Long-term HbA1c variability and macro-/micro-vascular complications in type 2 diabetes mellitus: a meta-analysis update

The association between duration of metformin and sulfonylurea treatment and microvascular complications in patients with incident type 2 diabetes: a pooled cohort analysis

Objectives

The effect of the duration of medication with metformin and sulfonylurea (SUs) on microvascular complications based on the duration of type 2 diabetes (DM2) is unclear. The aim of this study was to investigate the association of medication time with metformin and SUs and microvascular complications in newly diagnosed DM2 patients.

Methods

In this prospective multi-cohort study, data from 3,904 newly diagnosed DM from three cohorts of the Tehran Lipid and Glucose Study (TLGS), the Multi-Ethnic Study of Atherosclerosis (MESA), and the Atherosclerosis Risk in Communities (ARIC) with a mean age of 59.6 ± 08 years were pooled. Metformin medication time alone, SUs alone, and a combination of both since drug initiation were defined as exposure. The incidence of microvascular complications (diabetic nephropathy or retinopathy) was defined as outcomes. The cumulative exposure to metformin, SUs, aspirin, statin, and anti-hypertensive medication was also determined using the same approach.

Results

Metformin alone, SUs alone, and the combination of both reduced the hazard of microvascular complications by 8%(HRAdj: 0.92, 95% CI: 0.89, 0.96, P: 0.001), 6%(HRAdj: 0.94, 95% CI: 0.92, 0.97, P: 0.004), and 9%(HRAdj: 0.91, 95% CI: 0.89, 0.94, P: 0.001) for each year of use, respectively (p < 0.05). The protective effect of metformin and SUs, individually or in combination, on microvascular complications started approximately five years after the initial treatment and continued until approximately 15 years after the initial treatment and then reached a plato.

Conclusion

long-term use of metformin and SUs individually and in combination was associated with a decrease in the risk of microvascular outcomes in newly diagnosed DM for up to about one decade. These findings highlight the importance of choosing an appropriate treatment regimen for new patients with type 2 diabetes. Appropriate oral therapy can minimize microvascular complications and improve overall well-being.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40200-025-01577-w.

Long-term glycemic variability and the risk of cardiovascular diseases in type 2 diabetic patients: Effect of hypothetical interventions using parametric g-formula in a population-based historical cohort study

BACKGROUND

Harmful effects of long-term HbA1c and fasting plasma glucose (FPG) variability on cardiovascular diseases (CVD) have not been causally examined. We employed a parametric g-formula to estimate the causal effect of HbA1C and fasting plasma glucose (FPG) variability on CVD.

METHODS

This retrospective cohort study was conducted on 2078 patients with type 2 diabetes who were free of CVD and aged >18 years at the entrance to the clinic (2017-2022), with at least three HbA1c and FPG measurements. Variability was calculated using standard deviation (SD), and coefficient of variation (CV). We used the parametric g-formula to estimate the 5-year risk, risk ratio, and risk difference of CVD under different deciles of HbA1c-SD/CV, FPG-SD/CV, HbA1C levels (≤5%, 5 to ≤7%, and >7), and joint exposure to different deciles of HbA1c-SD and HbA1c values, adjusted for time-varying confounders that are affected by prior exposure.

RESULTS

The observed and simulated 5-year risk of CVD under no intervention were 11.6% (95% CI: 10.3, 13.1) and 11.03% (95% CI: 10.2, 12.6) for HbA1C-SD model. The estimated 5-year risk of CVD was increased from the 8.01% (95% CI: 7.5, 10.1%) in the first decile to 15.2% (95% CI: 14.1, 17.7%) in the tenth decile of HbA1c-SD. The results for FPG-SD were similar. Within the stable level of HbA1c (5 to ≤7%) the risk ratio increased from 1.37 (95% CI: 1.19, 1.48) in the first decile to 2.76 (95% CI: 2.06, 3.09) in the tenth decile of HbA1c-SD. Under a joint intervention of HbA1c <5% and the first decile of HbA1c-SD, CVD risk decreased by 6.4% (95%CI: 4.9, 7.3%) compared to the natural course.

CONCLUSIONS

Even within a stable HbA1c level, long-term glycemic variability may be a strong predictor of CVD.

