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Chalmoukou K, Polyzos D, Manta E, Tatakis F, Konstantinidis D, Thomopoulos C, Costas T. Renal outcomes associated with glucose-lowering agents: Systematic review and meta-analysis of randomized outcome trials. Eur J Intern Med 2022; 97:78-85. [PMID: 34953655 DOI: 10.1016/j.ejim.2021.12.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Revised: 12/03/2021] [Accepted: 12/17/2021] [Indexed: 11/22/2022]
Abstract
Although the clinical questions of the recent glucose-lowering trials are principally oriented towards preventing macrovascular events, an updated review regarding renal outcome prevention is lacking. We assessed the impact of different antihyperglycemic classes on kidney damage progression. A systematic review and meta-analysis was performed by searching PubMed, Cochrane Collaboration Library, Medline, and previous overviews through June 2021 (any language) for earlier and contemporary glucose-lowering trials, including patients with, but not limited to, type 2 diabetes mellitus vs. placebo or less intense treatment. Incidences of kidney function worsening and macroalbuminuria development was extracted, and risk ratios and 95% confidence intervals (CI) under the random-effects model were calculated. The association between outcome reductions and glycohemoglobin (HBA1c) reductions was investigated through the meta-regression analyses. Among 27 eligible trials (n = 198,532 patients) an averaged HBA1c reduction of 0.6 ± 0.3% was followed by a reduction of 17% (95% CI, 8-25%) in worsening of kidney function, and of 25% (95% CI, 19-32%) in macroalbuminuria. Analog of human glucagon-like peptide 1 (GLP1)-agonists, and sodium-glucose cotransporter (SGLT2)-inhibitors, considered separately, compared with placebo, were associated with a significant reduction of both renal outcomes, at variance with dipeptidyl peptidase 4 (DPP4)-inhibitors, where no outcome change was observed. Logarithmic risk ratios of macroalbuminuria were related to HBA1c reductions, in contrast to the worsening of kidney function related to systolic blood pressure reduction. Worsening of kidney function and macroalbuminuria development were reduced following glucose-lowering. GLP1 agonists and SGLPT2 inhibitors were associated with protection against both outcomes, while DPP4 inhibitors do not provide renal protection.
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Affiliation(s)
- Konstantina Chalmoukou
- First Cardiology Clinic, Medical School, National and Kapodistrian University of Athens, Hippokration Hospital, Athens, Greece
| | - Dimitris Polyzos
- First Cardiology Clinic, Medical School, National and Kapodistrian University of Athens, Hippokration Hospital, Athens, Greece
| | - Eleni Manta
- First Cardiology Clinic, Medical School, National and Kapodistrian University of Athens, Hippokration Hospital, Athens, Greece
| | - Fotis Tatakis
- First Cardiology Clinic, Medical School, National and Kapodistrian University of Athens, Hippokration Hospital, Athens, Greece
| | - Dimitris Konstantinidis
- First Cardiology Clinic, Medical School, National and Kapodistrian University of Athens, Hippokration Hospital, Athens, Greece
| | | | - Tsioufis Costas
- First Cardiology Clinic, Medical School, National and Kapodistrian University of Athens, Hippokration Hospital, Athens, Greece.
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Kim C. Management of Cardiovascular Risk in Perimenopausal Women with Diabetes. Diabetes Metab J 2021; 45:492-501. [PMID: 34352986 PMCID: PMC8369221 DOI: 10.4093/dmj.2020.0262] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Accepted: 01/10/2021] [Indexed: 01/14/2023] Open
Abstract
Cardiovascular disease is the primary cause of mortality in women and men with diabetes. Due to age and worsening of risk factors over the menopausal transition, risk of coronary heart disease events increases in postmenopausal women with diabetes. Randomized studies have conflicted regarding the beneficial impact of estrogen therapy upon intermediate cardiovascular disease markers and events. Therefore, estrogen therapy is not currently recommended for indications other than symptom management. However, for women at low risk of adverse events, estrogen therapy can be used to minimize menopausal symptoms. The risk of adverse events can be estimated using risk engines for the calculation of cardiovascular risk and breast cancer risk in conjunction with screening tools such as mammography. Use of estrogen therapy, statins, and anti-platelet agents can be guided by such calculators particularly for younger women with diabetes. Risk management remains focused upon lifestyle behaviors and achieving optimal levels of cardiovascular risk factors, including lipids, glucose, and blood pressure. Use of pharmacologic therapies to address these risk factors, particularly specific hypoglycemic agents, may provide some additional benefit for risk prevention. The minimal benefit for women with limited life expectancy and risk of complications with intensive therapy should also be considered.
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Affiliation(s)
- Catherine Kim
- Departments of Medicine, Obstetrics & Gynecology, and Epidemiology, University of Michigan, Ann Arbor, MI, USA
- Corresponding author: Catherine Kim https://orcid.org/0000-0001-9237-0532 Departments of Medicine, Obstetrics & Gynecology, and Epidemiology, University of Michigan, Room 405E, 2800 Plymouth Road, Ann Arbor, MI 48109, USA E-mail:
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3
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Sorber R, Abularrage CJ. Diabetic foot ulcers: Epidemiology and the role of multidisciplinary care teams. Semin Vasc Surg 2021; 34:47-53. [PMID: 33757635 DOI: 10.1053/j.semvascsurg.2021.02.006] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Diabetic foot ulcers (DFUs) are a common but highly morbid complication of long-standing diabetes, carrying high rates of associated major amputation and mortality. As the global incidence of diabetes has increased, along with the lifespan of the diabetic patient, the worldwide burden of DFUs has grown steadily. Outcomes in diabetes and DFUs are known to depend strongly on social determinants of health, with worse outcomes noted in minority and socioeconomically disadvantaged populations. Effective treatment of DFUs is complex, requiring considerable expenditure of resources and significant cost to the health care system. Comprehensive care models with multidisciplinary teams have proven effective in the treatment of DFUs by decreasing barriers to care and increasing access to the multiple specialists required to provide timely and effective DFU procedural intervention, surveillance, and preventative care. Vascular surgeons are an integral part throughout the cycle of care for DFUs and should be involved early in the course of such patients to maximize their contributions to a multidisciplinary care model.
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Affiliation(s)
- Rebecca Sorber
- Division of Vascular Surgery and Endovascular Therapy, Johns Hopkins Medical Institutions, Halsted 671, 600 N Wolfe Street, Baltimore, MD 21287
| | - Christopher J Abularrage
- Division of Vascular Surgery and Endovascular Therapy, Johns Hopkins Medical Institutions, Halsted 671, 600 N Wolfe Street, Baltimore, MD 21287.
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Forrester JV, Kuffova L, Delibegovic M. The Role of Inflammation in Diabetic Retinopathy. Front Immunol 2020; 11:583687. [PMID: 33240272 PMCID: PMC7677305 DOI: 10.3389/fimmu.2020.583687] [Citation(s) in RCA: 151] [Impact Index Per Article: 37.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Accepted: 09/21/2020] [Indexed: 12/14/2022] Open
Abstract
Inflammation is central to pathogenic processes in diabetes mellitus and the metabolic syndrome and particularly implicates innate immunity in the development of complications. Inflammation is a primary event in Type 1 diabetes where infectious (viral) and/or autoimmune processes initiate disease; in contrast, chronic inflammation is typical in Type 2 diabetes and is considered a sequel to increasing insulin resistance and disturbed glucose metabolism. Diabetic retinopathy (DR) is perceived as a vascular and neurodegenerative disease which occurs after some years of poorly controlled diabetes. However, many of the clinical features of DR are late events and reflect the nature of the retinal architecture and its cellular composition. Retinal microvascular disease is, in fact, an early event pathogenetically, induced by low grade, persistent leukocyte activation which causes repeated episodes of capillary occlusion and, progressive, attritional retinal ischemia. The later, overt clinical signs of DR are a consequence of the retinal ischemia. Metabolic dysregulation involving both lipid and glucose metabolism may lead to leukocyte activation. On a molecular level, we have shown that macrophage-restricted protein tyrosine phosphatase 1B (PTP1B) is a key regulator of inflammation in the metabolic syndrome involving insulin resistance and it is possible that PTP1B dysregulation may underlie retinal microvascular disease. We have also shown that adherent CCR5+CD11b+ monocyte macrophages appear to be selectively involved in retinal microvascular occlusion. In this review, we discuss the relationship between early leukocyte activation and the later features of DR, common pathogenetic processes between diabetic microvascular disease and other vascular retinopathies, the mechanisms whereby leukocyte activation is induced in hyperglycemia and dyslipidemia, the signaling mechanisms involved in diabetic microvascular disease, and possible interventions which may prevent these retinopathies. We also address a possible role for adaptive immunity in DR. Although significant improvements in treatment of DR have been made with intravitreal anti-VEGF therapy, a sizeable proportion of patients, particularly with sight-threatening macular edema, fail to respond. Alternative therapies targeting inflammatory processes may offer an advantage.
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Affiliation(s)
- John V Forrester
- Institute of Medical Sciences, University of Aberdeen, Scotland, United Kingdom
| | - Lucia Kuffova
- Institute of Medical Sciences, University of Aberdeen, Scotland, United Kingdom.,Eye Clinic, Aberdeen Royal Infirmary, Aberdeen, United Kingdom
| | - Mirela Delibegovic
- Institute of Medical Sciences, University of Aberdeen, Scotland, United Kingdom
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5
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Antidiabetic drugs and blood pressure changes. Pharmacol Res 2020; 161:105108. [PMID: 32738493 DOI: 10.1016/j.phrs.2020.105108] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2020] [Revised: 05/30/2020] [Accepted: 07/24/2020] [Indexed: 12/14/2022]
Abstract
New era antidiabetic drugs are characterized by cardiovascular safety, including specific outcome benefits observed in randomized clinical trials (RCTs). It has been postulated that the favorable effects of new antidiabetic agents are related both to better control of blood pressure (BP) levels and to activation of multiple anti-atherosclerotic properties. In this review, we aimed to assess whether antidiabetic drugs have a pressor effect in glucose control and outcome-oriented RCTs, and to summarize the activated pathophysiological mechanisms relevant to BP control following the use of different antidiabetic drug classes. We also tried to determine which, if any, are the BP-lowering effects of more intense vs less intense glucose-lowering strategy irrespectively of trial antidiabetic regimen. To provide more robust results and evidence-based argumentation, a meta-analysis of placebo-controlled antidiabetic drug RCTs was undertaken to estimate the ongoing BP reduction for all considered and each separate drug class alone. This quantitative synthesis might be helpful for the clinician 1) to select or avoid the use of some classes of antidiabetic agents with a potential favorable or adverse pressor effect, respectively 2) to organize the overall drug regimen in patients with diabetes mellitus and minimize side effects because of concomitant use of drugs with established pressor effect (i.e. antihypertensive agents). This review was also organized to indicate whether BP change associated with different antidiabetic treatments may explain the specific macrovascular outcome benefits. Between all antidiabetic drugs including exogenous insulin, only sodium-glucose cotransporter 2 inhibitors produce a clinically important BP-lowering effect, but this BP reduction alone cannot explain the observed cardiovascular benefit.
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Persaud N, Bedard M, Boozary AS, Glazier RH, Gomes T, Hwang SW, Jüni P, Law MR, Mamdani MM, Manns BJ, Martin D, Morgan SG, Oh PI, Pinto AD, Shah BR, Sullivan F, Umali N, Thorpe KE, Tu K, Laupacis A. Effect on Treatment Adherence of Distributing Essential Medicines at No Charge: The CLEAN Meds Randomized Clinical Trial. JAMA Intern Med 2020; 180:27-34. [PMID: 31589276 PMCID: PMC6784757 DOI: 10.1001/jamainternmed.2019.4472] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Accepted: 08/12/2019] [Indexed: 11/14/2022]
Abstract
Importance Nonadherence to treatment with medicines is common globally, even for life-saving treatments. Cost is one important barrier to access, and only some jurisdictions provide medicines at no charge to patients. Objective To determine whether providing essential medicines at no charge to outpatients who reported not being able to afford medicines improves adherence. Design, Setting, and Participants A multicenter, unblinded, parallel, 2-group, superiority, outcomes assessor-blinded, individually randomized clinical trial conducted at 9 primary care sites in Ontario, Canada, enrolled 786 patients between June 1, 2016, and April 28, 2017, who reported cost-related nonadherence. Follow-up occurred at 12 months. The primary analysis was performed using an intention-to-treat principle. Interventions Patients were randomly allocated to receive free medicines on a list of essential medicines in addition to otherwise usual care (n = 395) or usual medicine access and usual care (n = 391). Main Outcomes and Measures The primary outcome was adherence to treatment with all medicines that were appropriately prescribed for 1 year. Secondary outcomes were hemoglobin A1c level, blood pressure, and low-density lipoprotein cholesterol levels 1 year after randomization in participants taking corresponding medicines. Results Among the 786 participants analyzed (439 women and 347 men; mean [SD] age, 51.7 [14.3] years), 764 completed the trial. Adherence to treatment with all medicines was higher in those randomized to receive free distribution (151 of 395 [38.2%]) compared with usual access (104 of 391 [26.6%]; difference, 11.6%; 95% CI, 4.9%-18.4%). Control of type 1 and 2 diabetes was not significantly improved by free distribution (hemoglobin A1c, -0.38%; 95% CI, -0.76% to 0.00%), systolic blood pressure was reduced (-7.2 mm Hg; 95% CI, -11.7 to -2.8 mm Hg), and low-density lipoprotein cholesterol levels were not affected (-2.3 mg/dL; 95% CI, -14.7 to 10.0 mg/dL). Conclusions and Relevance The distribution of essential medicines at no charge for 1 year increased adherence to treatment with medicines and improved some, but not other, disease-specific surrogate health outcomes. These findings could help inform changes to medicine access policies such as publicly funding essential medicines. Trial Registration ClinicalTrials.gov identifier: NCT02744963.
