CV) events and death in patients with type 2 diabetes mellitus (T2DM) from population-based German samples.

METHODS

Analyses are based on data of 456 individuals diagnosed with T2DM who participated in two population-based studies in southern Germany (KORA (Cooperative Health Research in the Region of Augsburg)-A: 1997/1998, n = 178; KORA-S4: 1999-2001, n = 278). We compared the participants' 10-year observed incidence of mortality, CV mortality, myocardial infarction (MI), and stroke with the predicted event rate of the UKPDS-OM2. The model's calibration was evaluated by Greenwood-Nam-D'Agostino tests and discrimination was evaluated by C-statistics.

RESULTS

Of the 456 participants with T2DM (mean age 65 years, mean diabetes duration 8 years, 56% male), over the 10-year follow-up time 129 died (61 due to CV events), 64 experienced an MI, and 46 a stroke. The UKPDS-OM2 significantly over-predicted mortality and CV mortality by 25% and 28%, respectively (Greenwood-Nam-D'Agostino tests: p < 0.01), but there was no significant difference between predicted and observed MI and stroke risk. The model poorly discriminated for death (C-statistic [95% confidence interval] = 0.64 [0.60-0.69]), CV death (0.64 [0.58-0.71]), and MI (0.58 [0.52-0.66]), and failed to discriminate for stroke (0.57 [0.47-0.66]).

CONCLUSIONS

The study results demonstrate acceptable calibration and poor discrimination of the UKPDS-OM2 for predicting death and CV events in this population-based German sample. Those limitations should be considered when using the UKPDS-OM2 for economic evaluations of healthcare strategies or using the risk equations for clinical decision-making.

Hypocaloric, plant-based oatmeal interventions in the treatment of poorly-controlled type 2 diabetes: A review

BACKGROUND

Lifestyle interventions, including dietary modifications, play a key role in the treatment of type 2 diabetes. By the second half of the last century, dietary oatmeal interventions had frequently been used in patients with diabetes; however, with the widespread introduction of insulin, this practice gradually fell into disuse. Within the last decades, the original oatmeal intervention, first described in 1903, has been modified towards a hypocaloric, low-fat, and plant-based intervention.

AIM

The aim of this review was to investigate the current role of these adapted short-term dietary oatmeal interventions in the treatment of patients suffering from poorly-controlled type 2 diabetes. A special focus was put on opportunities for and barriers to its clinical implementation and its potential mechanisms of action.

METHODS

The electronic databases of PubMed and Google Scholar were searched using the keywords "oat," "oats," "oatmeal," and "diabetes."

RESULTS

While there are a limited number of clinical studies including hypocaloric short-term dietary oatmeal interventions, there is evidence that these interventions may lead to a significant decrease in mean blood glucose levels and a significant reduction of insulin dosage in patients suffering from poorly-controlled type 2 diabetes.

CONCLUSION

Modified short-term dietary oatmeal interventions are an effective and economical tool in the treatment of patients suffering from poorly-controlled type 2 diabetes.

Actionable Real-World Evidence to Improve Health Outcomes and Reduce Medical Spending Among Risk-Stratified Patients with Diabetes

BACKGROUND

Type 2 diabetes mellitus (T2DM) is a chronic condition with a high economic burden as well as drug treatments that have not all demonstrated effects on longevity. Managed care organizations want to improve health outcomes in these complex patients but lack actionable evidence to make informed decisions on which therapies are most effective among their members and may also control total health care spending.

OBJECTIVE

To produce actionable evidence by identifying antidiabetic treatments that are effective and may reduce total cost of care in various risk groups of patients with T2DM, using insurance claims data that includes medical claims and pharmacy dispensing data among members of Horizon Blue Cross Blue Shield of New Jersey with T2DM.

METHODS

We identified patients with T2DM in longitudinal claims data from Horizon between 2014 and 2017 with demographic and enrollment information, inpatient and outpatient diagnoses and procedures, and pharmacy dispensing. Outcomes included myocardial infarction, heart failure (HF), stroke, percutaneous revascularization, health care services utilization, and plan costs (i.e., medical, pharmacy, and total cost of care). After propensity score decile adjustment on over 20 covariates, we evaluated the effectiveness and safety of second-line antidiabetic treatment that included sodium-glucose co-transporter-2 (SGLT-2) inhibitors, sulfonylureas (SUs), dipeptidyl peptidase-4 (DPP-4) inhibitors, and glucagon-like peptide-1 (GLP-1) receptor agonists.

RESULTS

Among 115,308 members with T2DM, the most common comorbidities were cardiovascular risk factors, including hyperlipidemia (56%), hypertension (50%), and existing cardiovascular disease (CVD; 55%). Among members receiving dual antidiabetic treatment (n = 20,204), the most prevalent treatments were metformin plus the following second-line medications: SUs (42%), DPP-4 inhibitors (29%), SGLT-2 inhibitors (10%), or GLP-1 receptor agonists (3%). Approximately 20% of members accounted for 79% of total cost of care, with an average of $9,605 per member per year (PMPY). Compared with SU initiation and after propensity score decile adjustment, new users of SGLT-2 inhibitors had a reduced risk for HF hospitalization (HR = 0.35, 95% CI = 0.13-0.89), hypoglycemia, albuminuria, microvascular disease, and metabolic failure. Among SGLT-2 inhibitor initiators with established CVD, the savings in total cost of care compared with SU initiators was $5,520 per member over an average treatment duration of 6 months and an approximate savings of $11,000 PMPY if patients persisted on treatment for 12 months.

CONCLUSIONS

In the Horizon membership, we confirmed that SGLT-2 inhibitors reduce HF hospitalizations, resulting in reduced medical spending and savings in total cost of care. Regulatory-grade analytics of local data provided the confidence to encourage increased SGLT-2 inhibitor use to produce better outcomes and save total cost of care despite higher pharmacy spending.

DISCLOSURES

This research did not receive outside funding; however, Aetion has since begun a contractual relationship with Horizon Blue Cross Blue Shield of New Jersey. Garry, Petruski-Ivleva, Cheever, and Rajan are employees of and have stock options in Aetion, a company that makes software for the analysis of real-world data. Eapen was an employee of Aetion during the implementation of this study. Rassen is an employee of and has ownership interest in Aetion. Murk is a consultant to Aetion of which he owns equity. Schneeweiss is a consultant to WHISCON and to Aetion, of which he also owns equity. He is the principal investigator of investigator-initiated grants to the Brigham and Women's Hospital from Bayer, Genentech, Boehringer Ingelheim, and Vertex. Gambino is an employee and officer at Horizon Blue Cross and Blue Shield of New Jersey. He was recently appointed to a board observer position at Aetion, as Horizon has small equity interest in Aetion. Jan is an employee of Rutgers State University and Horizon Blue Cross Blue Shield of New Jersey and has no conflict of interest or association with Aetion or any pharmaceutical company. Jang and Rubin are employees of Horizon Blue Cross and Blue Shield of New Jersey and have no conflict of interest or association with Aetion. This work was presented as a poster at AMCP Nexus 2018, October 22-25, 2018, in Orlando, FL; as part of a continuing education session at the AMCP Managed Care & Specialty Pharmacy 2019 Annual Meeting in San Diego, CA, March 25-28, 2019; as invited podium presenter at the Blue Cross Blue Shield 2019 National Summit conference in Grapevine, TX, April 29-May 2, 2019; and was accepted for a podium presentation at the International Society for Pharmacoeconomics and Outcomes Research (ISPOR) 2019 annual conference in New Orleans, LA, May 18-22, 2019, where it won an award for Best Podium Presentation.