Impact of Pharmacist Interventions on Health Outcomes of Patients with Type 2 Diabetes Mellitus in the Middle East: A Systematic Review

This systematic review aimed to evaluate the association between pharmacists' interventions and health outcomes of patients with type 2 Diabetes Mellitus (DM) in the Middle East. A comprehensive database search was conducted in July 2024 using the electronic databases of PubMed, MEDLINE, Embase, Cochrane Library, Web of Science and Scopus. The search strategy involved the following keywords: "Impact", "Effect", "Pharmacist", "Pharmacy services", "Pharmaceutical Care", "Intervention", "Type 2 diabetes mellitus", "diabetes", and "Middle East". Articles published in the English language between January 2010 and July 2024 related to the research question were included. The data extracted from the included papers were summarized using narrative data synthesis. Twelve articles were selected from 536 retrieved articles, with most studies conducted in hospitals (n = 10) and randomized clinical trials (n = 8). The quality of studies was evaluated using the Cochrane risk of bias tool for RCTs and the Newcastle-Ottawa Scale for non-randomized studies to ensure transparent evaluation of the study quality. Narrative synthesis was employed to address variations in study design, outcomes, and biases. Pharmacist interventions reported included patient education (n = 11), counseling (n = 5), drug therapy initiation (n = 5), and dosage adjustment (n = 5). Studies reported significant reductions in glycosylated (HbA1c) (range: 1.4-1.78%) and fasting blood glucose levels (FBG) (range: 2.3-53 mg/dL), decreased systolic and diastolic blood pressure (range: 4.65-14.9 mmHg), body mass index (BMI) (range: 1-2.44 kg/m2), cholesterol, triglycerides, and total cholesterol, and improved medication adherence, self-care activities, and knowledge of diabetes management. In this review, pharmacist interventions reported were associated with improved clinical and humanistic outcomes among type 2 DM patients in the Middle-East. Therefore, collaborative care models involving pharmacists and other healthcare practitioners in the management of type 2 DM should be considered by health policymakers in the region.

The impact of diabetes duration and glycemic control on ejection fraction in heart failure patients

AIM

The potential effects of diabetes duration and glycemic control on ejection fraction (EF) in patients with heart failure (HF) remain unclear. We investigated the impact of diabetes duration and glycemic control on ejection fraction (EF), alongside other risk factors, in HF patients with type 2 diabetes mellitus (T2DM).

MATERIALS AND METHODS

This single-center retrospective study included 1265 patients who were admitted and discharged with a diagnosis of HF between January 2010 and January 2022, all of whom had a known diagnosis of T2DM prior to admission. The patients included in the study were divided into two groups: those with heart failure and reduced ejection fraction (HFrEF, EF ≤ 40%) and those with or mid-range or preserved ejection fraction (HFmrEF + HFpEF, EF > 40%).

RESULTS

Among the 1265 patients, 697 had HFrEF. The duration of diabetes was significantly longer (13 vs. 7 years, p < 0.001) and HbA1c levels were higher (8.4 ± 1.6% vs. 7.7 ± 1.5%, p < 0.001) in the HFrEF group. Multivariable analysis identified diabetes duration (OR 2.23, p < 0.001), hypertension (OR:6.62, p < 0.001), and the use of oral antidiabetic agents (OR 0.74, p = 0.042) as independent predictors of reduced EF. Prolonged diabetes duration was associated with a reduction in EF (AUC = 0.780, p < 0.001). Conversely, although glycemic control was poorer in the HFrEF group, it was not an independent predictor of EF.

CONCLUSION

Prolonged diabetes duration significantly reduces EF, among HF patients with T2DM, independent of glycemic control and other risk factors. While poor glycemic control was more prevalent in HFrEF patients, it did not independently affect EF.

Copper exposure at a daily dose twice the recommended in diabetic rats induces oxidative stress, vascular dysfunction and perivascular adipose tissue inflammation in diabetic rats