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Affiliation(s)
- Navindra Persaud
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
- Li Ka Shing Knowledge Institute, St Michael’s Hospital, Toronto, Ontario, Canada
- Department of Family and Community Medicine, St Michael’s Hospital, Toronto, Ontario, Canada
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Michael Bedard
- Department of Family Medicine, Northern Ontario School of Medicine, Sudbury, Ontario, Canada
| | - Andrew S. Boozary
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Department of Health Policy and Management, Harvard School of Public Health, Boston, Massachusetts
| | - Richard H. Glazier
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
- Li Ka Shing Knowledge Institute, St Michael’s Hospital, Toronto, Ontario, Canada
- Department of Family and Community Medicine, St Michael’s Hospital, Toronto, Ontario, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Tara Gomes
- Li Ka Shing Knowledge Institute, St Michael’s Hospital, Toronto, Ontario, Canada
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada
- Applied Health Research Centre, St Michael’s Hospital, Toronto, Ontario, Canada
| | - Stephen W. Hwang
- Li Ka Shing Knowledge Institute, St Michael’s Hospital, Toronto, Ontario, Canada
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Peter Jüni
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Michael R. Law
- Centre for Health Services and Policy Research, School of Population and Public Health, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Muhammad M. Mamdani
- Li Ka Shing Knowledge Institute, St Michael’s Hospital, Toronto, Ontario, Canada
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada
- Applied Health Research Centre, St Michael’s Hospital, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Centre for Healthcare Analytics Research and Training, St Michael’s Hospital, Toronto, Ontario, Canada
| | - Braden J. Manns
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- O’Brien Institute for Public Health, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Danielle Martin
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
- Women’s College Hospital Institute for Health Systems Solutions and Virtual Care, Women’s College Hospital, Toronto, Ontario, Canada
| | - Steven G. Morgan
- School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
| | - Paul I. Oh
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Toronto Rehabilitation Institute, University Health Network, Toronto, Ontario, Canada
| | - Andrew D. Pinto
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
- Li Ka Shing Knowledge Institute, St Michael’s Hospital, Toronto, Ontario, Canada
- Department of Family and Community Medicine, St Michael’s Hospital, Toronto, Ontario, Canada
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- The Upstream Lab, MAP Centre for Urban Health Solutions, St Michael’s Hospital, Toronto, Ontario, Canada
| | - Baiju R. Shah
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Frank Sullivan
- Department of Research and Innovation, North York General Hospital, Toronto, Ontario, Canada
- Division of Population and Behavioral Science, University of St Andrews, St Andrews, Scotland
| | - Norman Umali
- Li Ka Shing Knowledge Institute, St Michael’s Hospital, Toronto, Ontario, Canada
| | - Kevin E. Thorpe
- Li Ka Shing Knowledge Institute, St Michael’s Hospital, Toronto, Ontario, Canada
- Applied Health Research Centre, St Michael’s Hospital, Toronto, Ontario, Canada
| | - Karen Tu
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Andreas Laupacis
- Li Ka Shing Knowledge Institute, St Michael’s Hospital, Toronto, Ontario, Canada
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
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7
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Li YH, Chen JW, Lin TH, Wang YC, Wu CC, Yeh HI, Huang CC, Chang KC, Wu CK, Chen PW, Huang CW, Chen ZC, Chang WT, Huang WC, Wang CY, Lee MY, Chao AC, Fu WR, Tsai LK, Tang SC, Chan HL, Yang YC, Wu YW, Hwang JJ, Lin JL. A performance guide for major risk factors control in patients with atherosclerotic cardiovascular disease in Taiwan. J Formos Med Assoc 2019; 119:674-684. [PMID: 31113748 DOI: 10.1016/j.jfma.2019.04.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Revised: 02/12/2019] [Accepted: 04/10/2019] [Indexed: 12/22/2022] Open
Abstract
Atherosclerotic cardiovascular disease (ASCVD), including coronary artery disease, cerebrovascular disease, and peripheral artery disease, carries a high morbidity and mortality. Risk factor control is especially important for patients with ASCVD to reduce recurrent cardiovascular events. Clinical guidelines have been developed by the Taiwan Society of Cardiology, Taiwan Society of Lipids and Atherosclerosis, and Diabetes Association of Republic of China (Taiwan) to assist health care professionals in Taiwan about the control of hypertension, hypercholesterolemia and diabetes mellitus. This article is to highlight the recommendations about blood pressure, cholesterol, and sugar control for ASCVD. Some medications that are beneficial for ASCVD were also reviewed. We hope the clinical outcomes of ASCVD can be improved in Taiwan through the implementation of these recommendations.
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Affiliation(s)
- Yi-Heng Li
- Division of Cardiology, Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Jaw-Wen Chen
- Department of Medical Research and Education, Taipei Veterans General Hospital and Institute of Pharmacology, National Yang Ming University, Taipei, Taiwan
| | - Tsung-Hsien Lin
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Medical University Hospital and Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Yu-Chen Wang
- Division of Cardiology, Department of Internal Medicine, Asia University Hospital, China Medical University College of Medicine and Hospital, Taichung, Taiwan
| | - Chau-Chung Wu
- Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital and Graduate Institute of Medical Education & Bioethics, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Hung-I Yeh
- Department of Internal Medicine and Medical Research, Mackay Memorial Hospital, Taipei, Taiwan; Department of Medicine, Mackay Medical College, New Taipei City, Taiwan
| | - Chin-Chou Huang
- Department of Medical Education, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan
| | - Kuan-Cheng Chang
- Division of Cardiovascular Medicine, Department of Internal Medicine, China Medical University Hospital and College of Medicine, China Medical University, Taichung, Taiwan
| | - Cho-Kai Wu
- Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Po-Wei Chen
- Division of Cardiology, Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Chen-Wei Huang
- Division of Cardiology, Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Zhih-Cherng Chen
- Division of Cardiology, Department of Internal Medicine, Chi Mei Medical Center, Tainan, Taiwan; Department of Pharmacy, Chia Nan University of Pharmacy & Science, Tainan, Taiwan
| | - Wei-Ting Chang
- Division of Cardiology, Department of Internal Medicine, Chi Mei Medical Center, Tainan, Taiwan
| | - Wei-Chun Huang
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Chih-Yuan Wang
- Division of Endocrinology and Metabolism, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Mei-Yueh Lee
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Taiwan; Graduate Institute of Clinical Medicine, College of Medicine, Kaohsiung Medical University, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - A-Ching Chao
- Department of Neurology, Kaohsiung Medical University Hospital, Taiwan; Graduate Institute of Clinical Medicine and Department of Neurology, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Wei-Ren Fu
- Department of Neurology, Mackay Memorial Hospital, Taipei, Taiwan
| | - Li-Kai Tsai
- Stroke Center and Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
| | - Sung-Chun Tang
- Stroke Center and Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
| | - Hsin-Lung Chan
- Department of Family Medicine, Mackay Memorial Hospital, Department of Medicine, Mackay Medical College, Taipei, Taiwan
| | - Yi-Ching Yang
- Department of Family Medicine, National Cheng Kung University Hospital, Department of Family Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Yen-Wen Wu
- Cardiology Division, Cardiovascular Medical Center, Far Eastern Memorial Hospital, New Taipei City, Taiwan; National Yang-Ming University School of Medicine, Taipei, Taiwan
| | - Juey-Jen Hwang
- Cardiology Division, Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan; Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital Yun-Lin, Yun-Lin, Taiwan.
| | - Jiunn-Lee Lin
- Cardiology Division, Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan; Division of Cardiovascular Medicine, Department of Internal Medicine, Taipei Medical University Shuang Ho Hospital, New Taipei City, Taiwan.
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Dutra LMA, Melo MC, Moura MC, Leme LAP, De Carvalho MR, Mascarenhas AN, Novaes MRCG. Prognosis of the outcome of severe diabetic foot ulcers with multidisciplinary care. J Multidiscip Healthc 2019; 12:349-359. [PMID: 31118658 PMCID: PMC6506632 DOI: 10.2147/jmdh.s194969] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Accepted: 02/20/2019] [Indexed: 12/30/2022] Open
Abstract
Background: Approximately 2–4% of individuals worldwide with diabetes mellitus have foot ulcers. This study aims to assess the factors affecting the outcomes of severe foot ulcers in diabetic individuals. Methods: An analytical prospective cohort study was conducted from March 1st, 2015, to March 1st, 2017. A total of 34 individuals was selected. The study included patients with foot ulcers below the ankle who were at risk of amputation. All tests used a <5% level of significance and confidence interval of 95%. A Pearson’s chi-squared test and binary multiple regression were performed to assess the factors related to healing. Results: Only 11.7% of the individuals required amputation; ulcers classified as 2/B according to the University of Texas Diabetic Foot Ulcer Classification System healed before the 1/B ulcers. Neuropathic ulcers were the most prevalent (58.8%); 61.8% healed after 1 year. Most of the individuals were overweight, 47.1% had reduced glomerular filtration rates, and 78.8% had glycated hemoglobin >7%. Body mass index and osteomyelitis were the two significant variables in logistic regression. Conclusions: In this study, osteomyelitis was the main complication related to the risk of amputation, and elevated body mass index and osteomyelitis were the significant factors that induced a slower healing time.
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Affiliation(s)
| | - Manuela Costa Melo
- Departament of Nursing, Higher School of Health Sciences, Brasília, Federal District, Brazil
| | - Mirian Conceição Moura
- Department of Medicine, Higher School of Sciences and Hospital of the Secretary of Health of the Federal District, Clinical Neurophysiologist, Brasília, Federal District, Brazil
| | | | - Marta Rodrigues De Carvalho
- Department of Medicine, Higher School of Sciences and Hospital of the Secretary of Health of the Federal District, Clinical Neurophysiologist, Brasília, Federal District, Brazil
| | - Andre Neves Mascarenhas
- Department of Endocrinology, Regional Hospital of Asa Norte, Brasília, Federal District, Brazil
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Krishnasamy R, Periyasamy S. Regulating role of ethyl acetate fraction of Tephrosia tinctoria pers. in carbohydrate metabolism and oxidative stress in diabetic rats. Biomed Pharmacother 2019; 114:108842. [PMID: 30954891 DOI: 10.1016/j.biopha.2019.108842] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2018] [Revised: 03/28/2019] [Accepted: 03/31/2019] [Indexed: 12/26/2022] Open
Abstract
Traditionally, Tephrosia tinctoria (TT) is used as antimicrobial, larvicidal, antidiabetic and antioxidant agents. In the present study, the diabetes was induced in male albino - rats using alloxan (140 mg/kg b.w.) and treated with ethyl acetate extract (100 and 200 mg/kg b.w.) of T. tinctoria (TTEA) orally for 28 days. The effects of TTEA on biochemical paramets were studied. The results of this comprehensive study revealed that the TTEA significantly restored the altered parameters in alloxan-induced diabetic rats. The diabetes-induced elevated levels of glycogenolysis and gluconeogenesis metabolism were significantly controlled by TTEA. In the same, the decreased glycogenesis, glycolysis and TCA cycle metabolisms were significantly increased by TTEA. The enzymatic and non- enzymatic antioxidant levels were significantly elevated in TTEA treated diabetic rats and also the total non-enzymatic antioxidants capacity of serum and liver homogenate were calculated though DPPH inhibition. To conclude, this study demonstrates the anti-diabetic effect of TTEA possibly mediated through regulating carbohydrate metabolism and antioxidant status.
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Affiliation(s)
- Rajaram Krishnasamy
- Department of Biochemistry and Biotechnology, CSIR - Central Leather Research Institute, Adyar, 600 020, Tamil Nadu, India.
| | - Sureshkumar Periyasamy
- Department of Biotechnology, Bharathidasan Institute of Technology, Anna University, Tiruchirappalli, 620 024, Tamil Nadu, India.
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10
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Dhindsa DS, Sandesara PB, Shapiro MD. The Intersection of Diabetes and Cardiovascular Disease-A Focus on New Therapies. Front Cardiovasc Med 2018; 5:160. [PMID: 30555833 PMCID: PMC6282028 DOI: 10.3389/fcvm.2018.00160] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2018] [Accepted: 10/18/2018] [Indexed: 01/14/2023] Open
Abstract
Diabetes is a leading cause of cardiovascular disease and its associated morbidity. While the medical community has had access to numerous glucose lowering therapies over the last decades, it was not until recently that newer agents demonstrated improvement in cardiovascular outcomes. In particular, diabetes care and management of its attendant cardiovascular risk is now being revolutionized with the development and provision of the SGLT-2 inhibitors and GLP1-receptor agonists. Given the exciting data with these new classes of diabetes therapeutics, there is a clear need to improve education and utilization of these evidence-based medications across a wide spectrum of clinicians, including cardiologists. The aim of this review is to familiarize the cardiovascular specialist with the benefits and harms of the most commonly used oral anti- hyperglycemic medications, with an emphasis on SGLT-2 inhibitors and GLP-1 receptor agonists.