TRIal to slow the Progression Of Diabetes (TRIPOD): study protocol for a randomized controlled trial using wireless technology and incentives

BACKGROUND

The outcomes for those with type 2 diabetes mellitus (T2DM) in Singapore are poor. In this TRIal to slow the Progression Of Diabetes (TRIPOD), we will evaluate the effectiveness and cost-effectiveness of a comprehensive diabetes management package (DMP), with or without a financial incentives program, M-POWER Rewards, in efforts to improve HbA1c levels for individuals with T2DM.

METHODS/DESIGN

TRIPOD is a randomized, open-label, controlled, multi-center, superiority trial with three parallel arms: (1) usual care only, (2) usual care with DMP, and (3) usual care with DMP plus M-POWER Rewards. A total of 339 adults with sub-optimally controlled T2DM (self-reported HbA1c 7.5-11.0%) will be block randomized according to a 1:1:1 allocation ratio to the three arms. The primary outcome is mean change in HbA1c level at Month 12 from baseline. Secondary outcomes include mean change in HbA1c level at Months 6, 18, and 24; mean changes at Months 6, 12, 18, and 24 in weight, blood pressure, and self-reported physical activity, weight monitoring, blood glucose monitoring, medication adherence, diabetes self-management, sleep quality, work productivity and daily activity impairment, and health utility index; and proportion of participants initiating insulin treatment by Months 6, 12, 18, and 24. Incremental cost-effectiveness ratios will be computed based on costs per improvement in HbA1c at Month 12 and converted to cost per quality-adjusted life year gained.

DISCUSSION

The TRIPOD study will present insights about the long-term cost-effectiveness and financial viability of the interventions and the potential for integrating within usual care.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT03800680. Registered on 11 January 2019.

Impact of Coming Demographic Changes on the Number of Adults in Need of Care for Hypertension in Brazil, China, India, Indonesia, Mexico, and South Africa

Over the coming decades, middle-income countries are expected to undergo substantial demographic changes. We estimated the consequences of these changes on the number of adults in need of hypertension care between 2015 and 2050 using nationally representative household-survey data collected in Brazil, China, India, Indonesia, Mexico, and South Africa (N=770 121). To reflect unmet need for healthcare, we defined hypertension as systolic blood pressure ≥140 mm Hg or diastolic blood pressure ≥90 mm Hg regardless of treatment status. Using a mathematical disease projection equation, we calculated the change in the number of individuals in need of hypertension care in each country that was due to changes in population size, age composition, and age-specific prevalence under various epidemiological scenarios. If the current age-specific prevalence schedule of hypertension remains unchanged until 2050, demographic changes alone will increase the number of adults in need of hypertension care by 319.7 million individuals, ranging from a relative growth of 55% in China to 151% in Mexico. Even if the age-specific prevalence of hypertension is reduced by 25% by 2050 among adults aged ≥40 years, the number of individuals in need of hypertension care will still increase by 145.9 million individuals, with relative increases ranging from 16% in China to 88% in Mexico. Overall, our results suggest that coming demographic changes in middle-income countries will overpower even ideal prevention efforts. Middle-income countries will need to massively expand healthcare services for aging-related diseases, such as hypertension, if they are to meet the virtually inevitable future increase in care needs for these conditions.

Association Between Late Bedtime and Diabetes Mellitus: A Large Community-Based Study

STUDY OBJECTIVES

The aim of this study was to investigate the association of bedtime with the prevalence of diabetes mellitus (DM) based on a large community-based population.

METHODS

In total, 5,420 participants (2,574 males and 2,846 females; aged 63.5 ± 11.0 years) from the Sleep Heart Health Study database were selected in this study. Sleep habit was recorded based on a questionnaire administered to patients upon recruitment. Bedtime was categorized as 11:00 pm and before, 11:00 pm to 12:00 am, and 12:00 am and later in the current study. Multivariate logistic regression was used to estimate the odds ratios (ORs) and 95% confidence intervals (CIs) to determine the relationship between bedtime and the prevalence of DM.

RESULTS

The distribution of weekday bedtime at 11:00 pm and before, 11:00 pm to 12:00 am, 12:00 am and later was observed in 3,316 participants (61.2%), 991 participants (18.3%), and 1,113 participants (20.5%), respectively. Meanwhile, individuals with weekday bedtime of 12:00 am and later had a higher prevalence of DM than those with bedtime at 11:00 pm to 12:00 am, and 11:00 pm and before (10.6% versus 5.7% versus 6.6%, respectively; P < .001). In the adjusted multivariate logistic regression model, bedtime at 12:00 am and later on a weekday was significantly associated DM prevalence (OR 1.446, 95% CI 1.107-1.888, P = .007). No significant association was found between weekend bedtime and DM.

CONCLUSION

Late bedtime at 12:00 am and later on a weekday may be a risk factor for the prevalence of DM. Stable sleep timing leads to lower risk of DM deserves future exploration.

When Both Markets and Governments Fail Health

This paper presents the rationale and motivation for countries and the global development community to tackle a critical set of functions in the health sector that appear to be under-prioritized and underfunded. The recent eruptions of Ebola outbreaks in Africa and other communicable diseases like Zika and SARS elsewhere led scientific and medical commissions to call for global action. The calls for action motivated the World Health Organization (WHO) to respond by defining a new construct within the health sector: Common Good for Health (CGH). While the starting point for developing the CGH construct was the re-emergence of communicable diseases, it extends to additional outcomes resulting from failures to act and finance within and outside the health sector. This paper summarizes global evidence on failures to address CGHs effectively, identifies potential reasons for the public and private sectors' failures to respond, and lays out the first phase of the WHO program as represented by the papers in this special issue of Health Systems & Reform.