Individuals with diabetes often have a heightened risk of cardiovascular diseases and present copper (Cu) metabolism imbalances. We investigated the effect of chronic exposure to twice the recommended daily dose of CuCl2 on vascular reactivity in isolated thoracic aorta segments of diabetic and non-diabetic rats. Eighty male Wistar rats, aged 12 weeks, were divided into four groups: Control (Ct), Copper (Cu), Diabetes Mellitus (DM), and Diabetes + Copper (DM+Cu). Type 1 diabetes was induced using a single dose of streptozotocin (65 mg/kg i.p), and the animals exposed to Cu received twice the recommended daily dose (25.7 µg/Kg/day CuCl2) for 30 days. After treatment, we investigated vascular reactivity and performed histological evaluations on samples of aortas and perivascular adipose tissue (PVAT). Our findings revealed pronounced weight loss and higher hyperglycemia in the DM+Cu group compared to DM, along with increased pro-inflammatory factors in PVAT (IL-6). Vascular reactivity to phenylephrine decreased without PVAT, accompanied by elevated vasodilator factors: NO and H2O2, and involvement of K+ channels. Additionally, we observed an increase in the thickness of the aorta wall, collagen deposition. In the presence of PVAT, vascular reactivity increased in the DM+Cu and Cu groups. These findings demonstrate that exposure to double the recommended Cu dose in diabetic animals leads to endothelial and PVAT dysfunction, associated with elevation of vasodilator and pro-inflammatory factors.

Glycemic Variability and Its Association with Traditional Glycemic Control Biomarkers in Patients with Type 1 Diabetes: A Cross-Sectional, Multicenter Study

Background/Objectives: Glycemic variability (GV) is a novel concept in the assessment of the quality of glycemic control in patients with diabetes, with its importance emphasized in patients with type 1 diabetes. Its adoption in clinical practice emerged with the increased availability of continuous glycemic monitoring systems. The aim of this study is to evaluate the GV in patients with type 1 diabetes mellitus (T1DM) and to assess its associations with other parameters used to evaluate the glycemic control. Methods: GV indexes and classical glycemic control markers were analyzed for 147 adult patients with T1DM in a multicentric cross-sectional study. Results: Stable glycemia was associated with a higher time in range (TIR) (78% vs. 63%; p < 0.001) and a lower HbA1c (6.8% vs. 7.1%; p = 0.006). The coefficient of variation (CV) was reversely correlated with TIR (Spearman's r = -0.513; p < 0.001) and positively correlated with hemoglobin A1c (HbA1c) (Spearman's r = 0.349; p < 0.001), while TIR was reversely correlated with HbA1c (Spearman's r = -0.637; p < 0.001). The composite GV and metabolic outcome was achieved by 28.6% of the patients. Conclusions: Stable glycemia was associated with a lower HbA1c, average and SD of blood glucose, and a higher TIR. A TIR higher than 70% was associated with a lower HbA1c, and SD and average blood glucose. Only 28.6% of the patients with T1DM achieved the composite GV and metabolic outcome, despite 53.7% of them achieving the HbA1c target, emphasizing thus the role of GV in the assessment of the glycemic control.

Prevalence and concomitance of diabetic peripheral sensory neuropathy and lower limb peripheral arterial disease in type II diabetics and its correlation with obesity

Introduction

Among type 2 diabetics (T2D), macrovascular complication lower limb Peripheral Arterial Disease (PAD) and microvascular complication Diabetic Peripheral Sensory Neuropathy (DPSN) have scarcely studied concordance and their association with obesity. Qualitative and general body fat parameters give a complete picture of obesity. We studied the association of vibration perception threshold (VPT)-based DSPN and ankle brachial pressure index (ABPI))-based PAD, and the effect of obesity on them, in T2Ds.

Methods

A cross-sectional study was done on 152 under-treatment T2Ds. Bio-esthesiometer-based VPT from the sole of each foot and VersaDop-based ABPI from all limbs were assessed. Prevalence of DSPN (VPT ≥25) and PAD (ABPI ≤0.9) was measured and compared for concomitance. The odds ratio was used for testing association and multiple linear regressions were accomplished for predictors of VPT and ABPI taking P value < 0.05 as statistically significant.

Results

T2Ds had a mean age of 53 years, a mean duration of 67 months, and 48% glycemic control. The prevalence of abnormal VPT and ABPI was 64% and 23%, respectively. VPT-based subgroups do not defer significantly from ABPI and vice versa. Obesity was associated with only abnormal ABPI (visceral > general). Odd's ratio for neuropathy with vasculopathy was insignificant while VPT and ABPI had differences in significant predictors.

Conclusion

T2Ds having 64% neuropathy and 23% vasculopathy had one-third concomitance but lack of association and different predictors for each. Vasculopathy not neuropathy was associated with obesity; visceral more than general; suggesting scope for its rectification. It suggests different progression of these complications, despite some cross-talk between them.