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Affiliation(s)
- Devinder S. Dhindsa
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, GA, United States
| | - Pratik B. Sandesara
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, GA, United States
| | - Michael D. Shapiro
- Center for Preventive Cardiology, Knight Cardiovascular Institute, Oregon Health & Science University, Portland, OR, United States
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Jayawardena R, Ranasinghe P, Chathuranga T, Atapattu PM, Misra A. The benefits of yoga practice compared to physical exercise in the management of type 2 Diabetes Mellitus: A systematic review and meta-analysis. Diabetes Metab Syndr 2018; 12:795-805. [PMID: 29685823 DOI: 10.1016/j.dsx.2018.04.008] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2018] [Accepted: 04/09/2018] [Indexed: 12/26/2022]
Abstract
Yoga is increasingly used as an adjunctive therapy in the management of Type-2 Diabetes Mellitus (T2DM). The present study aims to systematically evaluate the literature and perform a meta-analysis on the effects of yoga practice compared to physical exercise in the management of T2DM. Data were obtained using a stepwise search process using keywords in the following online medical databases; PubMed, Web of Science and Scopus. All controlled clinical trials involving patients with T2DM, comparing yoga as an intervention with physical exercise and evaluating glycaemic control and other outcomes between the intervention and control groups were included in the analysis. Eight studies were eligible to be included in the systematic review. In total, 842 participants were assigned to a Yoga intervention or a control group with an Exercise intervention and the age range of participants was 30-78 years. A significant reduction in FBG (15.16 mg/dl), PPBG (28.66 mg/dl), HbA1c (0.39%) and BMI (0.71 kg/m2) was noted in the intervention group ('Yoga') compared to the control group ('Physical Exercise') in the pooled analysis. We did not observe any significant difference between the two groups for lipid parameters, other body composition measures (WC and WHR) and Blood Pressure. In conclusion, our results show that Yoga has beneficial effects on glycaemic control in comparison to physical exercise in T2DM However, individual studies showed considerable heterogeneity. Hence, further well-controlled randomized trials are required prior to drawing conclusions about the benefits of yoga in comparison to physical exercise.
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Affiliation(s)
- Ranil Jayawardena
- Department of Physiology, Faculty of Medicine, University of Colombo, Colombo, Sri Lanka; Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, Australia.
| | - Priyanga Ranasinghe
- Department of Pharmacology, Faculty of Medicine, University of Colombo, Colombo, Sri Lanka
| | - Tharindu Chathuranga
- Department of Physiology, Faculty of Medicine, University of Colombo, Colombo, Sri Lanka
| | | | - Anoop Misra
- Fortis-C-DOC Centre of Excellence for Diabetes, Metabolic Diseases and Endocrinology, Chirag Enclave, New Delhi, India, National Diabetes Obesity and Cholesterol Foundation and Diabetes Foundation, India
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12
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Lo SF, Chen WL, Muo CH, Chen PC, Chen SY, Kuo CL, Sung FC. Microvascular Parameters Help to Predict Stroke Risk in the Asian Diabetic Population in Taiwan: A Population Based Case-Control Study. Front Neurol 2018; 9:719. [PMID: 30210440 PMCID: PMC6123532 DOI: 10.3389/fneur.2018.00719] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2018] [Accepted: 08/08/2018] [Indexed: 02/02/2023] Open
Abstract
Intensive glycemic control has not shown consistent findings in stroke prevention for diabetes patients, particularly for those with microvascular complications. This case-control study evaluates the risks of stroke in Asian diabetic population with microvascular complications. From the insurance claims of Taiwan, we identified 67,426 type 2 diabetic mellitus (DM) patients with newly diagnosed stroke in 2000–2011 and 134,852 randomly selected controls with DM but without stroke, matched by sex, age, and number of years since diagnosis of DM. Conditional logistic regression analysis measured crude odds ratios (OR) and adjusted odds ratio (aOR) of stroke and 95% confidence intervals (CI) for associations with demographic status, comorbidities, and microvascular complications: retinopathy (RetP), neuropathy (NeuP) or nephropathy (NepP). The aOR of stroke increased significantly associated with each complication: 1.47 with RetP, 1.73 with NeuP and 1.23 with NepP. The risk increased further when there was a combination of complications. The overall aOR of stroke was 2.83 (95% CI 2.58–3.09) for stroke patients with 3 microvascular complications. The corresponding aOR of ischemic stroke was 2.64 (95% CI 2.39–2.91) and that of hemorrhagic stroke was 4.12 (95% CI 3.25–5.22). The number of microvascular complications positively correlated to the prevalence of comorbidity (p < 0.01). This study suggests that microvascular complications are significant stroke predictors, with a greater involvement for ischemic stroke than for hemorrhagic stroke. Multiple microvascular complications interactively increase the stroke risk. Our study contributes to the identification of high-risk subjects for stroke prevention and adequate glycemic control.
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Affiliation(s)
- Sui-Foon Lo
- Department of Physical Medicine and Rehabilitation, China Medical University Hospital, Taichung, Taiwan.,Department of Chinese Medicine, College of Chinese Medicine, China Medical University, Taichung, Taiwan
| | - Wei-Liang Chen
- Department of Chinese Medicine, College of Chinese Medicine, China Medical University, Taichung, Taiwan.,Medical College of Wisconsin and Children's Hospital of Wisconsin, Milwaukee, WI, United States
| | - Chih-Hsin Muo
- Management Office for Health Data, China Medical University Hospital, China Medical University, Taichung, Taiwan
| | - Pei-Chun Chen
- Department of Public Health, College of Public Health, China Medical University, Taichung, Taiwan
| | - Shih-Yin Chen
- Department of Chinese Medicine, College of Chinese Medicine, China Medical University, Taichung, Taiwan.,Department of Medical Genetics, China Medical University Hospital, Taichung, Taiwan
| | - Chih Lan Kuo
- Department of Physical Medicine and Rehabilitation, China Medical University Hospital, Taichung, Taiwan
| | - Fung-Chang Sung
- Management Office for Health Data, China Medical University Hospital, China Medical University, Taichung, Taiwan.,Department of Health Services Administration, College of Public Health, China Medical University, Taichung, Taiwan
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Hope SV, Taylor PJ, Shields BM, Hattersley AT, Hamilton W. Are we missing hypoglycaemia? Elderly patients with insulin-treated diabetes present to primary care frequently with non-specific symptoms associated with hypoglycaemia. Prim Care Diabetes 2018; 12:139-146. [PMID: 28918198 PMCID: PMC5857285 DOI: 10.1016/j.pcd.2017.08.004] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2017] [Accepted: 08/19/2017] [Indexed: 12/20/2022]
Abstract
INTRODUCTION We assessed if patients with known hypoglycaemia present on other occasions with non-specific symptoms associated with (but not diagnosed as) hypoglycaemia, potentially representing missed hypoglycaemia. METHODS 335 primary care records (5/2/12-4/2/13) from patients aged >65 (79 on insulin, 85 on sulphonylureas, 121 on metformin only, 50 without diabetes) were assessed for hypoglycaemia episodes and consultations with non-specific symptoms, "hypo clues". RESULTS 27/79(34%) insulin-treated patients had >1 documented hypoglycaemia episode, compared to 4/85(5%) sulphonylurea-treated patients, 2/121(2%) metformin-only treated patients, and none without diabetes, p<0.001. "Hypo clue" consultations were common: 1.37 consultations/patient/year in insulin-treated patients, 0.98/patient/year in sulphonylurea-treated, 0.97/patient/year in metformin only-treated, and 0.78/patient/year in non-diabetic patients, p=0.34. In insulin-treated patients with documented hypoglycaemia, 20/27(74%) attended on another occasion with a "hypo clue" symptom, compared to 21/52(40%) of those without hypoglycaemia, p=0.008. No significant difference in the other treatment groups. Nausea, falls and unsteadiness were the most discriminatory symptoms: 7/33(21%) with hypoglycaemia attended on another occasion with nausea compared to 14/302(5%) without hypoglycaemia, p=0.002; 10/33(30%) vs 36/302(12%) with falls, p=0.007; and 5/33(15%) vs 13/302(4%) with unsteadiness, p=0.023. CONCLUSIONS Non-specific symptoms are common in those >65 years. In insulin-treated patients at high hypoglycaemia risk, nausea, falls and unsteadiness should prompt consideration of hypoglycaemia.
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Affiliation(s)
- Suzy V Hope
- Exeter NIHR Clinical Research Facility, RILD Building, Royal Devon & Exeter Hospital, Barrack Road, Exeter, Devon EX2 5DW, UK.
| | - Phil J Taylor
- Axminster Medical Practice, St Thomas Court, Church Street, Axminster, EX13 5AG Devon, UK.
| | - Beverley M Shields
- Exeter NIHR Clinical Research Facility, RILD Building, Royal Devon & Exeter Hospital, Barrack Road, Exeter, Devon EX2 5DW, UK.
| | - Andrew T Hattersley
- Exeter NIHR Clinical Research Facility, RILD Building, Royal Devon & Exeter Hospital, Barrack Road, Exeter, Devon EX2 5DW, UK.
| | - Willie Hamilton
- Department of Primary Care, University of Exeter Medical School, St Luke's Campus, University of Exeter, Heavitree Rd, Exeter, Devon EX1 2LU, UK.
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MacIsaac RJ, Jerums G, Ekinci EI. Effects of glycaemic management on diabetic kidney disease. World J Diabetes 2017; 8:172-186. [PMID: 28572879 PMCID: PMC5437616 DOI: 10.4239/wjd.v8.i5.172] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2016] [Revised: 11/07/2016] [Accepted: 03/17/2017] [Indexed: 02/05/2023] Open
Abstract
Hyperglycaemia contributes to the onset and progression of diabetic kidney disease (DKD). Observational studies have not consistently demonstrated a glucose threshold, in terms of HbA1c levels, for the onset of DKD. Tight glucose control has clearly been shown to reduce the incidence of micro- or macroalbuminuria. However, evidence is now also emerging to suggest that intensive glucose control can slow glomerular filtration rate loss and possibly progression to end stage kidney disease. Achieving tight glucose control needs to be balanced against the increasing appreciation that glucose targets for the prevention of diabetes related complications need be individualised for each patient. Recently, empagliflozin which is an oral glucose lowering agent of the sodium glucose cotransporter-2 inhibitor class has been shown to have renal protective effects. However, the magnitude of empagliflozin’s reno-protective properties are over and above that expected from its glucose lowering effects and most likely largely result from mechanisms involving alterations in intra-renal haemodynamics. Liraglutide and semaglutide, both injectable glucose lowering agents which are analogues of human glucagon like peptide-1 have also been shown to reduce progression to macroalbuminuria through mechanisms that remain to be fully elucidated. Here we review the evidence from observational and interventional studies that link good glucose control with improved renal outcomes. We also briefly review the potential reno-protective effects of newer glucose lowering agents.
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Blonde L, Aschner P, Bailey C, Ji L, Leiter LA, Matthaei S. Gaps and barriers in the control of blood glucose in people with type 2 diabetes. Diab Vasc Dis Res 2017; 14:172-183. [PMID: 28467203 PMCID: PMC5418936 DOI: 10.1177/1479164116679775] [Citation(s) in RCA: 88] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Glycaemic control is suboptimal in a large proportion of people with type 2 diabetes who are consequently at an increased and avoidable risk of potentially severe complications. We sought to explore attitudes and practices among healthcare professionals that may contribute to suboptimal glycaemic control through a review of recent relevant publications in the scientific literature. METHODS An electronic search of the PubMed database was performed to identify relevant publications from January 2011 to July 2015. The electronic search was complemented by a manual search of abstracts from key diabetes conferences in 2014/2015 available online. RESULTS Recently published data indicate that glycaemic control is suboptimal in a substantial proportion (typically 40%-60%) of people with diabetes. This is the case across geographic regions and in both low- and higher-income countries. Therapeutic inertia appears to be an important contributor to poor glycaemic control in up to half of people with type 2 diabetes. In particular, prescribers are often willing to tolerate extended periods of 'mild' hyperglycaemia as well as having low expectations for their patients. There are often delays of 3 years or longer in initiating or intensifying glucose-lowering therapy when needed. CONCLUSION Many people with type 2 diabetes are failed by current management, with approximately half not achieving or maintaining appropriate target blood glucose levels, leaving these patients at increased and avoidable risk of serious complications. Review criteria: The methodology of this review article is detailed in the 'Methods' section.