From Hong Kong Diabetes Register to JADE Program to RAMP-DM for Data-Driven Actions

In 1995, the Hong Kong Diabetes Register (HKDR) was established by a doctor-nurse team at a university-affiliated, publicly funded, hospital-based diabetes center using a structured protocol for gathering data to stratify risk, triage care, empower patients, and individualize treatment. This research-driven quality improvement program has motivated the introduction of a territory-wide diabetes risk assessment and management program provided by 18 hospital-based diabetes centers since 2000. By linking the data-rich HKDR to the territory-wide electronic medical record, risk equations were developed and validated to predict clinical outcomes. In 2007, the HKDR protocol was digitalized to establish the web-based Joint Asia Diabetes Evaluation (JADE) Program complete with risk levels and algorithms for issuance of personalized reports to reduce clinical inertia and empower self-management. Through this technologically assisted, integrated diabetes care program, we have generated big data to track secular trends, identify unmet needs, and verify interventions in a naturalistic environment. In 2009, the JADE Program was adapted to form the Risk Assessment and Management Program for Diabetes Mellitus (RAMP-DM) in the publicly funded primary care clinics, which reduced all major events by 30-60% in patients without complications. Meanwhile, a JADE-assisted assessment and empowerment program provided by a university-affiliated, self-funded, nurse-coordinated diabetes center, aimed at complementing medical care in the community, also reduced all major events by 30-50% in patients with different risk levels. By combining universal health coverage, public-private partnerships, and data-driven integrated care, the Hong Kong experience provides a possible solution than can be adapted elsewhere to make quality diabetes care accessible, affordable, and sustainable.

Determinants of diabetes in Bangladesh using two approaches: an analysis of the Demographic and Health Survey 2011

This cross-sectional study analysed data from the Bangladesh Demographic and Health Survey 2011 to investigate factors associated with diabetes in Bangladesh. Data were analysed using logistic and log-binomial regressions to estimate odds ratios (ORs) and prevalence ratios (PRs), respectively. Among the 7544 respondents aged ≥35 years, the estimated prevalence of diabetes was 11.0%. In the adjusted analysis, survey participants in the age group 55-64 years (adjusted PR [APR]: 1.8, 95% Confidence Interval (CI): 1.4, 2.2; adjusted OR [AOR]: 1.9, 95% CI: 1.5, 2.5) and those with at least secondary education level (APR: 1.3, 95% CI: 1.0, 1.6; AOR: 1.3, 95% CI: 1.0, 1.7) were more likely to have diabetes than those in the age group 35-44 years and those with no education. Furthermore, respondents living in Khulna (APR: 0.5, 95% CI: 0.4, 0.6; AOR: 0.4, 95% CI: 0.3, 0.6) were less likely to have diabetes than people living in Barisal. While adjusted estimates of PR and OR were similar in terms of significance of association, the magnitude of the point estimate was attenuated in PR compared with the OR. Nevertheless, the measured factors still had a significant association with diabetes in Bangladesh. The results of this study suggest that Bangladeshi adults would benefit from increased education on, and awareness of, the risk factors for diabetes. Focused public health intervention should target these high-risk populations.

Relationship between Gout and Diabetes Mellitus after Acute Pancreatitis: A Nationwide Cohort Study

OBJECTIVE

After acute pancreatitis, individuals often have low-grade inflammation, and subsequently develop metabolic sequelae such as post-pancreatitis diabetes mellitus (PPDM). Although numerous studies have investigated the relationship between gout and type 2 diabetes, little is known about the relationship between gout and PPDM. The aim was to investigate the associations between gout and PPDM.

METHODS

Using nationwide pharmaceutical dispensing data linked to hospital discharge data in New Zealand, gout and PPDM were identified among individuals after first episode of acute pancreatitis between January 1, 2007, and December 31, 2015. Multivariable Cox regression analyses were conducted, adjusting for age, sex, ethnicity, social deprivation index, alcohol consumption, tobacco smoking, comorbidities, medications (glucocorticoids, statins, and estrogens), and characteristics of acute pancreatitis.

RESULTS

A total of 10,117 individuals were included in the analysis of risk for gout and 9471 in the analysis of risk for PPDM. PPDM was significantly associated with a higher risk of gout in the overall cohort (adjusted HR 1.88, 95% CI 1.15-3.06) and women (2.72, 95% CI 1.31-5.65), but not in men (1.42, 95% CI 0.73-2.78). Preexisting gout was significantly associated with a higher risk of PPDM in the overall cohort (adjusted HR 1.58, 95% CI 1.04-2.41) and women (2.66, 95% CI 1.29-5.49), but not in men (1.31, 95% CI 0.78-2.20).

CONCLUSION

The relationship between gout and PPDM is bidirectional in the post-pancreatitis setting. A history of gout is a risk factor of PPDM, particularly in women.

Exposição crônica ao cloridrato de metformina e à glibenclamida causa alterações comportamentais, glicêmicas e de mortalidade em Hemigrammus caudovittatus e Danio rerio

RESUMO Hemigrammus caudovittatus e Danio rerio foram expostos aos hipoglicemiantes orais (HOs) cloridrato de metformina a 40µg/L e 120µg/L e glibenclamida a 0,13µg/L e 0,39µg/L durante 100 dias. Foram avaliados os efeitos tóxicos dos fármacos em relação ao peso, ao comportamento animal, à glicemia e à mortalidade. H. caudovittatus expostos à menor concentração dos fármacos apresentaram aumento significativo (P<0,05) no evento Respiração Aérea. Ainda, foi observado aumento no comportamento Descansar quando os animais foram expostos à glibenclamida a 0,39µg/L. Em D. rerio expostos ao cloridrato de metformina a 120µg/L, foi observado aumento (P<0,05) no comportamento Descansar. A glibenclamida provocou redução (P<0,05) na glicemia de H. caudovittatus. Ambos os fármacos causaram efeito letal na espécie D. rerio, contudo a glibenclamida foi mais tóxica, causando 100% de mortalidade em 30 dias de exposição. Os animais que vieram a óbito apresentaram congestão nos arcos branquiais e hemorragia. Os HOs foram desenvolvidos para apresentarem efeitos fisiológicos em mamíferos, entretanto efeitos tóxicos foram encontrados nas duas espécies de peixe estudadas. Isso levanta a preocupação sobre possíveis efeitos tóxicos de HOs e sobre quais métodos serão utilizados para a sua degradação no ambiente aquático.

Appraisal of Non-Cardiovascular Safety for Sodium-Glucose Co-Transporter 2 Inhibitors: A Systematic Review and Meta-Analysis of Placebo-Controlled Randomized Clinical Trials

Background: Whereas the cardiovascular safety of sodium-glucose co-transporter 2 (SGLT2) inhibitors has been well reported, there is limited data from controlled clinical trials regarding the non-cardiovascular safety. This was the focus of our study.

Methods and Findings: We systematically searched MEDLINE, EMBASE, and Cochrane Library (5^th Sep 2018) for randomized controlled trials (RCTs) that reported safety data for SGLT2 inhibitors and placebo. Relative risks (RRs) and their 95% confidence intervals (CIs) were pooled using random-effects models. Seventy RCTs (83 studies enrolling 36,958 patients in 78 publications) were identified. SGLT2 inhibitors were associated with a lower risk of serious adverse events (RR 0.90, 95% CI 0.86 to 0.94, P < 0.001), death (RR 0.78, 95% CI 0.64 to 0.94, P < 0.05), gastroenteritis (RR 0.38, 95% CI 0.20 to 0.72, P < 0.05), arthralgia (RR 0.72, 95% CI 0.54 to 0.96, P < 0.05), hypertension (RR 0.61, 95% CI 0.50 to 0.75, P < 0.001), and edema/peripheral edema (RR 0.49, 95% CI 0.33 to 0.72, P < 0.001) compared to placebo. SGLT2 inhibitors were associated with higher risk of infections compared to placebo (RR 1.27, 95% CI 1.17 to 1.37, P < 0.001), especially for genital mycotic infection (GMI) (RR 3.71, 95% CI 3.19 to 4.32, P < 0.001). Other significant effects were observed for osmotic diuresis–related AEs (RR 2.73, 95% CI 2.20 to 3.40, P < 0.001), volume-related AEs (RR 1.26, 95% CI 1.08 to 1.46, P < 0.05), renal-related AEs (RR 1.36, 95% CI 1.02 to 1.80, P < 0.05), hypoglycemia (RR 1.18, 95% CI 1.10 to 1.26, P < 0.001), and increased blood ketone bodies (RR 2.00, 95% CI 1.01 to 3.97, P < 0.05). Subgroup and sensitivity analyses strengthened the robustness of primary results.