Differences in risk factor profiles for peripheral artery disease compared to coronary, cerebral and carotid artery

The aim of this study was to evaluate the greatest drivers for development of lower extremity peripheral artery disease (PAD) in relation to coronary, precerebral, or cerebral artery disease This prospective study (Malmö Diet and Cancer study) included 26,681 participants. The diagnosis of incident PAD, coronary artery disease (CoAD), atherothrombotic ischemic stroke (IS) free from atrial fibrillation or flutter, and carotid artery disease (CaAD) was validated. A modified Lunn-McNeil competing risk analysis was performed to compare the Hazard Ratio (HR) strength of PAD in relation to CoAD, IS, or CaAD. The estimated population attributable risk fractions (PAF) for each atherosclerotic manifestation were estimated by first fit an age and sex adjusted Cox proportional hazard regression, and then estimate the PAF using the Direct method. Male sex, age, and hypertension were risk factors for development of all atherosclerotic manifestations. Current smoking accounted for 45.6% (95% CI 41.1-47.2), 16.1%, 14.0%, and 23.3% of the risk for development of PAD, CoAD, IS, and CaAD, respectively. Hypertension was more associated with development of PAD than CoAD (p = 0.009). Smoking and diabetes mellitus were positively associated with all four manifestations, but these associations were significantly stronger for PAD than the other three manifestations. Smoking and diabetes mellitus had a larger impact on incident PAD than incident coronary, cerebral or precerebral artery manifestations. Since the lower extremity arteries are the easiest to access and examine, they may be considered as the first arterial bed to examine in patients at increased risk for atherosclerotic manifestations.

Continuous Glucose Monitoring in Comorbid Dementia and Diabetes: The Evidence So Far

BACKGROUND

Type 2 diabetes mellitus (T2DM) and dementia are two of the leading chronic diseases in aging and are known to influence each other's disease progression. There is well-established evidence that T2DM increases the risk for cognitive decline and dementia. At the same time, people with cognitive changes or dementia can find it difficult to manage their diabetes, resulting in hyper- or hypoglycemic events which can exacerbate the dementia disease progression further. Monitoring of glucose variability is, therefore, of critical importance during aging and when people with T2DM develop dementia. The advent of continuous glucose monitoring (CGM) has allowed the monitoring of glucose variability in T2DM more closely. The CGM seems to be highly feasible and acceptable to use in older people with T2DM and has been shown to significantly reduce their hypoglycemic events, often resulting in falls. Less is known as to whether CGM can have a similar beneficial effect on people with T2DM who have cognitive impairment or dementia in community or hospital settings.

AIMS

The current perspective will explore how CGM has made an impact on T2DM management in older people and those with comorbid cognitive impairment or dementia. We will further explore opportunities and challenges of using CGM in comorbid T2DM and dementia in community and hospital settings.

The association of glycaemic risk factors and diabetes duration with risk of heart failure in people with type 2 diabetes: A systematic review and meta-analysis

AIMS

To conduct a systematic review in order to better understand the association of glycaemic risk factors and diabetes duration with risk of heart failure (HF) in individuals with type 2 diabetes (T2D).

METHODS

We identified longitudinal studies investigating the association of glycaemic factors (glycated haemoglobin [HbA1c], HbA1c variability, and hypoglycaemia) and diabetes duration with HF in individuals with T2D. Hazard ratios and odds ratios were extracted and meta-analysed using a random-effects model where appropriate. Risk of bias assessment was carried out using a modified Newcastle-Ottawa Scale. Egger's test along with the trim-and-fill method were used to assess and account for publication bias.

RESULTS

Forty studies representing 4 102 589 people met the inclusion criteria. The risk of developing HF significantly increased by 15% for each percentage point increase in HbA1c, by 2% for each additional year of diabetes duration, and by 43% for having a history of severe hypoglycaemia. Additionally, variability in HbA1c levels was associated with a 20%-26% increased risk of HF for each unit increase in the metrics of variability (HbA1c standard deviation, coefficient of variation, and average successive variability). All included studies scored high in the risk of bias assessment. Egger's test suggested publication bias, with trim-and-fill analyses revealing a significant 14% increased risk of HF per percentage point increase in HbA1c.

CONCLUSIONS

Glycaemic risk factors and diabetes duration significantly contribute to the heightened risk of HF among individuals with T2D. A reduction in risk of HF is anticipated with better management of glycaemic risk factors.