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Affiliation(s)
- Lawrence Blonde
- Department of Endocrinology, Ochsner Medical Center, New Orleans, LA, USA
- Lawrence Blonde, Department of Endocrinology, Ochsner Medical Center, 1514 Jefferson Highway, New Orleans, LA 70121, USA.
| | - Pablo Aschner
- Endocrinology Unit, Javeriana University School of Medicine, Bogotá, Colombia
| | - Clifford Bailey
- School of Life & Health Sciences, Aston University, Birmingham, UK
| | - Linong Ji
- Peking University People’s Hospital, Beijing, China
| | - Lawrence A Leiter
- Keenan Research Center in the Li Ka Shing Knowledge Institute, St. Michael’s Hospital and Division of Endocrinology & Metabolism, University of Toronto, Toronto, ON, Canada
| | - Stephan Matthaei
- Diabetes, Metabolism and Endocrinology Center, Quakenbrück Hospital, Quakenbrück, Germany
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Basu S, Shankar V, Yudkin JS. Comparative effectiveness and cost-effectiveness of treat-to-target versus benefit-based tailored treatment of type 2 diabetes in low-income and middle-income countries: a modelling analysis. Lancet Diabetes Endocrinol 2016; 4:922-932. [PMID: 27717768 PMCID: PMC5315061 DOI: 10.1016/s2213-8587(16)30270-4] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2016] [Revised: 08/25/2016] [Accepted: 08/30/2016] [Indexed: 12/27/2022]
Abstract
BACKGROUND Optimal prescription of blood pressure, lipid, and glycaemic control treatments for adults with type 2 diabetes remains unclear. We aimed to compare the effectiveness and cost-effectiveness of two treatment approaches for diabetes management in five low-income and middle-income countries. METHODS We developed a microsimulation model to compare a treat-to-target (TTT) strategy, aiming to achieve target levels of biomarkers (blood pressure <130/80 mm Hg, LDL <2·59 mmol/L, and HbA1c <7% [ie, 53·0 mmol/mol]), with a benefit-based tailored treatment (BTT) strategy, aiming to lower estimated risk for complications (to a 10 year cardiovascular risk <10% and lifetime microvascular risk <5%) on the basis of age, sex, and biomarker values. Data were obtained from cohorts in China, Ghana, India, Mexico, and South Africa to span a spectrum of risk profiles. FINDINGS The TTT strategy recommended treatment to a larger number of people-who were generally at lower risk of diabetes complications-than the BTT. The BTT strategy recommended treatment to fewer people at higher risk. Compared with the TTT strategy, the BTT strategy would be expected to avert 24·4-30·5% more complications and be more cost-effective from a societal perspective (saving US$4·0-300·0 per disability-adjusted life-year averted in the countries simulated). Alternative treatment thresholds, matched by total cost or population size treated, did not change the comparative superiority of the BTT strategy, nor did titrating treatment using fasting plasma glucose (for areas without HbA1c testing). However, if insulin were unavailable, the BTT strategy would no longer be superior for preventing microvascular events and was superior only for preventing cardiovascular events. INTERPRETATION A BTT strategy is more effective and cost-effective than a TTT strategy in low-income and middle-income countries for prevention of both cardiovascular and microvascular complications of type 2 diabetes. However, the superiority of the BTT strategy for averting microvascular complications is contingent on insulin availability. FUNDING Rosenkranz Prize for Healthcare Research in Developing Countries and US National Institutes of Health (U54 MD010724, DP2 MD010478).
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Affiliation(s)
- Sanjay Basu
- Department of Medicine, Stanford University, Palo Alto, CA, USA; Center for Primary Care, Harvard Medical School, Boston, MA, USA.
| | - Vishnu Shankar
- Department of Medicine, Stanford University, Palo Alto, CA, USA
| | - John S Yudkin
- Division of Medicine, University College London, London, UK
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Sarraju A, Kim SH, Knowles JW. Cardiometabolic Effects of Glucagon-Like Peptide-1 Agonists. Curr Atheroscler Rep 2016; 18:7. [PMID: 26782825 DOI: 10.1007/s11883-016-0558-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Cardiovascular disease is the leading cause of death among adults in the USA. Both type 1 (T1DM) and type 2 diabetes mellitus (T2DM) are known risk factors for cardiovascular disease. Despite the development of numerous effective anti-glycemic therapies, we have been unable to completely mitigate cardiovascular risk with glucose lowering alone, and prevention of cardiovascular disease in patients with diabetes is primarily achieved with the use of medications that address other risk factors such as anti-hypertensives or statins. Glucagon-like peptide-1 (GLP-1) is a key hormone in the pathophysiology of diabetes. GLP-1 agonists have been recently approved for the treatment of T2DM as well as for chronic weight management. In this review, we aim to explore the effects of GLP-1 agonists on cardiovascular health with a focus on cardiometabolic variables and cardiac function.
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Affiliation(s)
- Ashish Sarraju
- Department of Medicine, Stanford University School of Medicine, Stanford, CA, 94305, USA
| | - Sun H Kim
- Division of Endocrinology, Stanford University School of Medicine, Stanford, CA, 94305, USA
| | - Joshua W Knowles
- Division of Cardiovascular Medicine and Cardiovascular Institute, Stanford University School of Medicine, Falk CVRC, Room CV273, MC 5406, 300 Pasteur Drive, Stanford, CA, 94305, USA.
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Chang PY, Chien LN, Lin YF, Wu MS, Chiu WT, Chiou HY. Risk factors of gender for renal progression in patients with early chronic kidney disease. Medicine (Baltimore) 2016; 95:e4203. [PMID: 27472690 PMCID: PMC5265827 DOI: 10.1097/md.0000000000004203] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
Risk factors for chronic kidney disease (CKD), such as hypertension, hyperglycemia, albuminuria, renal structure, and sex hormones, have been reported to have different effects on males and females. Thus, CKD progression may differ depending on sex. In addition to CKD management, treatment at earlier stages can reduce complications and prevent disease progression as well as high medical expenses at late stages. We examined the differences in predictive risk factors for renal progression between male and female patients with early CKD.This case-cohort study recruited patients aged 18 years or older treated in the outpatient departments of 8 hospitals in Taiwan between August 2008 and September 2014. In total, 1530 patients were included in the analysis. Renal progression was defined as ≥25% decline based on baseline estimated glomerular filtration rate. To examine the predictive risk factors for renal progression, we constructed a subset multivariate logistic model with stepwise variable selection by using P < 0.10 for variable retention.The numbers of male and female patients with CKD exhibiting renal progression were 100 (11.64%) and 84 (12.52%), respectively. After adjusting for all the potential confounders, stepwise logistic regression analysis showed that main independent predictive risk factors for the male patients- (C statistic = 0.72) were proteinuria (odds ratio [OR] 2.20; 95% confidence interval [CI] 1.26-3.84), age (OR 1.04; 95% CI 1.02-1.06), anemia (OR 2.75; 95% CI 1.20-6.30), and poor control of blood pressure (OR 1.84; 95% CI 1.05-3.22). However, the main independent predictive factors for the female patients were (C statistic = 0.75) poor glycemic control (OR 2.28; 95% CI 1.22-4.25), poor blood pressure control (OR 1.93; 95% CI 1.06-3.50), and family income (OR 2.51; 95% CI 1.01-6.20).In conclusion, this study demonstrated that proteinuria was the most crucial risk factor for male patients, whereas poor glycemic control was the main risk factor for female patients. Poor blood pressure control was a shared risk factor for male and female patients.
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Affiliation(s)
| | | | | | | | - Wen-Ta Chiu
- Graduate Institute of Injury Prevention and Control, Taipei Medical University, Taipei, Taiwan.
- Correspondence: Hung-Yi Chiou, PhD, School of Public Health, Taipei Medical University, No. 250, Wu-Hsing Street, Taipei 110, Taiwan (e-mail: ); Wen-Ta Chiu, Graduate Institute of Injury Prevention and Control, Taipei Medical University, No. 250, Wu-Hsing Street, Taipei 110, Taiwan (e-mail: )
| | - Hung-Yi Chiou
- School of Public Health
- Correspondence: Hung-Yi Chiou, PhD, School of Public Health, Taipei Medical University, No. 250, Wu-Hsing Street, Taipei 110, Taiwan (e-mail: ); Wen-Ta Chiu, Graduate Institute of Injury Prevention and Control, Taipei Medical University, No. 250, Wu-Hsing Street, Taipei 110, Taiwan (e-mail: )
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Lipska KJ, Krumholz H, Soones T, Lee SJ. Polypharmacy in the Aging Patient: A Review of Glycemic Control in Older Adults With Type 2 Diabetes. JAMA 2016; 315:1034-45. [PMID: 26954412 PMCID: PMC4823136 DOI: 10.1001/jama.2016.0299] [Citation(s) in RCA: 159] [Impact Index Per Article: 19.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
IMPORTANCE There is substantial uncertainty about optimal glycemic control in older adults with type 2 diabetes mellitus. OBSERVATIONS Four large randomized clinical trials (RCTs), ranging in size from 1791 to 11,440 patients, provide the majority of the evidence used to guide diabetes therapy. Most RCTs of intensive vs standard glycemic control excluded adults older than 80 years, used surrogate end points to evaluate microvascular outcomes and provided limited data on which subgroups are most likely to benefit or be harmed by specific therapies. Available data from randomized clinical trials suggest that intensive glycemic control does not reduce major macrovascular events in older adults for at least 10 years. Furthermore, intensive glycemic control does not lead to improved patient-centered microvascular outcomes for at least 8 years. Data from randomized clinical trials consistently suggest that intensive glycemic control immediately increases the risk of severe hypoglycemia 1.5- to 3-fold. Based on these data and observational studies, for the majority of adults older than 65 years, the harms associated with a hemoglobin A1c (HbA1c) target lower than 7.5% or higher than 9% are likely to outweigh the benefits. However, the optimal target depends on patient factors, medications used to reach the target, life expectancy, and patient preferences about treatment. If only medications with low treatment burden and hypoglycemia risk (such as metformin) are required, a lower HbA1c target may be appropriate. If patients strongly prefer to avoid injections or frequent fingerstick monitoring, a higher HbA1c target that obviates the need for insulin may be appropriate. CONCLUSIONS AND RELEVANCE High-quality evidence about glycemic treatment in older adults is lacking. Optimal decisions need to be made collaboratively with patients, incorporating the likelihood of benefits and harms and patient preferences about treatment and treatment burden. For the majority of older adults, an HbA1c target between 7.5% and 9% will maximize benefits and minimize harms.
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Affiliation(s)
- Kasia J Lipska
- Department of Internal Medicine, Section of Endocrinology, Yale School of Medicine, New Haven, Connecticut
| | - Harlan Krumholz
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut3Section of Cardiovascular Medicine and the Robert Wood Johnson Foundation Clinical Scholars Program, Yale School of Medicine, New Haven, Connecticut4Department of
| | - Tacara Soones
- Department of Geriatrics and Palliative Medicine; Icahn School of Medicine at Mount Sinai; New York
| | - Sei J Lee
- Division of Geriatrics, Department of Medicine, University of California, San Francisco7San Francisco VA Medical Center, California
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Fernando ME, Seneviratne RM, Tan YM, Lazzarini PA, Sangla KS, Cunningham M, Buttner PG, Golledge J. Intensive versus conventional glycaemic control for treating diabetic foot ulcers. Cochrane Database Syst Rev 2016; 2016:CD010764. [PMID: 26758576 PMCID: PMC8627701 DOI: 10.1002/14651858.cd010764.pub2] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND The estimated likelihood of lower limb amputation is 10 to 30 times higher amongst people with diabetes compared to those without diabetes. Of all non-traumatic amputations in people with diabetes, 85% are preceded by a foot ulcer. Foot ulceration associated with diabetes (diabetic foot ulcers) is caused by the interplay of several factors, most notably diabetic peripheral neuropathy (DPN), peripheral arterial disease (PAD) and changes in foot structure. These factors have been linked to chronic hyperglycaemia (high levels of glucose in the blood) and the altered metabolic state of diabetes. Control of hyperglycaemia may be important in the healing of ulcers. OBJECTIVES To assess the effects of intensive glycaemic control compared to conventional control on the outcome of foot ulcers in people with type 1 and type 2 diabetes. SEARCH METHODS In December 2015 we searched: The Cochrane Wounds Specialised Register; The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library); Ovid MEDLINE; Ovid MEDLINE (In-Process & Other Non-Indexed Citations); Ovid EMBASE; EBSCO CINAHL; Elsevier SCOPUS; ISI Web of Knowledge Web of Science; BioMed Central and LILACS. We also searched clinical trial databases, pharmaceutical trial databases and current international and national clinical guidelines on diabetes foot management for relevant published, non-published, ongoing and terminated clinical trials. There were no restrictions based on language or date of publication or study setting. SELECTION CRITERIA Published, unpublished and ongoing randomised controlled trials (RCTs) were considered for inclusion where they investigated the effects of intensive glycaemic control on the outcome of active foot ulcers in people with diabetes. Non randomised and quasi-randomised trials were excluded. In order to be included the trial had to have: 1) attempted to maintain or control blood glucose levels and measured changes in markers of glycaemic control (HbA1c or fasting, random, mean, home capillary or urine glucose), and 2) documented the effect of these interventions on active foot ulcer outcomes. Glycaemic interventions included subcutaneous insulin administration, continuous insulin infusion, oral anti-diabetes agents, lifestyle interventions or a combination of these interventions. The definition of the interventional (intensive) group was that it should have a lower glycaemic target than the comparison (conventional) group. DATA COLLECTION AND ANALYSIS All review authors independently evaluated the papers identified by the search strategy against the inclusion criteria. Two review authors then independently reviewed all potential full-text articles and trials registry results for inclusion. MAIN RESULTS We only identified one trial that met the inclusion criteria but this trial did not have any results so we could not perform the planned subgroup and sensitivity analyses in the absence of data. Two ongoing trials were identified which may provide data for analyses in a later version of this review. The completion date of these trials is currently unknown. AUTHORS' CONCLUSIONS The current review failed to find any completed randomised clinical trials with results. Therefore we are unable to conclude whether intensive glycaemic control when compared to conventional glycaemic control has a positive or detrimental effect on the treatment of foot ulcers in people with diabetes. Previous evidence has however highlighted a reduction in risk of limb amputation (from various causes) in people with type 2 diabetes with intensive glycaemic control. Whether this applies to people with foot ulcers in particular is unknown. The exact role that intensive glycaemic control has in treating foot ulcers in multidisciplinary care (alongside other interventions targeted at treating foot ulcers) requires further investigation.