Conclusion: Results from RCTs confirmed lower risk of death, serious adverse events, hypertension, and edema associated with type 2 diabetes mellitus (T2DM) patients treated with SGLT2 inhibitors when compared with placebo. The use of SGLT2 inhibitors were associated with higher risk of infection, osmotic diuresis, volume depletion effects, renal related AEs, and higher blood ketone bodies when compared with placebo.

Prevalence of gestational diabetes mellitus in Eastern Mediterranean region: a systematic review and meta-analysis

PURPOSE

Gestational diabetes mellitus (GDM) is one of the costly challenges in the health field. Despite the individual studies in the Eastern Mediterranean, there is no comprehensive study in this regard. The aim of this study was to determine the prevalence of GDM in the Eastern Mediterranean region.

METHODS

In this meta-analysis and systematic review, three international databases (PubMed, Web of science and Scopus) were searched from inception until 30 December 2018. The Hui tool was used to assess the quality of the included studies.

RESULTS

Thirty-three studies performed on 887166 participants were included in the meta-analysis. Based on the results of random effect method, the overall prevalence of GDM was 11.7%. Between six country with have three or more study, pooled prevalence for Saudi Arabi it was 3.6 times more than Israel (17.6 vs. 4.9%), and for Pakistan, Qatar, Bahrain and Iran were 15.3%, 14.7%, 12.2%, and 8.6%, respectively.

CONCLUSION

Despite the high diversity of methods, the results of the present study indicate a high prevalence of GDM in the Eastern Mediterranean region, indicating more policymakers' interest in timely screening and proper management.

Feasibility of a Low-Intensity, Technology-Based Intervention for Increasing Physical Activity in Adults at Risk for a Diabetic Foot Ulcer: A Mixed-Methods Study

BACKGROUND

Among adults with diabetes, 19-34% will develop a diabetic foot ulcer (DFU), which increases amputation risk and health care costs, and worsens quality of life. Regular physical activity, when increased gradually, may help prevent DFUs. In this mixed-methods study, we examined the feasibility of a low-intensity, technology-based behavioral intervention to increase activity in adults at risk for DFUs.

METHOD

Participants at risk for a DFU (n = 12; 66% female; mean age = 59.9 years) received four in-person exercise and behavioral counseling sessions over 2-3 weeks, supplemented with use of an activity monitor (to track steps) and text messages (to reinforce behavioral strategies) for an added 8 weeks. Pre- and postintervention assessments of accelerometer measured activity, daily mobility, and glycemic control (A1C) were completed. Treatment acceptability was assessed by questionnaire and via key informant interview.

RESULTS

The program appears feasible since all but one participant attended all four sessions, all used the activity monitor and all responded to text messages. Treatment acceptability (scale: 1 = very dissatisfied, 5 = extremely satisfied) was high; average item ratings were 4.79 (SD = 0.24). Participants increased their steps by an average of 881.89 steps/day (d = 0.66). A1C decreased on average by 0.33% (d = 0.23). Daily mobility did not change. Interview results suggest that participants perceived benefits from the intervention. Participant recommended improvements included providing more physical activity information, addressing pain, and intervention delivery in a podiatry clinic.

CONCLUSION

Individuals at risk for a DFU might benefit from a minimally intensive, technology-based intervention to increase their physical activity. Future research comparing the intervention to usual care is warranted.

Genetics, adaptation to environmental changes and archaic admixture in the pathogenesis of diabetes mellitus in Indigenous Australians

Indigenous Australians are particularly affected by type 2 diabetes mellitus (T2D) due to both their genetic susceptibility and a range of environmental and lifestyle risk factors. Recent genetic studies link predisposition to some diseases, including T2D, to alleles acquired from archaic hominins, such as Neanderthals and Denisovans, which persist in the genomes of modern humans today. Indo-Pacific human populations, including Indigenous Australians, remain extremely underrepresented in genomic research with a paucity of data examining the impact of Denisovan or Neanderthal lineages on human phenotypes in Oceania. The few genetic studies undertaken emphasize the uniqueness and antiquity of Indigenous Australian genomes, with possibly the largest proportion of Denisovan ancestry of any population in the world. In this review, we focus on the potential contributions of ancient genes/pathways to modern human phenotypes, while also highlighting the evolutionary roles of genetic adaptation to dietary and environmental changes associated with an adopted Western lifestyle. We discuss the role of genetic and epigenetic factors in the pathogenesis of T2D in understudied Indigenous Australians, including the potential impact of archaic gene lineages on this disease. Finally, we propose that greater understanding of the underlying genetic predisposition may contribute to the clinical efficacy of diabetes management in Indigenous Australians. We suggest that improved identification of T2D risk variants in Oceania is needed. Such studies promise to clarify how genetic and phenotypic differences vary between populations and, crucially, provide novel targets for personalised medical therapies in currently marginalized groups.

Pay-for-performance for shared care of diabetes in Taiwan

BACKGROUND/PURPOSE

Comprehensive and continuous care is crucial for patients with diabetes. The diabetes pay-for-performance (P4P) program launched by the National Health Insurance (NHI) administration in Taiwan provides a financial incentive to facilitate this goal. In this study, we explored the characteristics of patients in the P4P program between 2005 and 2014.

METHODS

Data of patients with diabetes enrolled in the NHI program between 2005 and 2014 were extracted from the NHI research database. Patients were classed as having diabetes if they had three or more outpatient visits within 365 calendar days with an International Classification of Diseases, 9th Revision, Clinical Modification diagnostic code of 250 or hospitalization one or more times with such a diagnosis. The trends of participating in the P4P program were analyzed.

RESULTS

Participation rate of the P4P program increased from 12.1% to 19% between 2005 and 2014. Participants were younger and more likely to be female than those not participating in the program. Lower risks of cancer-related mortality, annual mortality and heart failure were seen in patients participating in the P4P program than in those not participating.

CONCLUSION

Older, male patients with a high disease severity may be less likely to enroll in the P4P program. Although participation rate is increasing, a broad enrollment is expected.