Antidiabetic potential of thiazolidinedione derivatives with efficient design, molecular docking, structural activity relationship, and biological activity: an update review (2021-2023)

Thiazolidinedione has been used successfully by medicinal chemists all over the world in the development of potent antidiabetic derivatives. The few compounds with excellent antidiabetic potency that we have identified in this review could be used as a lead for further research into additional antidiabetic mechanisms. The information provided in this review regarding the design, biological activity, structure-activity relationships, and docking studies may be useful for scientists who wish to further explore this scaffold in order to fully utilize its biological potential and develop antidiabetic agents that would overcome the limitations of currently available medications for the treatment of diabetes. This review outlines the antidiabetic potential of Thiazolidinedione-based derivatives that have been published in the year 2021- till date.

Time to development of macrovascular complications and its predictors among type 2 diabetes mellitus patients at Jimma University Medical Center

BACKGROUND

Type 2 diabetes mellitus is a serious metabolic disease that is often associated with vascular complications. The increasing prevalence of type 2 diabetes mellitus poses significant public health challenges, particularly in Low and Middle-Income Countries where healthcare resources are often limited. In Africa, the burden of T2DM is rising rapidly, leading to a consequential increase in macrovascular complications such as cardiovascular disease and stroke. These complications not only affect the quality of life but also significantly contribute to morbidity and mortality among affected individuals. The main objective of this study was to assess the time to development of macrovascular complications and identify its predictors among type 2 diabetes mellitus patients in Jimma University medical center from 2018-2022.

METHODS

Institutional-based retrospective follow-up study was conducted in Jimma University Medical Center among newly diagnosed type 2 diabetes mellitus patient from 2018, to 2022. A systematic sampling technique was used to recruit 452 records of type 2 diabetes mellitus patients. The Kaplan-Meier curve and the log-rank tests were used to determine the time to macro-vascular complications, and evaluate the significant difference in survival probability among predictors respectively. The overall goodness of the Cox proportional hazard model was checked by Cox-Snell residuals. Bivariable and multivariable cox-proportional hazard regression were used to identify the association between the variables and survival time.

RESULTS

The median survival time to development of macro vascular complications was 24 months. Urban residence [(Adjusted hazard ratio = 2.02; 95% CI: (1.33, 3.05)], having hypertension at start of diabetic treatment [(AHR = 1.52; 95% CI: (1.06, 2.13)], baseline age ≥ 60 years [(AHR = 4.42; 95% CI: (1.72, 11.29)], having dyslipidemia at baseline [(AHR = 1.82; 95% CI: (1.13, 2.93)], High density lipoprotein cholesterol levels < 40 mg/dl [(AHR = 2.11; (1.16, 3.81)], triglycerides > 150 mg/dl [(AHR = 1.48; 95% CI:( 1.02, 2.13)], Hemoglobin A1C level > 7% [(AHR = 1.49; 95% CI: (1.04, 2.14)], and Oral hypoglycemic agents + insulin [(AHR = 2.73; 95% CI: (1.81, 4.09)] were the significant predictors of the time to development of macro vascular complications.

CONCLUSION

Findings in this study indicated that the median time to development of macro vascular complications among type 2 diabetes mellitus patients was 24 months. Baseline age category in years, residence, presence of hypertension, presence of dyslipidemia, High density lipoprotein-cholesterol level < 40 mg/dl, triglyceride > 150 mg/dl, HgbA1C > 7% at baseline, and medication regimens were identified as independent significant predictors of the time to development of macro vascular complications among type 2 diabetes mellitus patients. The findings call attention to the role of treatment regimens, particularly the use of combination therapies involving oral hypoglycemic agents and insulin, which were associated with increased hazards for complications. High incidence of macrovascular complications within a short follow-up period underscores the need for proactive, individualized care strategies in T2DM management. By focusing on early identification of at-risk patients and tailoring treatment plans accordingly, healthcare providers can potentially improve outcomes and reduce the burden of macro vascular complications in this population.