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Affiliation(s)
- Malindu E Fernando
- College of Medicine and Dentistry, James Cook UniversityVascular Biology Unit, Queensland Research Centre for Peripheral Vascular DiseaseTownsvilleQueenslandAustralia4814
- Kirwan Community Health CampusPodiatry ServiceTownsvilleQueenslandAustralia
| | - Ridmee M Seneviratne
- College of Medicine and Dentistry, James Cook UniversityVascular Biology Unit, Queensland Research Centre for Peripheral Vascular DiseaseTownsvilleQueenslandAustralia4814
| | - Yong Mong Tan
- The Townsville HospitalDepartment of Diabetes and Endocrinology100 Angus Smith DriveTownsvilleQueenslandAustralia4814
| | - Peter A Lazzarini
- Queensland HealthAllied Health Research CollaborativeLevel 315 Butterfield StreetHerston, BrisbaneQueenslandAustralia4029
- Queensland University of TechnologySchool of Clinical SciencesBrisbaneQueenslandAustralia
| | - Kunwarjit S Sangla
- The Townsville HospitalDepartment of Diabetes and Endocrinology100 Angus Smith DriveTownsvilleQueenslandAustralia4814
| | - Margaret Cunningham
- University of StirlingNursing, Midwifery and Allied Health Professions Research Unit (NMAHP RU)StirlingStirlingshireUKFK9 4LA
| | - Petra G Buttner
- Tropical Health Solutions Pty Ltd72 Kokoda StTownsvilleQueenslandAustralia4811
| | - Jonathan Golledge
- College of Medicine and Dentistry, James Cook UniversityVascular Biology Unit, Queensland Research Centre for Peripheral Vascular DiseaseTownsvilleQueenslandAustralia4814
- The Townsville HospitalDepartment of Vascular and Endovascular SurgeryTownsvilleQueenslandAustralia4814
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Shen W, Li Y, Zhang Y, Wu T, Hung Yu Ng E, Wu X. Acupuncture for adults with type 2 diabetes mellitus. Hippokratia 2015. [DOI: 10.1002/14651858.cd010491.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Affiliation(s)
- Wenjuan Shen
- First Affiliated Hospital, Heilongjiang University of Chinese Medicine; Department of Obstetrics and Gynecology; No.26 Heping Road, Xiangfang District Harbin Heilongjiang China 150040
| | - Yan Li
- First Affiliated Hospital, Heilongjiang University of Chinese Medicine; Department of Obstetrics and Gynecology; No.26 Heping Road, Xiangfang District Harbin Heilongjiang China 150040
| | - Yang Zhang
- First Affiliated Hospital, Heilongjiang University of Chinese Medicine; Department of Internal Medicine; Heping Road 26, Xiangfang District Harbin Heilongjiang China 150040
| | - Taixiang Wu
- West China Hospital, Sichuan University; Chinese Clinical Trial Registry, Chinese Ethics Committee of Registering Clinical Trials; No. 37, Guo Xue Xiang Chengdu Sichuan China 610041
| | - Ernest Hung Yu Ng
- University of Hong Kong, Queen Mary Hospital; Department of Obstetrics and Gynaecology; Pokfulam Road Hong Kong Hong Kong Hong Kong
| | - XiaoKe Wu
- National Key Discipline and Clinical Base, Heilongjiang University of Chinese Medicine; Department of Obstetrics and Gynaecology; Harbin China 150040
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Chen DY, Wang SH, Mao CT, Tsai ML, Lin YS, Su FC, Chou CC, Wen MS, Wang CC, Hsieh IC, Hung KC, Cherng WJ, Chen TH. Sitagliptin After Ischemic Stroke in Type 2 Diabetic Patients: A Nationwide Cohort Study. Medicine (Baltimore) 2015; 94:e1128. [PMID: 26181549 PMCID: PMC4617065 DOI: 10.1097/md.0000000000001128] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
The cerebrovascular safety and efficacy of sitagliptin, a dipeptidyl peptidase-4 inhibitor, in patients with type 2 diabetes mellitus (T2DM) with ischemic stroke remains uncertain. The aim of this study was to assess the efficacy and safety of sitagliptin in patients with T2DM with recent ischemic stroke. We analyzed data from the Taiwan National Health Insurance Research Database between March 1, 2009, and December 31, 2011. Ischemic stroke patients were identified from individuals with T2DM. Patients who received sitagliptin were compared with those who did not to evaluate the cardiovascular safety and efficacy of sitagliptin. The primary outcome was a composite of ischemic stroke, myocardial infarction, or cardiovascular death. A total of 5145 type 2 diabetic patients with ischemic stroke met our inclusion criteria and were followed for up to 2.83 years (mean, 1.17 years). Overall, 1715 patients (33.3%) received sitagliptin and 3430 patients (66.7%) did not. The primary composite outcome occurred in 190 patients in the sitagliptin group (11.1%) and in 370 patients in the comparison group (10.8%) (hazard ratio [HR] = 1.02; 95% confidence interval [CI], 0.85-1.21). Patients treated with sitagliptin had a similar risk of ischemic stroke, hemorrhagic stroke, and all-cause mortality with an HR of 0.95 (95% CI, 0.78-1.16, P = 0.612), 1.07 (95% CI, 0.55-2.11, P = 0.834), and 1.00 (95% CI, 0.82-1.22, P = 0.989), respectively, compared with patients not treated with sitagliptin. Treatment with sitagliptin in type 2 diabetic patients with recent ischemic stroke was not associated with increased or decreased risks of adverse cerebrovascular outcomes.
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Affiliation(s)
- Dong-Yi Chen
- From the Division of Cardiology (DYC, MLT, CCC, MSW, CCW, ICH, KCH), Department of Internal Medicine; Department of Medical Education (SHW), Chang Gung Memorial Hospital, Chang Gung University College of Medicine; Division of Cardiology (CTM, WJC, THC), Department of Internal Medicine, Chang Gung Memorial Hospital, Keelung, and Chang Gung University College of Medicine, Taoyuan; Division of Cardiology (YSL), Department of Internal Medicine, Chang Gung Memorial Hospital, Chiayi, and Chang Gung University College of Medicine, Taoyuan; and Department of Neurology (FCS), Chang Gung Memorial Hospital, Keelung, Taiwan
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Sardar P, Udell JA, Chatterjee S, Bansilal S, Mukherjee D, Farkouh ME. Effect of Intensive Versus Standard Blood Glucose Control in Patients With Type 2 Diabetes Mellitus in Different Regions of the World: Systematic Review and Meta-analysis of Randomized Controlled Trials. J Am Heart Assoc 2015; 4:e001577. [PMID: 25944874 PMCID: PMC4599400 DOI: 10.1161/jaha.114.001577] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2014] [Accepted: 04/01/2015] [Indexed: 01/21/2023]
Abstract
BACKGROUND Regional variation in type 2 diabetes mellitus care may affect outcomes in patients treated with intensive versus standard blood glucose control. We sought to evaluate these differences between North America and the rest of the world. METHODS AND RESULTS Databases were searched from their inception through December 2013. Randomized controlled trials comparing the effects of intensive therapy with standard therapy for macro- and microvascular complications in adults with type 2 diabetes mellitus were selected. We calculated summary odds ratios (ORs) and 95% CIs with the random-effects model. The analysis included 34 967 patients from 17 randomized controlled trials (7 in North America and 10 in the rest of the world). There were no significant differences between intensive and standard therapy groups for all-cause mortality (OR 1.03, 95% CI 0.93 to 1.13) and cardiovascular mortality (OR 1.09, 95% CI 0.90 to 1.32). For trials conducted in North America, intensive therapy compared with standard glycemic control resulted in significantly higher all-cause mortality (OR 1.21, 95% CI 1.05 to 1.40) and cardiovascular mortality (OR 1.41, 95% CI 1.05 to 1.90) than trials conducted in the rest of the world (all-cause mortality OR 0.93, 95% CI 0.85 to 1.03; interaction P=0.006; cardiovascular mortality OR 0.89, 95% CI, 0.79 to 1.00; interaction P=0.007). Analysis of individual macro- and microvascular outcomes revealed no significant regional differences; however, the risk of severe hypoglycemia was significantly higher in trials of intensive therapy in North America (OR 3.52, 95% CI 3.07 to 4.03) compared with the rest of the world (OR 1.45, 95% CI 0.85 to 2.47; interaction P=0.001). CONCLUSION Randomization to intensive glycemic control in type 2 diabetes mellitus patients was associated with increases in all-cause mortality, cardiovascular mortality, and severe hypoglycemia in North America compared with the rest of the world. Further investigation into the pathobiology or patient variability underlying these findings is warranted.
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Affiliation(s)
- Partha Sardar
- Division of Cardiovascular Medicine, University of UtahSalt Lake City, UT (P.S.)
| | - Jacob A Udell
- Cardiovascular Division, Department of Medicine, Women's College Hospital, University of TorontoOntario, Canada (J.A.U.)
- Peter Munk Centre of Excellence in Multinational Clinical Trials, University Health Network, Heart & Stroke Richard Lewar Centre of Excellence, University of TorontoOntario, Canada (J.A.U., M.E.F.)
| | - Saurav Chatterjee
- Division of Cardiovascular Diseases, St. Luke's-Roosevelt Hospital Center of the Mount Sinai Health SystemNew York, NY (S.C.)
| | - Sameer Bansilal
- Cardiovascular Institute, The Mount Sinai Medical CenterNew York, NY (S.B.)
| | - Debabrata Mukherjee
- Division of Cardiovascular Diseases, Texas Tech University Health Sciences Center, Paul L. Foster School of MedicineEl Paso, TX (D.M.)
| | - Michael E Farkouh
- Peter Munk Centre of Excellence in Multinational Clinical Trials, University Health Network, Heart & Stroke Richard Lewar Centre of Excellence, University of TorontoOntario, Canada (J.A.U., M.E.F.)
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Hajek T, Calkin C, Blagdon R, Slaney C, Uher R, Alda M. Insulin resistance, diabetes mellitus, and brain structure in bipolar disorders. Neuropsychopharmacology 2014; 39:2910-8. [PMID: 25074491 PMCID: PMC4200504 DOI: 10.1038/npp.2014.148] [Citation(s) in RCA: 63] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2014] [Revised: 05/27/2014] [Accepted: 06/05/2014] [Indexed: 12/21/2022]
Abstract
Type 2 diabetes mellitus (T2DM) damages the brain, especially the hippocampus, and frequently co-occurs with bipolar disorders (BD). Reduced hippocampal volumes are found only in some studies of BD subjects and may thus be secondary to the presence of certain clinical variables. Studying BD patients with abnormal glucose metabolism could help identify preventable risk factors for hippocampal atrophy in BD. We compared brain structure using optimized voxel-based morphometry of 1.5T MRI scans in 33 BD subjects with impaired glucose metabolism (19 with insulin resistance/glucose intolerance (IR/GI), 14 with T2DM), 15 euglycemic BD participants and 11 euglycemic, nonpsychiatric controls. The group of BD patients with IR, GI or T2DM had significantly smaller hippocampal volumes than the euglycemic BD participants (corrected p=0.02) or euglycemic, nonpsychiatric controls (corrected p=0.004). Already the BD subjects with IR/GI had smaller hippocampal volumes than euglycemic BD participants (t(32)=-3.15, p=0.004). Age was significantly more negatively associated with hippocampal volumes in BD subjects with IR/GI/T2DM than in the euglycemic BD participants (F(2, 44)=9.96, p=0.0003). The gray matter reductions in dysglycemic subjects extended to the cerebral cortex, including the insula. In conclusion, this is the first study demonstrating that T2DM or even prediabetes may be risk factors for smaller hippocampal and cortical volumes in BD. Abnormal glucose metabolism may accelerate the age-related decline in hippocampal volumes in BD. These findings raise the possibility that improving diabetes care among BD subjects and intervening already at the level of prediabetes could slow brain aging in BD.