The Role of DPP-4 Inhibitors in the Treatment Algorithm of Type 2 Diabetes Mellitus: When to Select, What to Expect

Type 2 diabetes mellitus is a growing global public health problem, the prevalence of which is projected to increase in the succeeding decades. It is potentially associated with many complications, affecting multiple organs and causing a huge burden to the society. Due to its multi-factorial pathophysiology, its treatment is varied and based upon a multitude of pharmacologic agents aiming to tackle the many aspects of the disease pathophysiology (increasing insulin availability [either through direct insulin administration or through agents that promote insulin secretion], improving sensitivity to insulin, delaying the delivery and absorption of carbohydrates from the gastrointestinal tract, or increasing urinary glucose excretion). DPP-4 (dipeptidyl peptidase-4) inhibitors (or “gliptins”) represent a class of oral anti-hyperglycemic agents that inhibit the enzyme DPP-4, thus augmenting the biological activity of the “incretin” hormones (glucagon-like peptide-1 [GLP-1] and glucose-dependent insulinotropic polypeptide [GIP]) and restoring many of the pathophysiological problems of diabetes. They have already been used over more than a decade in the treatment of the disease. The current manuscript will review the mechanism of action, therapeutic utility, and the role of DPP-4 inhibitors for the treatment of type 2 diabetes mellitus.

Economic burden of diabetic patients in India: A review

The Indian diabetic population is predicted to reach more than 80 million by the year 2030. It indicates that immediate health policy restructuring and investment will be needed if the best use is to be made of scarce health care resources with accompanying economic constraints. The costs of treatment of diabetes exists among the patients of all socioeconomic groups.A recent study showed that, in India, the total annual expenditure by patients on diabetes care was, on average, Rs. 10,000 in urban areas and Rs. 6260 in rural areas. The studies related to diabetes indicate that the direct and indirect cost implications of diabetes are multifold worldwide. The direct costs are related to the medical and non-medical cost of people with diabetes, mostly the burden on individual and at the family level. The indirect costs are related to the society and government, which are associated to loss of productivity. The review also finds that the annual direct and indirect medical costs per patient increase with the number of microvascular and macrovascular complications. A study in India during the years 2008 and 2009 found that total costs for patients without complications were Rs. 4493 compared to Rs. 14,692for patients with complications.The review reveals that it is imperative to work effectively towards implementing a holistic programme for diabetes prevention and reduce diabetic expenditure burden in the community.

Beyond Race Disparities: Accounting for Socioeconomic Status in Diabetes Self-Care

INTRODUCTION

Among patients with type 2 diabetes, racial disparities are prevalent across a variety of outcomes; however, inconsistent disparities in determinants of outcomes warrants exploring the impact of other, related factors. This study sought to examine whether disparities in health literacy, numeracy, self-care behaviors, and HbA1c persisted between non-Hispanic blacks and non-Hispanic whites after applying a robust adjustment for socioeconomic status (SES).

METHODS

From 2016 to 2018, adult patients with type 2 diabetes (N=444) were recruited from primary care clinics. Participants self-reported demographics; indicators of SES (i.e., income, education, health insurance, housing status, and financial strain); subjective health literacy and numeracy; and self-care behaviors. Participants also completed an HbA1c test. In 2018, differences were examined between non-Hispanic blacks and non-Hispanic whites in health literacy, numeracy, self-care, and HbA1c, first unadjusted and then adjusted using propensity score weighting.

RESULTS

In unadjusted analyses, compared with non-Hispanic whites, non-Hispanic blacks had lower health literacy (p=0.039) and numeracy (p<0.001); less medication adherence (p=0.009); use of information for dietary decisions (p=0.013); and problem eating behaviors (p<0.001; i.e., non-Hispanic blacks reported fewer problems); and higher HbA1c levels (p=0.005). After adjusting for all SES indicators, only the reverse disparity in problem eating behaviors (p=0.016) and the disparity in HbA1c (p=0.011) remained.

CONCLUSIONS

Findings highlight the importance of considering SES when examining disparities in health-related skills and behaviors. Moving beyond education and income to inclusion of more comprehensive markers of SES can improve understanding of how SES may contribute to disparities and the ability to appropriately target factors leading to inequality.

Antiplatelet therapy for tibial balloon angioplasty: A clinical perspective

Percutaneous transluminal tibial balloon angioplasty has an important role in the therapeutic approach of critical limb ischaemia. Despite a growing number of patients with critical limb ischaemia, there are no trials to guide the pharmacologic approach post intervention. Guidelines pertaining to the antiplatelet therapy post percutaneous transluminal tibial balloon angioplasty have not been developed. In addition, critical limb ischaemia patients have multiple comorbidities and a higher risk of bleeding. To examine the shortest duration of antiplatelet therapy post percutaneous transluminal tibial balloon angioplasty, we reviewed the preclinical data used to develop the standards for the current angioplasty technique.

Spirituality, Social Support, and Diabetes: A Cross-Sectional Study of People Enrolled in a Nurse-Led Diabetes Management Program in Peru

INTRODUCTION

In Peru, people living with diabetes mellitus (PLDM) represent 7% of the adult population, each with a $54,000 lifetime cost. For Latinos, spirituality provides meaning and purpose of life while social support affects behavioral choices and adherence decisions. The purpose of this study was to determine the relationship between spirituality and social support for PLDM participating in a nurse-led diabetes management program in a public hospital in Lima, Peru.

METHOD

This cross-sectional study included adult PLDM (N = 54). The instrument included demographic items and the Spanish versions of the social/vocational concern dimension of the Diabetes Quality of Life Questionnaire and the Reed's scale of spiritual perspective.

RESULTS

There was an inverse relation between social support and spiritually practices (p = .020) and spiritual beliefs (p = .005). PLDM with 5 years or more in the program had significantly higher scores in social support (p = .020) and spiritual practices (p = .010).

CONCLUSION

Spirituality and social support are important factors for managing PLDM. Nurse-led diabetes management programs with Latino participants should consider targeted spiritual and social support strategies to expand the holistic management. Future studies should explore the impact and effectiveness of spiritual and social support interventions on clinical outcomes.

Economic Impact of Diabetes in South Asia: the Magnitude of the Problem

PURPOSE OF REVIEW

To critically assess and identify gaps in the current literature on the economic impact of diabetes in South Asia.

RECENT FINDINGS

The total annual (direct medical and non-medical and indirect) costs for diabetes care in South Asia range from $483-$2637 per patient, and on an average 5.8% of patients with diabetes suffer catastrophic spending i.e. when households reduce basic expenditure by 40% to cope with healthcare costs. The mean direct costs per patient are positively associated with a country's gross domestic product (GDP) per capita, although there is wide heterogeneity across South Asian countries. With an estimated 84 million people suffering from diabetes in South Asia, diabetes imposes a substantial economic burden on individuals, families, and society. Since the disease burden increasingly occurs in the most productive midlife period, it adversely affects workforce productivity and macroeconomic development. Diabetes-related complications lead to markedly higher treatment costs, causing catastrophic medical spending for many households, thus underscoring the importance of preventing diabetes-related complications.