Prevalence of Type 2 Diabetes, Overweight, Obesity, and Metabolic Syndrome in Adults in Bogotá, Colombia, 2022-2023: A Cross‑Sectional Population Survey

Objective: To establish the prevalence of type 2 diabetes, overweight/obesity, and metabolic syndrome in individuals aged >18 years in Bogotá, Colombia and the variables associated with diabetes prevalence. Research Design and Methods: This was a cross‑sectional population survey with a representative, probabilistic sample of Bogotá, Colombia collected between 2022 and 2023. The final sample size included 2,860 households, distributed among 19 localities of Bogotá. Clinical laboratory samples were taken from randomly selected individuals (n = 1,070). Data on the Adult Treatment Panel III (ATP III) and Latin American Diabetes Association (ALAD) criteria for metabolic syndrome were collected, including physical measurements. Results: The prevalence of type 2 diabetes in Bogotá was 11.0% (95% confidence interval [CI], 9.0-13.5%). According to the ATP III and ALAD criteria, the prevalence proportions of metabolic syndrome were 33.9% (95% CI, 29.5-38.6) and 29.3% (95% CI, 26.1-32.7), respectively. The age of ≥55 years, abdominal obesity, hypertriglyceridemia, and noneducational level had higher adjusted prevalence ratios (APRs) of diabetes. The APRs of metabolic syndrome were higher in adults with a low education level (LEL) and female sex, with the ATP III and ALAD criteria, and noninsured adults or those with unknown affiliation with the healthcare system, with the ATP III criteria. Conclusions: We found a higher prevalence of type 2 diabetes in adults in Bogotá than expected in previous studies. Intervention from public policy should be requested, especially in those of lowest socioeconomic and education levels, to avoid a future increase in this prevalence. Studies on other Colombian cities are required.

Dynamic observation and analysis of factors influencing the progression of diabetic retinopathy

OBJECTIVE

To actively monitor and analyze the factors that affect the advancement of diabetic retinopathy (DR).

METHOD

In this study, we prospectively recruited patients diagnosed with non-proliferative diabetic retinopathy (NPDR) for concurrent monitoring. A total of 75 patients who transitioned from NPDR to proliferative diabetic retinopathy (PDR) comprised the progression group, while 112 NPDR patients who did not develop PDR formed the stable group in a prospective cohort study. Follow-up assessments occurred every six months, and patients were observed continuously over an eight-year period. Clinical parameters from both NPDR and PDR groups were collected to assess the stability of these indicators (with a coefficient of variation [CV] > 5 % indicating instability and CV < 5 % indicating stability).

RESULTS

In the NPDR cohort, 80.4 % Control the stability ratio regulation of glycosylated hemoglobin (HbA1c), whereas in the PDR cohort, 80.0 % Control the proportion of instability (P = 0.001); for blood creatinine (Cr), 64.3 % of NPDR patients maintained stable levels, contrasting with 77.3 % of PDR patients with fluctuating levels (P = 0.001). Blood urea nitrogen (BUN) and homocysteine (HCY) control demonstrated instability in both NPDR and PDR groups. Instability in regulating HbA1c, Cr, BUN, and HCY served as independent risk factors for DR progression, with significant associations found between HbA1c CV (HR: 15.586; 95 % CI: 14.205-15.988; p = 0.001), Cr CV (HR: 9.231; 95 % CI: 9.088-10.235; p = 0.005), BUN CV (HR: 3.568; 95 % CI: 3.183-4.367; p = 0.01), and HCY CV (HR: 8.678; 95 % CI: 7.754-8.998；p = 0.003).

CONCLUSION

Inadequate regulation of HbA1c, Cr, BUN, and HCY independently impact the advancement of DR.

The Association of HbA1c Variability with 12 Week and 12 Month Outcomes on Diabetes Related Foot Ulcer Healing

INTRODUCTION

This study aimed to determine the relationship between HbA1c variability and foot ulcer healing at 12 weeks and 12 months.

METHODS

Using National Diabetic Foot Care Audit (NDFA) and hospital records, demographics, baseline ulcer characteristics and healing outcomes for subjects presenting with a foot ulcer between 2017-2022 were collected at 12 weeks and 12 months. Subjects had diabetes duration > 3 years and ≥ 3 HbA1c recordings in the 5 years prior to presentation.

RESULTS

At 12 weeks, factors associated with an active ulcer were presence on hind foot (adjusted odds ratios) (2.1 [95% CI 1.3-3.7]), ischaemia (2.1 [95% CI:1.4-3.2]), area > 1 cm2 (2.7 [95% CI:1.7-4.2]) and diabetes duration > 24 years vs 3-10 (AOR 2.0 [95% CI 1.2-3.5]). After adjustment, HbA1c variability 6-10 mmol/mol and > 14.5 mmol/mol had AOR of 1.76 (95% CI 1.1-2.8; p = 0.0192) and 1.5 (95% CI 0.9-2.6; p = 0.1148) of an active ulcer at 12 weeks vs variability < 6 mmol/mol. At 12 months, ischaemia (AOR 2.4 [95% CI 1.5-3.8]) and diabetes duration > 24 years vs 3-10 years (AOR 3.3 [95% CI 1.7-6.4] were significant factors. HbA1c variability was not significant at 12 months.