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Affiliation(s)
- Tomas Hajek
- Department of Psychiatry, Dalhousie University, Halifax, NS, Canada,Prague Psychiatric Center, Department of Psychiatry and Medical Psychology, 3rd School of Medicine, Charles University, Prague, Czech Republic,Department of Psychiatry, Dalhousie University, QEII HSC, A.J.Lane Bldg., Room 3093, 5909 Veteran's Memorial Lane, Halifax, NS B3H 2E2, Canada, Tel: +1 902 473 8299, Fax: +1 902 473 1583, E-mail:
| | - Cynthia Calkin
- Department of Psychiatry, Dalhousie University, Halifax, NS, Canada
| | - Ryan Blagdon
- Department of Psychiatry, Dalhousie University, Halifax, NS, Canada
| | - Claire Slaney
- Department of Psychiatry, Dalhousie University, Halifax, NS, Canada
| | - Rudolf Uher
- Department of Psychiatry, Dalhousie University, Halifax, NS, Canada
| | - Martin Alda
- Department of Psychiatry, Dalhousie University, Halifax, NS, Canada,Prague Psychiatric Center, Department of Psychiatry and Medical Psychology, 3rd School of Medicine, Charles University, Prague, Czech Republic
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Abstract
With respect to clinical phenotype and pathophysiology, prediabetes is akin to diabetes. Prediabetes is prevalent in the global population, and those affected are at high risk of progression to overt diabetes, and also at risk of cardiovascular disease (CVD). Progression to diabetes can occur because of worsening insulin resistance, β-cell dysfunction, or both, but the timecourse can be non-linear and, therefore, unpredictable. Intervention-by lifestyle modification, glucose-lowering drugs, or a combination-can postpone deterioration of glucose control, but effects of intervention are variable and can be transient. Furthermore, to what extent interventions can reduce cardiovascular risk is uncertain. Lifestyle intervention mainly hinges on weight loss; as such, risk of failure in the long-term is high, and implementation at the community level is difficult. The ideal candidate for intervention is an individual with prediabetes-identified by targeted screening-with many well documented cardiovascular risk factors, and who is highly motivated to initiate and maintain multifactorial risk-control using a personalised mix of lifestyle-adaptation and pharmacological treatment.
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Affiliation(s)
- Ele Ferrannini
- Department of Clinical and Experimental Medicine, University of Pisa School of Medicine, Pisa, Italy.
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Pan J, Guleria RS, Zhu S, Baker KM. Molecular Mechanisms of Retinoid Receptors in Diabetes-Induced Cardiac Remodeling. J Clin Med 2014; 3:566-94. [PMID: 26237391 PMCID: PMC4449696 DOI: 10.3390/jcm3020566] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2014] [Revised: 03/17/2014] [Accepted: 03/25/2014] [Indexed: 02/07/2023] Open
Abstract
Diabetic cardiomyopathy (DCM), a significant contributor to morbidity and mortality in diabetic patients, is characterized by ventricular dysfunction, in the absence of coronary atherosclerosis and hypertension. There is no specific therapeutic strategy to effectively treat patients with DCM, due to a lack of a mechanistic understanding of the disease process. Retinoic acid, the active metabolite of vitamin A, is involved in a wide range of biological processes, through binding and activation of nuclear receptors: retinoic acid receptors (RAR) and retinoid X receptors (RXR). RAR/RXR-mediated signaling has been implicated in the regulation of glucose and lipid metabolism. Recently, it has been reported that activation of RAR/RXR has an important role in preventing the development of diabetic cardiomyopathy, through improving cardiac insulin resistance, inhibition of intracellular oxidative stress, NF-κB-mediated inflammatory responses and the renin-angiotensin system. Moreover, downregulated RAR/RXR signaling has been demonstrated in diabetic myocardium, suggesting that impaired RAR/RXR signaling may be a trigger to accelerate diabetes-induced development of DCM. Understanding the molecular mechanisms of retinoid receptors in the regulation of cardiac metabolism and remodeling under diabetic conditions is important in providing the impetus for generating novel therapeutic approaches for the prevention and treatment of diabetes-induced cardiac complications and heart failure.
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Affiliation(s)
- Jing Pan
- Division of Molecular Cardiology, Department of Medicine, College of Medicine, Texas A & M Health Science Center, Baylor Scott & White Health, Central Texas Veterans Health Care System, Temple, TX, 76504, USA.
| | - Rakeshwar S Guleria
- Division of Molecular Cardiology, Department of Medicine, College of Medicine, Texas A & M Health Science Center, Baylor Scott & White Health, Central Texas Veterans Health Care System, Temple, TX, 76504, USA.
| | - Sen Zhu
- Division of Molecular Cardiology, Department of Medicine, College of Medicine, Texas A & M Health Science Center, Baylor Scott & White Health, Central Texas Veterans Health Care System, Temple, TX, 76504, USA.
| | - Kenneth M Baker
- Division of Molecular Cardiology, Department of Medicine, College of Medicine, Texas A & M Health Science Center, Baylor Scott & White Health, Central Texas Veterans Health Care System, Temple, TX, 76504, USA.
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Berkowitz SA, Karter AJ, Lyles CR, Liu JY, Schillinger D, Adler NE, Moffet HH, Sarkar U. Low socioeconomic status is associated with increased risk for hypoglycemia in diabetes patients: the Diabetes Study of Northern California (DISTANCE). J Health Care Poor Underserved 2014; 25:478-90. [PMID: 24858863 PMCID: PMC4034138 DOI: 10.1353/hpu.2014.0106] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Social risk factors for hypoglycemia are not well understood. METHODS Cross-sectional analysis from the DISTANCE study, a multi-language, ethnically-stratified random sample of adults in the Kaiser Permanente Northern California diabetes registry, conducted in 2005-2006 (response rate 62%). Exposures were income and educational attainment; outcome was patient report of severe hypoglycemia. To test the association, we used multivariable logistic regression to adjust for demographic and clinical factors. RESULTS 14,357 patients were included. Reports of severe hypoglycemia were common (11%), and higher in low-income vs. high-income (16% vs. 8.8) and low-education vs. high-education (11.9% vs. 8.9%) groups. In multivariable analysis, incomes of less than $15,000 (OR 1.51 95%CI 1.19-1.91), $15,000-$24,999 (OR 1.57 95%CI 1.27-1.94), and high school or less education (OR 1.42, 95% CI 1.24-1.63) were associated with increased hypoglycemia, similar to insulin use (OR 1.44 95%CI 1.19-1.74). CONCLUSIONS Low income and educational attainment are important risk factors for hypoglycemia.
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Ryan R, Santesso N, Lowe D, Hill S, Grimshaw J, Prictor M, Kaufman C, Cowie G, Taylor M. Interventions to improve safe and effective medicines use by consumers: an overview of systematic reviews. Cochrane Database Syst Rev 2014; 2014:CD007768. [PMID: 24777444 PMCID: PMC6491214 DOI: 10.1002/14651858.cd007768.pub3] [Citation(s) in RCA: 121] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND Many systematic reviews exist on interventions to improve safe and effective medicines use by consumers, but research is distributed across diseases, populations and settings. The scope and focus of such reviews also vary widely, creating challenges for decision-makers seeking to inform decisions by using the evidence on consumers' medicines use.This is an update of a 2011 overview of systematic reviews, which synthesises the evidence, irrespective of disease, medicine type, population or setting, on the effectiveness of interventions to improve consumers' medicines use. OBJECTIVES To assess the effects of interventions which target healthcare consumers to promote safe and effective medicines use, by synthesising review-level evidence. SEARCH METHODS We included systematic reviews published on the Cochrane Database of Systematic Reviews and the Database of Abstracts of Reviews of Effects. We identified relevant reviews by handsearching databases from their start dates to March 2012. SELECTION CRITERIA We screened and ranked reviews based on relevance to consumers' medicines use, using criteria developed for this overview. DATA COLLECTION AND ANALYSIS We used standardised forms to extract data, and assessed reviews for methodological quality using the AMSTAR tool. We used standardised language to summarise results within and across reviews; and gave bottom-line statements about intervention effectiveness. Two review authors screened and selected reviews, and extracted and analysed data. We used a taxonomy of interventions to categorise reviews and guide syntheses. MAIN RESULTS We included 75 systematic reviews of varied methodological quality. Reviews assessed interventions with diverse aims including support for behaviour change, risk minimisation and skills acquisition. No reviews aimed to promote systems-level consumer participation in medicines-related activities. Medicines adherence was the most frequently-reported outcome, but others such as knowledge, clinical and service-use outcomes were also reported. Adverse events were less commonly identified, while those associated with the interventions themselves, or costs, were rarely reported.Looking across reviews, for most outcomes, medicines self-monitoring and self-management programmes appear generally effective to improve medicines use, adherence, adverse events and clinical outcomes; and to reduce mortality in people self-managing antithrombotic therapy. However, some participants were unable to complete these interventions, suggesting they may not be suitable for everyone.Other promising interventions to improve adherence and other key medicines-use outcomes, which require further investigation to be more certain of their effects, include:· simplified dosing regimens: with positive effects on adherence;· interventions involving pharmacists in medicines management, such as medicines reviews (with positive effects on adherence and use, medicines problems and clinical outcomes) and pharmaceutical care services (consultation between pharmacist and patient to resolve medicines problems, develop a care plan and provide follow-up; with positive effects on adherence and knowledge).Several other strategies showed some positive effects, particularly relating to adherence, and other outcomes, but their effects were less consistent overall and so need further study. These included:· delayed antibiotic prescriptions: effective to decrease antibiotic use but with mixed effects on clinical outcomes, adverse effects and satisfaction;· practical strategies like reminders, cues and/or organisers, reminder packaging and material incentives: with positive, although somewhat mixed effects on adherence;· education delivered with self-management skills training, counselling, support, training or enhanced follow-up; information and counselling delivered together; or education/information as part of pharmacist-delivered packages of care: with positive effects on adherence, medicines use, clinical outcomes and knowledge, but with mixed effects in some studies;· financial incentives: with positive, but mixed, effects on adherence.Several strategies also showed promise in promoting immunisation uptake, but require further study to be more certain of their effects. These included organisational interventions; reminders and recall; financial incentives; home visits; free vaccination; lay health worker interventions; and facilitators working with physicians to promote immunisation uptake. Education and/or information strategies also showed some positive but even less consistent effects on immunisation uptake, and need further assessment of effectiveness and investigation of heterogeneity.There are many different potential pathways through which consumers' use of medicines could be targeted to improve outcomes, and simple interventions may be as effective as complex strategies. However, no single intervention assessed was effective to improve all medicines-use outcomes across all diseases, medicines, populations or settings.Even where interventions showed promise, the assembled evidence often only provided part of the picture: for example, simplified dosing regimens seem effective for improving adherence, but there is not yet sufficient information to identify an optimal regimen.In some instances interventions appear ineffective: for example, the evidence suggests that directly observed therapy may be generally ineffective for improving treatment completion, adherence or clinical outcomes.In other cases, interventions may have variable effects across outcomes. As an example, strategies providing information or education as single interventions appear ineffective to improve medicines adherence or clinical outcomes, but may be effective to improve knowledge; an important outcome for promoting consumers' informed medicines choices.Despite a doubling in the number of reviews included in this updated overview, uncertainty still exists about the effectiveness of many interventions, and the evidence on what works remains sparse for several populations, including children and young people, carers, and people with multimorbidity. AUTHORS' CONCLUSIONS This overview presents evidence from 75 reviews that have synthesised trials and other studies evaluating the effects of interventions to improve consumers' medicines use.Systematically assembling the evidence across reviews allows identification of effective or promising interventions to improve consumers' medicines use, as well as those for which the evidence indicates ineffectiveness or uncertainty.Decision makers faced with implementing interventions to improve consumers' medicines use can use this overview to inform decisions about which interventions may be most promising to improve particular outcomes. The intervention taxonomy may also assist people to consider the strategies available in relation to specific purposes, for example, gaining skills or being involved in decision making. Researchers and funders can use this overview to identify where more research is needed and assess its priority. The limitations of the available literature due to the lack of evidence for important outcomes and important populations, such as people with multimorbidity, should also be considered in practice and policy decisions.
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Affiliation(s)
- Rebecca Ryan
- Centre for Health Communication and Participation, School of Public Health and Human Biosciences, La Trobe University, Bundoora, VIC, Australia, 3086
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Szuszkiewicz-Garcia MM, Davidson JA. Cardiovascular disease in diabetes mellitus: risk factors and medical therapy. Endocrinol Metab Clin North Am 2014; 43:25-40. [PMID: 24582090 DOI: 10.1016/j.ecl.2013.09.001] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Cardiovascular disease is a serious complication of diabetes mellitus. In the last 2 decades, great strides have been made in reducing microvascular complications in patients with diabetes through improving glycemic control. Decreasing rates of cardiovascular events have proved to be more difficult than simply intensifying the management of hyperglycemia. A tremendous effort has been made to deepen understanding of cardiovascular disease in diabetes and to formulate the best treatment approach. This review summarizes the current state of knowledge and discusses areas of uncertainty in the care of patients with diabetes who are at risk for cardiovascular disease.