Variation in health system performance for managing diabetes among states in India: a cross-sectional study of individuals aged 15 to 49 years

BACKGROUND

Understanding where adults with diabetes in India are lost in the diabetes care cascade is essential for the design of targeted health interventions and to monitor progress in health system performance for managing diabetes over time. This study aimed to determine (i) the proportion of adults with diabetes in India who have reached each step of the care cascade and (ii) the variation of these cascade indicators among states and socio-demographic groups.

METHODS

We used data from a population-based household survey carried out in 2015 and 2016 among women and men aged 15-49 years in all states of India. Diabetes was defined as a random blood glucose (RBG) ≥ 200 mg/dL or reporting to have diabetes. The care cascade-constructed among those with diabetes-consisted of the proportion who (i) reported having diabetes ("aware"), (ii) had sought treatment ("treated"), and (iii) had sought treatment and had a RBG < 200 mg/dL ("controlled"). The care cascade was disaggregated by state, rural-urban location, age, sex, household wealth quintile, education, and marital status.

RESULTS

This analysis included 729,829 participants. Among those with diabetes (19,453 participants), 52.5% (95% CI, 50.6-54.4%) were "aware", 40.5% (95% CI, 38.6-42.3%) "treated", and 24.8% (95% CI, 23.1-26.4%) "controlled". Living in a rural area, male sex, less household wealth, and lower education were associated with worse care cascade indicators. Adults with untreated diabetes constituted the highest percentage of the adult population (irrespective of diabetes status) aged 15 to 49 years in Goa (4.2%; 95% CI, 3.2-5.2%) and Tamil Nadu (3.8%; 95% CI, 3.4-4.1%). The highest absolute number of adults with untreated diabetes lived in Tamil Nadu (1,670,035; 95% CI, 1,519,130-1,812,278) and Uttar Pradesh (1,506,638; 95% CI, 1,419,466-1,589,832).

CONCLUSIONS

There are large losses to diabetes care at each step of the care cascade in India, with the greatest loss occurring at the awareness stage. While health system performance for managing diabetes varies greatly among India's states, improvements are particularly needed for rural areas, those with less household wealth and education, and men. Although such improvements will likely have the greatest benefits for population health in Goa and Tamil Nadu, large states with a low diabetes prevalence but a high absolute number of adults with untreated diabetes, such as Uttar Pradesh, should not be neglected.

The risk of mortality among people with type 2 diabetes in Latin America: A systematic review and meta-analysis of population-based cohort studies

Type 2 diabetes mellitus (T2DM) is associated with a high mortality risk, although the magnitude of this association remains unknown in Latin America (LA). We aimed to assess the strength of the association between T2DM and all-cause and cause-specific mortality in population-based cohort studies in LA. Systematic review and meta-analysis: inclusion criteria were (1) men and women 18 years old and above with T2DM; (2) study outcomes all-cause and/or cause-specific mortality; and (3) using people without T2DM as comparison group. Five databases (Scopus, Medline, Embase, Global Health, and LILACS) were searched. Risk of bias was evaluated with the ROBINS-I criteria. Initially, there were 979 identified studies, of which 17 were selected for qualitative synthesis; 14 were included in the meta-analysis (N = 416 821). Self-reported T2DM showed a pooled relative risk (RR) of 2.49 for all-causes mortality (I-squared [I² ] = 85.7%, p < 0.001; 95% confidence interval [CI], 1.96-3.15). T2DM based on a composite definition was associated with a 2.26-fold higher all-cause mortality (I²  = 93.9%, p < 0.001; 95% CI, 1.36-3.74). The pooled risk estimates were similar between men and women, although higher at younger ages. The pooled RR for cardiovascular mortality was 2.76 (I²  = 59.2%; p < 0.061; 95% CI, 1.99-3.82) and for renal mortality 15.85 (I²  = 0.00%; p < 0.645; 95% CI, 9.82-25.57). Using available population-based cohort studies, this work has identified and estimated the strength of the association between T2DM and mortality in LA. The higher mortality risk compared with high-income countries deserves close attention from health policies makers and clinicians to improve diabetes care and control hence preventing complications and delaying death.

Communication strategies in the prevention of type 2 and gestational diabetes in vulnerable groups: protocol for a scoping review

BACKGROUND

The global prevalence of diabetes mellitus is nearly 9%, with an upward trend in type 2 and gestational diabetes mellitus (T2DM/GDM). Evidence shows that vulnerable groups are affected disproportionally. Therefore, there is an increasing need to implement policies to prevent risk factors for T2DM/GDM and to promote a healthy lifestyle. However, up to now, no gold standard in terms of communication strategies and/or public awareness campaigns is known.

METHODS/DESIGN

We will conduct a systematic scoping review to evaluate communication strategies in the prevention of T2DM/GDM in vulnerable groups. Two reviewers will independently screen the results of the electronic literature search in PubMed, EMBASE, PsycINFO, PSYNDEX, Social Science Citation Index, and CINAHL. Extracted data will be charted, categorized, and summarized.

DISCUSSION

The results will be used to inform the National education and communication strategy on diabetes mellitus in Germany. In particular, the results will be discussed in focus groups of experts to develop recommendations for communication strategies.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO does not register scoping reviews.

Negative pressure wound therapy use in diabetic foot syndrome-from mechanisms of action to clinical practice

BACKGROUND

Diabetes and its complications constitute a rising medical challenge. Special attention should be given to diabetic foot syndrome (DFS) due to its high rate of associated amputation and mortality. Negative pressure wound therapy (NPWT) is a frequently used supportive modality in a diabetic foot with ulcerations (DFUs).

DESIGN

Here, we reviewed the current knowledge concerning the tissue and molecular mechanisms of NPWT action with an emphasis on diabetes research followed by a summary of clinical DFU studies and practice guidelines.

RESULTS

Negative pressure wound therapy action results in two types of tissue deformations-macrodeformation, such as wound contraction, and microdeformation occurring at microscopic level. Both of them stimulate a wound healing cascade including tissue granulation promotion, vessel proliferation, neoangiogenesis, epithelialization and excess extracellular fluid removal. On the molecular level, NPWT results in an alteration towards more pro-angiogenic and anti-inflammatory conditions. It increases expression of several key growth factors, including vascular endothelial growth factor and fibroblast growth factor 2, while expression of inflammatory cytokinesis reduced. The NPWT application also alters the presence and function of matrix metalloproteinases. Clinical studies in DFU patients showed a superiority of NPWT over standard therapy in terms of efficacy outcomes, primarily wound healing and amputation rate, without a rise in adverse events. International guidelines point to NPWT as an important adjuvant therapy in DFU whose use is expected to increase.

CONCLUSIONS

This current knowledge improves our understanding of NPWT action and its tailoring for application in diabetic patients. It may inform the development of new treatments for DFU.

Peroxidase-Like Activity of Smart Nanomaterials and Their Advanced Application in Colorimetric Glucose Biosensors

Diabetes is a dominating health issue with 425 million people suffering from the disease worldwide and 4 million deaths each year. To avoid further complications, the diabetic patient blood glucose level should be strictly monitored despite there being no cure for diabetes. Colorimetric biosensing has attracted significant attention because of its low cost, simplicity, and practicality. Recently, some nanomaterials have been found that possess unexpected peroxidase-like activity, and great advances have been made in fabricating colorimetric glucose biosensors based on the peroxidase-like activity of these nanomaterials using glucose oxidase. Compared with natural horseradish peroxidase, the nanomaterials exhibit flexibility in structure design and composition, and have easy separation and storage, high stability, simple preparation, and tunable catalytic activity. To highlight the significant progress in the field of nanomaterial-based peroxidase-like activity, this work discusses the various smart nanomaterials that mimic horseradish peroxidase and its mechanism and development history, and the applications in colorimetric glucose biosensors. Different approaches for tunable peroxidase-like activity of nanomaterials are summarized, such as size, morphology, and shape; surface modification and coating; and metal doping and alloy. Finally, the conclusion and challenges facing peroxidase-like activity of nanomaterials and future directions are discussed.

Autologous nanofat transplantation accelerates foot wound healing in diabetic rats

Aim: This study explored the effects of local transplantation of autologous nanofat in the treatment of rats with diabetic foot wounds. Materials & methods: Nanofat was transplanted into the left foot wound of diabetic rats. Phosphate-buffered saline injection in the right served as control. We measured wound size, the extent of epithelization, microvessel density and the expression levels of cytokines at six different time-points postoperation. Results: Compared with the control feet, nanofat-treated feet had significantly smaller wound areas at 7 and 9 days after grafting and showed better re-epithelialization, a greater number of microvessels and higher levels of angiogenic factor expression. Conclusion: This research shows that autologous nanofat transplantation can promote diabetic foot wound healing in rats.

The costs of diabetes treatment in low- and middle-income countries: a systematic review

Introduction

The rising burden of diabetes in low- and middle-income countries may cause financial strain on individuals and health systems. This paper presents a systematic review of direct medical costs for diabetes (types 1 and 2) in low- and middle-income countries.

Methods

Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, databases (PubMed, International Bibliography of Social Science, EconLit) were searched for publications reporting direct medical costs of type 1 and 2 diabetes. Data were extracted from all peer-reviewed papers meeting inclusion criteria, and were standardised into per-patient-visit, per-patient-year and/or per-complication-case costs (2016 US$).

Results

The search yielded 584 abstracts, and 52 publications were included in the analysis. Most articles were from Asia and Latin America, and most focused on type 2 diabetes. Per-visit outpatient costs ranged from under $5 to over $40 (median: $7); annual inpatient costs ranged from approximately $10 to over $1000 (median: $290); annual laboratory costs ranged from under $5 to over $100 (median: $25); and annual medication costs ranged from $15 to over $500 (median: $177), with particularly wide variation found for insulin. Care for complications was generally high-cost, but varied widely across countries and complication types.

Conclusion

This review identified substantial variation in diabetes treatment costs; some heterogeneity could be mitigated through improved methods for collecting, analysing and reporting data. Diabetes is a costly disease to manage in low- and middle-income countriesand should be a priority for the global health community seeking to achieve Universal Health Coverage.

Clinical and Economic Outcomes of Patients with Type 2 Diabetes on Multiple Daily Injections of Basal-bolus Insulin (MDI) Therapy: A Retrospective Cohort Study

PURPOSE

Therapy for patients with type 2 diabetes (T2DM) not achieving hemoglobin (Hb) A_1c targets may progress from an oral antidiabetic drug (OAD) to added basal insulin and then to multiple daily injections of basal-bolus insulin (MDI); however, the relative clinical and economic burden experienced by patients prescribed MDI for T2DM is not well quantified. The intent of this work was to describe direct medical costs, health care resource utilization, and glycemic control in patients with T2DM exposed to MDI in a clinical practice setting.

METHODS

This retrospective cohort study used administrative claims data (2012-2015, United States) from patients aged 18 to 64 years with T2DM prescribed OAD, basal insulin, or MDI therapy. Eligible patients had continuous enrollment from ≥6 months before to 12 months after the date of the index prescription drug claim. Patients eligible for inclusion in the MDI cohort had ≥2 pharmacy claims each for basal and bolus insulin from the index date through the postindex period. Glycemic control, defined as an HbA1c value of <7% during the last 9 postindex months, was assessed in a subset of patients with HbA_1c data available from that period. Descriptive analyses were performed.

FINDINGS

We identified 225,135 patients with T2DM and claims for an OAD (n = 188,230), basal insulin (n = 23,724), or MDI (n = 13,181). The mean age was 51 or 52 years in each cohort; 54% to 59% of patients in each cohort were men. The mean Charlson comorbidity index scores were 0.8, 1.4, and 1.8, respectively; the percentages of patients with obesity and diabetes-related complications were greatest in the MDI cohort compared with OAD and basal insulin cohorts. The mean direct medical costs (all-cause; year-2015 US $) were $9368 in the OAD cohort, $14,420 in the basal insulin cohort, and $25,624 in the MDI cohort; diabetes-related costs were $3396, $7285, and $13,538. In the OAD, basal insulin, and MDI cohorts, 7%, 9%, and 14% of patients had ≥1 hospitalization, and 17%, 20%, and 24% had ≥1 emergency department visit, while 5%, 7%, and 11% had ≥1 diabetes-related hospitalization, and 8%, 11%, and 15% had ≥1 diabetes-related emergency department visit. Glycemic control was found in 64%, 22%, and 15% of patients in the OAD, basal insulin, and MDI cohorts.

IMPLICATIONS

These findings suggest that patients prescribed MDI therapy for T2DM have greater disease burden, experience greater medical costs and health care resource utilization, and exhibit poorer glycemic control than do patients treated with OAD or basal insulin therapy.

Performance of a computable phenotype for identification of patients with diabetes within PCORnet: The Patient-Centered Clinical Research Network

PURPOSE

PCORnet, the National Patient-Centered Clinical Research Network, represents an innovative system for the conduct of observational and pragmatic studies. We describe the identification and validation of a retrospective cohort of patients with type 2 diabetes (T2DM) from four PCORnet sites.

METHODS

We adapted existing computable phenotypes (CP) for the identification of patients with T2DM and evaluated their performance across four PCORnet sites (2012-2016). Patients entered the cohort on the earliest date they met one of three CP categories: (CP1) coded T2DM diagnosis (ICD-9/ICD-10) and an antidiabetic prescription, (CP2) diagnosis and glycosylated hemoglobin (HbA1c) ≥6.5%, or (CP3) an antidiabetic prescription and HbA1c ≥6.5%. We required evidence of health care utilization in each of the 2 prior years for each patient, as we also developed an incident T2DM CP to identify the subset of patients without documentation of T2DM in the 365 days before t₀ . Among a systematic sample of patients, we calculated the positive predictive value (PPV) for the T2DM CP and incident-T2DM CP using electronic health record (EHR) review as reference.

RESULTS

The CP identified 50 657 patients with T2DM. The PPV of patients randomly selected for validation was 96.2% (n = 1572; CI:95.1-97.0) and was consistently high across sites. The PPV for the incident-T2DM CP was 5.8% (CI:4.5-7.5).