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Affiliation(s)
- Magdalene M Szuszkiewicz-Garcia
- Division of Endocrinology and Metabolism, Center for Human Nutrition, Department of Medicine, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390-8857, USA.
| | - Jaime A Davidson
- Division of Endocrinology, Diabetes and Metabolism, Touchstone Diabetes Center, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard K5.246, Dallas, TX 75390, USA
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Landman GWD, de Bock GH, van Hateren KJJ, van Dijk PR, Groenier KH, Gans ROB, Houweling ST, Bilo HJG, Kleefstra N. Safety and efficacy of gliclazide as treatment for type 2 diabetes: a systematic review and meta-analysis of randomized trials. PLoS One 2014; 9:e82880. [PMID: 24533045 PMCID: PMC3922704 DOI: 10.1371/journal.pone.0082880] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2013] [Accepted: 10/28/2013] [Indexed: 11/23/2022] Open
Abstract
Objective and Design Gliclazide has been associated with a low risk of hypoglycemic episodes and beneficial long-term cardiovascular safety in observational cohorts. The aim of this study was to assess in a systematic review and meta-analysis of randomized controlled trials the safety and efficacy of gliclazide compared to other oral glucose-lowering agents (PROSPERO2013:CRD42013004156) Data Sources Medline, EMBASE, Clinicaltrials.gov, Trialregister.nl, Clinicaltrialsregister.eu and the Cochrane database. Selection Included were randomized studies of at least 12 weeks duration with the following outcomes: HbA1c change, incidence of severe hypoglycemia, weight change, cardiovascular events and/or mortality when comparing gliclazide with other oral blood glucose lowering drugs. Bias was assessed with the Cochrane risk of bias tool. The inverse variance random effects model was used. Results Nineteen trials were included; 3,083 patients treated with gliclazide and 3,155 patients treated with other oral blood glucose lowering drugs. There was a considerable amount of heterogeneity between and bias in studies. Compared to other glucose lowering agents except metformin, gliclazide was slightly more effective (−0.13% (95%CI: −0.25, −0.02, I2 55%)). One out of 2,387 gliclazide users experienced a severe hypoglycemic event, whilst also using insulin. There were 25 confirmed non-severe hypoglycemic events (2.2%) in 1,152 gliclazide users and 22 events (1.8%) in 1,163 patients in the comparator group (risk ratio 1.09 (95% CI: 0.20, 5.78, I2 77%)). Few studies reported differences in weight and none were designed to evaluate cardiovascular outcomes. Conclusions The methodological quality of randomized trials comparing gliclazide to other oral glucose lowering agents was poor and effect estimates on weight were limited by publication bias. The number of severe hypoglycemic episodes was extremely low, and gliclazide appears at least equally effective compared to other glucose lowering agents. None of the trials were designed for evaluating cardiovascular outcomes, which warrants attention in future randomized trials.
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Affiliation(s)
| | - Geertruide H. de Bock
- Department of Epidemiology, University Medical Centre Groningen, Groningen, The Netherlands
| | | | | | - Klaas H. Groenier
- Department of General Practice, University Medical Centre Groningen, Groningen, The Netherlands
| | - Rijk O. B. Gans
- Department Internal Medicine, University Medical Centre Groningen, Groningen, The Netherlands
| | | | - Henk J. G. Bilo
- Diabetes Centre Zwolle, Zwolle, The Netherlands
- Department Internal Medicine, University Medical Centre Groningen, Groningen, The Netherlands
- Department of Internal Medicine, Isala Clinics, Zwolle, The Netherlands
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31
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Fernando ME, Seneviratne RM, Cunningham M, Lazzarini PA, Sangla KS, Tan YM, Buttner PG, Golledge J. Intensive versus conventional glycaemic control for treating diabetic foot ulcers. Cochrane Database Syst Rev 2013. [DOI: 10.1002/14651858.cd010764] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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Elley CR, Robinson T, Moyes SA, Kenealy T, Collins J, Robinson E, Orr-Walker B, Drury PL. Derivation and validation of a renal risk score for people with type 2 diabetes. Diabetes Care 2013; 36:3113-20. [PMID: 23801726 PMCID: PMC3781509 DOI: 10.2337/dc13-0190] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Diabetes has become the leading cause of end-stage renal disease (ESRD). Renal risk stratification could assist in earlier identification and targeted prevention. This study aimed to derive risk models to predict ESRD events in type 2 diabetes in primary care. RESEARCH DESIGN AND METHODS The nationwide derivation cohort included adults with type 2 diabetes from the New Zealand Diabetes Cohort Study initially assessed during 2000-2006 and followed until December 2010, excluding those with pre-existing ESRD. The outcome was fatal or nonfatal ESRD event (peritoneal dialysis or hemodialysis for ESRD, renal transplantation, or death from ESRD). Risk models were developed using Cox proportional hazards models, and their performance was assessed in a separate validation cohort. RESULTS The derivation cohort included 25,736 individuals followed for up to 11 years (180,497 person-years; 86% followed for ≥5 years). At baseline, mean age was 62 years, median diabetes duration 5 years, and median HbA1c 7.2% (55 mmol/mol); 37% had albuminuria; and median estimated glomerular filtration rate (eGFR) was 77 mL/min/1.73 m2. There were 637 ESRD events (2.5%) during follow-up. Models that included sex, ethnicity, age, diabetes duration, albuminuria, serum creatinine, systolic blood pressure, HbA1c, smoking status, and previous cardiovascular disease status performed well with good discrimination and calibration in the derivation cohort and the validation cohort (n=5,877) (C-statistics 0.89-0.92), improving predictive performance compared with previous models. CONCLUSIONS These 5-year renal risk models performed very well in two large primary care populations with type 2 diabetes. More accurate risk stratification could facilitate earlier intervention than using eGFR and/or albuminuria alone.
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Abstract
High glucose concentrations are independent risk factors for many serious disorders. Glucose lowering can reduce or prevent many of these disorders. The mechanisms that cause glucose-linked tissue damage are unclear; however, the sequence of tissue changes that lead to one of these consequences (ie, retinopathy) have been understood for decades because the retina can be easily inspected and changes in its vascular supply can easily be assessed. The possibility that the long-term harms of raised glucose concentrations are mediated through reduced capillary perfusion (ie, vasculopenia) is suggested by strong epidemiological links between capillary abnormalities in the retina and most of the complications of diabetes, a delay between the therapeutic effect of glucose lowering in the retina and in other tissues, laboratory evidence that atherosclerosis is promoted by abnormalities in the capillary-rich vasa vasorum of conductance vessels, and similarities in capillary abnormalities in the retina and the kidney of people with diabetes. These findings also suggest that the retina might be a window through which the effect of raised glucose concentrations on a wide range of tissues can be seen. If continuing research lends support to this theory, treatments that counteract the effect of glucose on capillaries such as those in the retina might ultimately also reduce other serious consequences of dysglycaemia.
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Affiliation(s)
- Hertzel C Gerstein
- Department of Medicine, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada; Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada.
| | - Geoff H Werstuck
- Thrombosis and Atherosclerosis Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada
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Bailey CJ, Aschner P, Del Prato S, LaSalle J, Ji L, Matthaei S. Individualized glycaemic targets and pharmacotherapy in type 2 diabetes. Diab Vasc Dis Res 2013; 10:397-409. [PMID: 23711582 DOI: 10.1177/1479164113490765] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
The Global Partnership for Effective Diabetes Management, established to provide practical guidance to improve patient outcomes in diabetes, has developed and modified recommendations to improve glycaemic control in type 2 diabetes. The Global Partnership advocates an individualized therapeutic approach and, as part of the process to customize therapy, has previously identified specific type 2 diabetes patient subgroups that require special consideration. This article builds on earlier publications, expanding the scope of practical guidance to include newly diagnosed individuals with complications and women with diabetes in pregnancy. Good glycaemic control remains the cornerstone of managing type 2 diabetes, and plays a vital role in preventing or delaying the onset and progression of diabetic complications. Individualizing therapeutic goals and treatments to meet glycaemic targets safely and without delay remains paramount, in addition to a wider programme of care to reduce cardiovascular risk factors and improve patient outcomes.
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Affiliation(s)
- Clifford J Bailey
- Diabetes Research, School of Life & Health Sciences, Aston University, Birmingham, UK.
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Abstract
Accelerated atherosclerosis and its long-term sequelae are a major cause of late mortality among patients with systemic lupus erythematosus (SLE). Traditional Framingham risk factors such as hypertension, hypercholesterolemia, diabetes, and smoking do not account in entirety for this risk. SLE specific factors like disease activity and duration, use of corticosteroids, presence of antiphospholipid antibodies, and others are important risk factors. SLE is considered a coronary heart disease; equivalent and aggressive management of all traditional risk factors is recommended. Despite their role in primary and secondary prevention in the general population, statins seem to have no effect on cardiovascular outcomes in adult or pediatric SLE populations. The use of hydroxychloroquine has a cardioprotective effect, and mycophenolate mofetil may reduce cardiovascular events based on basic science data and data from the transplant population. The role of vitamin D supplementation and treatment of hyperhomocysteinemia remain controversial, but due to the safety of therapy and the potential benefit, they remain as optional therapies.
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Affiliation(s)
- George Stojan
- Division of Rheumatology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
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Ng CJ, Liew SM, Vethakkan SR, Abdullah A, Teng CL. Patient-adjusted versus health professional-adjusted insulin dosing for type 2 diabetes mellitus. Hippokratia 2013. [DOI: 10.1002/14651858.cd010574] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Chirk Jenn Ng
- University of Malaya; Department of Primary Care Medicine; Faculty of Medicine Kuala Lumpur Malaysia Kuala
| | - Su May Liew
- University of Malaya; Department of Primary Care Medicine; Faculty of Medicine Kuala Lumpur Malaysia Kuala
| | - Shireene R Vethakkan
- University of Malaya; Department of Primary Care Medicine; Faculty of Medicine Kuala Lumpur Malaysia Kuala
| | - Adina Abdullah
- University of Malaya; Department of Primary Care Medicine; Faculty of Medicine Kuala Lumpur Malaysia Kuala
| | - Cheong Lieng Teng
- International Medical University Jalan Rasah; Department of Family Medicine; Seremban Negeri Sembilan Darul Khusus Malaysia 70300
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American Geriatrics Society identifies five things that healthcare providers and patients should question. J Am Geriatr Soc 2013; 61:622-31. [PMID: 23469880 PMCID: PMC3786213 DOI: 10.1111/jgs.12226] [Citation(s) in RCA: 79] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Given the American Geriatrics Society's (AGS) commitment to improving health care for older adults by, among other means, educating older people and their caregivers about their health and healthcare choices, the AGS was delighted when, in late 2011, the American Board of Internal Medicine Foundation invited the Society to join its "Choosing Wisely(®) " campaign. Choosing Wisely is designed to engage patients, healthcare professionals, and family caregivers in discussions about the safety and appropriateness of medical tests, medications, and procedures. Ideally, these discussions should examine whether the tests and procedures are evidence-based, whether any risks they pose might overshadow their potential benefits, whether they are redundant, and whether they are truly necessary. In addition to improving the quality of care, the initiative aims to rein in unneeded healthcare spending. According to a 2008 Congressional Budget Office report, as much as 30% of healthcare spending in the United States may be unnecessary.
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Giorgino F, Leonardini A, Laviola L. Cardiovascular disease and glycemic control in type 2 diabetes: now that the dust is settling from large clinical trials. Ann N Y Acad Sci 2013; 1281:36-50. [PMID: 23387439 PMCID: PMC3715107 DOI: 10.1111/nyas.12044] [Citation(s) in RCA: 67] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
The relationship between glucose control and cardiovascular outcomes in type 2 diabetes has been a matter of controversy over the years. Although epidemiological evidence exists in favor of an adverse role of poor glucose control on cardiovascular events, intervention trials have been less conclusive. The Action to Control Cardiovascular Risk in Diabetes (ACCORD) study, the Action in Diabetes and Vascular Disease (ADVANCE) study, and the Veterans Affairs Diabetes Trial (VADT) have shown no beneficial effect of intensive glucose control on primary cardiovascular endpoints in type 2 diabetes. However, subgroup analysis has provided evidence suggesting that the potential beneficial effect largely depends on patients’ characteristics, including age, diabetes duration, previous glucose control, presence of cardiovascular disease, and risk of hypoglycemia. The benefit of strict glucose control on cardiovascular outcomes and mortality may be indeed hampered by the extent and frequency of hypoglycemic events and could be enhanced if glucose-lowering medications, capable of exerting favorable effects on the cardiovascular system, were used. This review examines the relationship between intensive glucose control and cardiovascular outcomes in type 2 diabetes, addressing the need for individualization of glucose targets and careful consideration of the benefit/risk profile of antidiabetes medications.
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Affiliation(s)
- Francesco Giorgino
- Department of Emergency and Organ Transplantation, Section of Internal Medicine, Endocrinology, Andrology and Metabolic Diseases, University of Bari Aldo Moro, Bari, Italy.