CONCLUSIONS

The T2DM CP accurately and efficiently identified patients with T2DM across multiple sites that participate in PCORnet, although the incident T2DM CP requires further study. PCORnet is a valuable data source for future epidemiological and comparative effectiveness research among patients with T2DM.

Economic Impact of Diabetes in Japan

PURPOSE OF REVIEW

The economic burden of diabetes in Japan is already serious and will become greater in the future. We review the economic impact of diabetes in Japan to examine viable options for mitigating its effects.

RECENT FINDINGS

Medical costs for diabetes have been increasing by US $1 million annually, reaching US $11 million in 2009, of which US $7 million was accounted for by people aged 65 years or older. The quality of treatment of diabetes in Japan is higher than in other regions in the world. This can be more effective for achieving glycemic control, but is also more expensive compared with conventional treatment. Because of the high cost of diabetes in Japan, a coordinated response is needed. Intervention trials for people with prediabetes aimed at preventing the occurrence of diabetes seem to be the most cost-effective method for lowering the medical costs of diabetes, rather than the use of new, expensive antidiabetic drugs in patients with established diabetes.

Therapeutic medications against diabetes: What we have and what we expect

Diabetes has become one of the largest global health and economic burdens, with its increased prevalence and high complication ratio. Stable and satisfactory blood glucose control are vital to reduce diabetes-related complications. Therefore, continuous attempts have been made in antidiabetic drugs, treatment routes, and traditional Chinese medicine to achieve better disease control. New antidiabetic drugs and appropriate combinations of these drugs have increased diabetes control significantly. Besides, novel treatment routes including oral antidiabetic peptide delivery, nanocarrier delivery system, implantable drug delivery system are also pivotal for diabetes control, with its greater efficiency, increased bioavailability, decreased toxicity and reduced dosing frequency. Among these new routes, nanotechnology, artificial pancreas and islet cell implantation have shown great potential in diabetes therapy. Traditional Chinese medicine also offer new options for diabetes treatment. Our paper aim to overview these therapeutic methods for diabetes therapy. Proper combinations of these existing anti-diabetic medications and searching for novel routes are both necessary for better diabetes control.

Effect of liraglutide on blood pressure: a meta-analysis of liraglutide randomized controlled trials

BACKGROUND

Several clinical trials have studied the effects of glucagon-like peptide-1 receptor agonists (GLP-1RAs) on glycometabolism and cardiovascular risk factors since they were identified. Because of their cardiovascular benefits and efficacy in lowering glucose, GLP-1RAs are becoming increasingly important in clinical therapy for patients with or without pathoglycaemia. The aim of this study was to assess the effect of the GLP-1RA liraglutide on blood pressure based on randomised controlled trials (RCTs).

METHODS

We searched PubMed for RCTs published from 2009 to 2018 comparing the effect of liraglutide on blood pressure with that of placebo in individuals with or without pathoglycaemia. RCTs in humans that included data describing blood pressure changes from baseline to the end of the trial were selected for inclusion in the meta-analysis.

RESULTS

A total of 18 RCTs that enrolled 7616 individuals in the liraglutide group and 6046 individuals in the control group were included in this meta-analysis. Compared with placebo, liraglutide reduced systolic blood pressure (SBP) by 3.18 mmHg (95% CI -4.32, - 2.05), P < 0.00001, but had no significant effect on diastolic blood pressure (DBP). Subgroup analysis showed that the degree of reduction in SBP was associated with the dose of liraglutide but that significance disappeared when the intervention lasted over 1 year. Liraglutide 3.0 mg/d significantly reduced DBP by 1.46 mmHg (95% CI -2.61, 0.32), P = 0.01, but liraglutide 1.8 mg/d slightly increased DBP by 0.47 mmHg (95% CI 0.11, 0.83), P = 0.01, compared with placebo.

CONCLUSIONS

This meta-analysis demonstrated that liraglutide significantly reduced SBP in individuals with or without pathoglycaemia compared with placebo, but the difference was no longer significant when the intervention lasted over 1 year. Moreover, the effect of liraglutide on blood pressure is associated with the dose. This finding may provide additional evidence for cardiovascular protection.

Exploring Different Strategies of Assessing the Economic Impact of Multiple Diabetes-Associated Complications and Their Interactions: A Large Claims-Based Study in Germany

BACKGROUND

In the context of an aging population with increasing diabetes prevalence, people are living longer with diabetes, which leads to increased multimorbidity and economic burden.

OBJECTIVE

The primary aim was to explore different strategies that address the economic impact of multiple type 2 diabetes-related complications and their interactions.

METHODS

We used a generalized estimating equations approach based on nationwide statutory health insurance data from 316,220 patients with type 2 diabetes (baseline year 2012, 3 years of follow-up). We estimated annual total costs (in 2015 euros) for type 2 diabetes-related complications and, in addition, explored different strategies to assess diabetes-related multimorbidity: number of prevalent complications, co-occurrence of micro- and macrovascular complications, disease-disease interactions of prevalent complications, and interactions between prevalent/incident complications.

RESULTS

The increased number of complications was significantly associated with higher total costs. Further assessment of interactions showed that macrovascular complications (e.g., chronic heart failure) and high-cost complications (e.g., end-stage renal disease, amputation) led to significant positive effects of interactions on costs, whereas early microvascular complications (e.g., retinopathy) caused negative interactions. The chronology of the onset of these complications turned out to have an additional impact on the interactions and their effect on total costs.

CONCLUSIONS

Health economic diabetes models and evaluations of interventions in patients with diabetes-related complications should pay more attention to the economic effect of specific disease interactions. Politically, our findings support the development of more integrated diabetes care programs that take better account of multimorbidity. Further observational studies are needed to elucidate the shared pathogenic mechanisms of diabetes complications.

The Role of Occupational Therapy in Secondary Prevention of Diabetes

Diabetes mellitus is becoming a global health concern due to its prevalence and projected growth. Despite a growing number of interventions for secondary prevention of diabetes, there is a persistent poor glycemic control and poor adherence to the prescribed diabetes management regimen. In light of the tremendous costs of diabetes to both individuals and the society, it is pressing to find effective ways to improve diabetes self-management (DSM) and treatment adherence. Occupational therapists can bring values to the diabetes care team by evaluating multiple levels of influence on DSM, addressing personal and environmental barriers to well-being and DSM, and supporting patients to develop of a highly complex competences and skills to satisfactorily self-manage diabetes. This article summarizes two evidence-based, well-structured occupational therapy (OT) programs that use activity-based treatments and psychosocial strategies, respectively, to improve DSM abilities and to enhance quality of life. As the needs of adolescents with diabetes are quite different from other diabetic populations, this article also provides a summary of pediatric OT interventions that aim to facilitate autonomy and development of DSM ability among adolescents with diabetes. Evidence indicates that OT interventions can improve the quality of life and treatment adherence in patients with diabetes and hence should be continued and built on to address the increasing needs of diabetic populations.