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Ooi CP, Loke SC. Bromocriptine for type 2 diabetes mellitus. Hippokratia 2013. [DOI: 10.1002/14651858.cd010319] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Cheow Peng Ooi
- Faculty of Medicine and Health Sciences, Universiti Putra Malaysia; Endocrine Unit, Department of Medicine; Serdang Selangor DE Malaysia 43400
| | - Seng Cheong Loke
- Universiti Putra Malaysia; Institute of Gerontology; Serdang Selangor DE Malaysia 43400
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Joshi PH, Kalyani RR, Blumenthal RS, Donner TW. Cardiovascular effects of noninsulin, glucose-lowering agents: need for more outcomes data. Am J Cardiol 2012; 110:32B-42B. [PMID: 23062565 DOI: 10.1016/j.amjcard.2012.08.030] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Macrovascular complications of type 2 diabetes mellitus (DM) are primarily driven by the combination of underlying atherosclerosis and propensity for thrombosis. Prevention of macrovascular complications in DM relies on therapies directed at multiple coexisting intermediary pathophysiologies that contribute to cardiovascular events, including hyperglycemia, lipoprotein abnormalities, hypertension, inflammation, and propensity for thrombosis. Multiple noninsulin, glucose-lowering agents have been developed that effectively lower blood glucose levels. This review explores the literature on the cardiovascular benefits and harms associated with these therapies, with an emphasis on cardiovascular outcomes when available. The lack of long-term data on cardiovascular outcomes regarding safety and efficacy of available traditional glucose-lowering agents has led to recommendations for more thorough evaluations of new therapies before approval. Furthermore, recent data suggest harm from intensive hemoglobin A(1c) reductions. Accordingly, there are multiple, large, cardiovascular-event driven phase 3-4 trials of therapies from the incretin axis currently enrolling. Recommendations for a therapeutic approach with noninsulin, glucose-lowering agents for the prevention of cardiovascular events in patients with type 2 DM are provided based on current data. Ultimately, multifactorial risk interventions, including lifestyle modifications, antihyperglycemic agents, antihypertensives, statins, and aspirin remain the primary focus to prevent macrovascular complications in patients with type 2 DM.
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Affiliation(s)
- Parag H Joshi
- Johns Hopkins Ciccarone Center for Prevention of Heart Disease, Johns Hopkins University School of Medicine, Baltimore, Maryland 21287, USA.
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Andersson C, van Gaal L, Caterson ID, Weeke P, James WPT, Coutinho W, Finer N, Sharma AM, Maggioni AP, Torp-Pedersen C. Relationship between HbA1c levels and risk of cardiovascular adverse outcomes and all-cause mortality in overweight and obese cardiovascular high-risk women and men with type 2 diabetes. Diabetologia 2012; 55:2348-55. [PMID: 22638548 DOI: 10.1007/s00125-012-2584-3] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2011] [Accepted: 04/11/2012] [Indexed: 12/25/2022]
Abstract
AIMS/HYPOTHESIS The optimal HbA(1c) concentration for prevention of macrovascular complications and deaths in obese cardiovascular high-risk patients with type 2 diabetes remains to be established and was therefore studied in this post hoc analysis of the Sibutramine Cardiovascular OUTcomes (SCOUT) trial, which enrolled overweight and obese patients with type 2 diabetes and/or cardiovascular disease. METHODS HRs for meeting the primary endpoint (nonfatal myocardial infarction, nonfatal stroke, resuscitated cardiac arrest or cardiovascular death) and all-cause mortality were analysed using Cox regression models. RESULTS Of 8,252 patients with type 2 diabetes included in SCOUT, 7,479 had measurements of HbA(1c) available at baseline (i.e. study randomisation). Median age was 62 years (range 51-86 years), median BMI was 34.0 kg/m(2) (24.8-65.1 kg/m(2)) and 44% were women. The median HbA(1c) concentration was 7.2% (3.8-15.9%) (55 mmol/l [18-150 mmol/l]) and median diabetes duration was 7 years (0-57 years). For each 1 percentage point HbA(1c) increase, the adjusted HR for the primary endpoint was 1.17 (95% CI 1.11, 1.23); no differential sex effect was observed (p = 0.12 for interaction). In contrast, the risk of all-cause mortality was found to be greater in women than in men: HR 1.22 (1.10, 1.34) vs 1.12 (1.04, 1.20) for each 1 percentage point HbA(1c) increase (p = 0.02 for interaction). There was no evidence of increased risk associated with HbA(1c) ≤ 6.4% (≤ 46 mmol/l). Glucose-lowering treatment regimens, diabetes duration or a history of cardiovascular disease did not modify the associations. CONCLUSIONS/INTERPRETATION In overweight, cardiovascular high-risk patients with type 2 diabetes, increasing HbA(1c) concentrations were associated with increasing risks of cardiovascular adverse outcomes and all-cause mortality.
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Affiliation(s)
- C Andersson
- Department of Cardiology, Gentofte University Hospital of Copenhagen, Niels Andersens vej 65, 2900 Hellerup, Denmark.
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Middleton P, Crowther CA, Simmonds L. Different intensities of glycaemic control for pregnant women with pre-existing diabetes. Cochrane Database Syst Rev 2012; 8:CD008540. [PMID: 22895976 PMCID: PMC4164477 DOI: 10.1002/14651858.cd008540.pub3] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND The optimal glycaemic control target in pregnant women with pre-existing diabetes is unclear, although there is a clear link between high glucose concentrations and adverse birth outcomes. OBJECTIVES To assess the effects of different intensities of glycaemic control in pregnant women with pre-existing type 1 or type 2 diabetes. SEARCH METHODS We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 April 2012). SELECTION CRITERIA We included randomised controlled trials comparing different glycaemic control targets in pregnant women with pre-existing diabetes. DATA COLLECTION AND ANALYSIS Two review authors assessed trial eligibility and risk of bias, and extracted data. MAIN RESULTS We included three trials all in women with type 1 diabetes (223 women and babies), and all with a high risk of bias. Two trials compared very tight (3.33 to 5.0 mmol/L fasting blood glucose (FBG)) with tight-moderate (4.45 to 6.38) glycaemic control targets, with one trial of 22 babies reporting no perinatal deaths or serious perinatal morbidity. In the same trial, there were two birth defects in the very tight and none in the tight-moderate group with no significant differences in caesarean section between groups (risk ratio 0.92, 95% confidence interval (CI) 0.49 to 1.73). In these two trials glycaemic control was not significantly different between the very tight and tight-moderate groups by the third trimester, although one trial of 22 women found significantly less maternal hypoglycaemia in the tight-moderate group.In a trial of 60 women and babies comparing tight (≤ 5.6 mmol/L FBG); moderate (5.6 to 6.7); and loose (6.7 to 8.9) glycaemic control targets, there were two neonatal deaths in the loose and none in the tight or moderate groups. There were significantly fewer women with pre-eclampsia, fewer caesareans and fewer birthweights greater than 90th centile in the combined tight-moderate compared with the loose group. AUTHORS' CONCLUSIONS In a very limited body of evidence, few differences in outcomes were seen between very tight and tight-moderate glycaemic control targets in pregnant women with pre-existing type 1 diabetes, including actual glycaemic control achieved. There is evidence of harm (increased pre-eclampsia, caesareans and birthweights greater than 90th centile) for 'loose' control (FBG above 7 mmol/L). Future trials comparing interventions, rather than glycaemic control targets, may be more feasible particularly for pregnant women with type 2 diabetes.
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Affiliation(s)
- Philippa Middleton
- ARCH: Australian Research Centre for Health of Women and Babies, Discipline of Obstetrics and Gynaecology, Robinson Institute,The University of Adelaide, Adelaide, Australia..
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Cohen RV, Pinheiro JC, Schiavon CA, Salles JE, Wajchenberg BL, Cummings DE. Effects of gastric bypass surgery in patients with type 2 diabetes and only mild obesity. Diabetes Care 2012; 35:1420-8. [PMID: 22723580 PMCID: PMC3379595 DOI: 10.2337/dc11-2289] [Citation(s) in RCA: 189] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Roux-en-Y gastric bypass (RYGB) ameliorates type 2 diabetes in severely obese patients through mechanisms beyond just weight loss, and it may benefit less obese diabetic patients. We determined the long-term impact of RYGB on patients with diabetes and only class I obesity. RESEARCH DESIGN AND METHODS Sixty-six consecutively selected diabetic patients with BMI 30-35 kg/m(2) underwent RYGB in a tertiary-care hospital and were prospectively studied for up to 6 years (median 5 years [range 1-6]), with 100% follow-up. Main outcome measures were safety and the percentage of patients experiencing diabetes remission (HbA(1c) <6.5% without diabetes medication). RESULTS Participants had severe, longstanding diabetes, with disease duration 12.5 ± 7.4 years and HbA(1c) 9.7 ± 1.5%, despite insulin and/or oral diabetes medication usage in everyone. For up to 6 years following RYGB, durable diabetes remission occurred in 88% of cases, with glycemic improvement in 11%. Mean HbA(1c) fell from 9.7 ± 1.5 to 5.9 ± 0.1% (P < 0.001), despite diabetes medication cessation in the majority. Weight loss failed to correlate with several measures of improved glucose homeostasis, consistent with weight-independent antidiabetes mechanisms of RYGB. C-peptide responses to glucose increased substantially, suggesting improved β-cell function. There was no mortality, major surgical morbidity, or excessive weight loss. Hypertension and dyslipidemia also improved, yielding 50-84% reductions in predicted 10-year cardiovascular disease risks of fatal and nonfatal coronary heart disease and stroke. CONCLUSIONS This is the largest, longest-term study examining RYGB for diabetic patients without severe obesity. RYGB safely and effectively ameliorated diabetes and associated comorbidities, reducing cardiovascular risk, in patients with a BMI of only 30-35 kg/m(2).
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Affiliation(s)
- Ricardo V Cohen
- The Center of Excellence in Bariatric and Metabolic Surgery, Oswaldo Cruz Hospital, São Paulo, Brazil
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Abstract
Diabetes and ischaemic stroke often arise together. People with diabetes have more than double the risk of ischaemic stroke after correction for other risk factors, relative to individuals without diabetes. Multifactorial treatment of risk factors for stroke-in particular, lifestyle factors, hypertension, and dyslipidaemia-will prevent a substantial number of these disabling strokes. Hyperglycaemia occurs in 30-40% of patients with acute ischaemic stroke, also in individuals without a known history of diabetes. Admission hyperglycaemia is associated with poor functional outcome, possibly through aggravation of ischaemic damage by disturbing recanalisation and increasing reperfusion injury. Uncertainty surrounds the question of whether glucose-lowering treatment for early stroke can improve clinical outcome. Achievement of normoglycaemia in the early stage of stroke can be difficult, and the possibility of hypoglycaemia remains a concern. Phase 3 studies of glucose-lowering therapy in acute ischaemic stroke are underway.
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Zhang HM, Dang H, Kamat A, Yeh CK, Zhang BX. Geldanamycin derivative ameliorates high fat diet-induced renal failure in diabetes. PLoS One 2012; 7:e32746. [PMID: 22412919 PMCID: PMC3295767 DOI: 10.1371/journal.pone.0032746] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2011] [Accepted: 02/01/2012] [Indexed: 11/25/2022] Open
Abstract
Diabetic nephropathy is a serious complication of longstanding diabetes and its pathogenesis remains unclear. Oxidative stress may play a critical role in the pathogenesis and progression of diabetic nephropathy. Our previous studies have demonstrated that polyunsaturated fatty acids (PUFA) induce peroxynitrite generation in primary human kidney mesangial cells and heat shock protein 90β1 (hsp90β1) is indispensable for the PUFA action. Here we investigated the effects of high fat diet (HFD) on kidney function and structure of db/db mice, a widely used rodent model of type 2 diabetes. Our results indicated that HFD dramatically increased the 24 h-urine output and worsened albuminuria in db/db mice. Discontinuation of HFD reversed the exacerbated albuminuria but not the increased urine output. Prolonged HFD feeding resulted in early death of db/db mice, which was associated with oliguria and anuria. Treatment with the geldanamycin derivative, 17-(dimethylaminoehtylamino)-17-demethoxygeldanamycin (17-DMAG), an hsp90 inhibitor, preserved kidney function, and ameliorated glomerular and tubular damage by HFD. 17-DMAG also significantly extended survival of the animals and protected them from the high mortality associated with renal failure. The benefit effect of 17-DMAG on renal function and structure was associated with a decreased level of kidney nitrotyrosine and a diminished kidney mitochondrial Ca2+ efflux in HFD-fed db/db mice. These results suggest that hsp90β1 is a potential target for the treatment of nephropathy and renal failure in diabetes.
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Affiliation(s)
- Hong-Mei Zhang
- Department of Clinical Oncology, Xijing Hospital, The Fourth Military Medical University, Xi'an, China
- Department of Medicine, Health Science Center, University of Texas, San Antonio, Texas, United States of America
| | - Howard Dang
- Department of Comprehensive Dentistry, Health Science Center, University of Texas, San Antonio, Texas, United States of America
| | - Amrita Kamat
- Department of Medicine, Health Science Center, University of Texas, San Antonio, Texas, United States of America
- Audie L. Murphy Division, Geriatric Research, Education and Clinical Center, South Texas Veterans Health Care System, San Antonio, Texas, United States of America
| | - Chih-Ko Yeh
- Department of Comprehensive Dentistry, Health Science Center, University of Texas, San Antonio, Texas, United States of America
- Audie L. Murphy Division, Geriatric Research, Education and Clinical Center, South Texas Veterans Health Care System, San Antonio, Texas, United States of America
| | - Bin-Xian Zhang
- Department of Medicine, Health Science Center, University of Texas, San Antonio, Texas, United States of America
- Department of Comprehensive Dentistry, Health Science Center, University of Texas, San Antonio, Texas, United States of America
- Audie L. Murphy Division, Geriatric Research, Education and Clinical Center, South Texas Veterans Health Care System, San Antonio, Texas, United States of America
- * E-mail:
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