CONCLUSION

In keeping with the national NDFA data, in our cohort ulcer characteristics, but not HbA1c variability, were the key factors associated with ulcer healing at 12 weeks and 12 months.

Non-diabetic nephropathy in diabetic patients: incidence, HbA1c variability and other predictive factors, and implications

PURPOSE

Diabetes mellitus (DM) is the leading cause of chronic kidney disease (CKD) in the population. In patients with diabetes mellitus, the incidence of non-diabetic nephropathy (NDNP) has been estimated to range from 3% to 69.5%. Personal judgment is frequently employed while deciding whether or not to do a kidney biopsy (KB) on diabetic patients. NDNP alters the prognosis and course of treatment for people with DM. In our study, we examined the incidence of NDNP concurrent with the progression of diabetes mellitus, as well as the laboratory and clinical indicators that could be utilized to forecast it.

METHODS

A retrospective analysis of 76 diabetic patients who underwent KB was conducted. Based on the pathological diagnoses of these patients, they were categorized as DNP (diabetic nephropathy) or NDNP. The definition of HbA1c variability was determined by calculating the mean HbA1c and the average value of the HbA1c measurements, as well as the standard deviation (SD) for each participant.

RESULTS

NDNP was detected in 50% of 76 patients. Among patients with NDNP, 36.8% had focal segmental glomerulosclerosis (FSGS), 23.6% had membranous glomerulonephritis, and 7.8% had IgA nephritis. The NDNP group exhibited significantly higher rates of female gender, absence of diabetic retinopathy, shorter time to diagnosis of diabetes mellitus, chronic kidney disease, and proteinuria, less intensive medication for diabetes mellitus, presence of hematuria and leukociduria, immunological serological marker positivity, and non-HbA1C variability. Risk factors for predicting non-diabetic nephropathy, as determined by multivariate analysis, included female gender, the absence of diabetic retinopathy, non-HbA1c variability and a positive immunological serological test.

CONCLUSION

In this study, a significant number of diabetic patients with chronic kidney disease were diagnosed with NDNP. Identifying these patients allows for treatment of the specific underlying disease. Factors such as the absence of DR, non-HbA1c variability, female gender, and immunological serological test positivity can predict NDNP and guide the clinician's decision on kidney biopsy. Further prospective studies are warranted to validate the efficacy of potential predictive factors like HbA1c variability.

Glycemic Variability as a Predictor of Graft Failure Following Infrainguinal Bypass for Peripheral Arterial Disease: A Retrospective Cohort Study

BACKGROUND

Glycemic variability (GV), measured as the change in visit-to-visit glycated hemoglobin (HbA1c), increases the risk of multiple adverse outcomes. However, the impact of GV on graft patency following infrainguinal bypass (IIB) is unknown. A retrospective cohort study was undertaken to assess the impact of GV on graft patency.

METHODS

A 3-year single-center retrospective case notes analysis of all people undergoing IIB between 2017 and 2019. Rutherford stage, graft conduit, level of bypass, procedure details, baseline demographics, comorbidities, and GV were assessed. Time to reintervention, ipsilateral amputation, or death was recorded to determine primary patency (PP).

RESULTS

One hundred six IIB outcomes were analyzed: mean (± standard deviation) age 68.0 (9.2) years; 69 (65.1%) male, 37 (33.9%), 75 (70.8%) had diabetes mellitus; and 46 (43.4%) underwent elective procedures. GV > 9.1% was associated with significantly lower median PP than GV < 9.1%, 198 (97-753.5) vs. 713 (166.5-1,044.5) days (P = 0.045). On univariate analysis, GV > 9.1% vs. < 9.1% was significantly associated with PP (hazard ratio [HR] 1.85 [confidence interval {CI} 1.091-3.136], P = 0.022). Bypass level was also a univariate predictor, with below knee bypasses (HR 2.31 [CI 1.164-4.564], P = 0.017), and tibial (HR 2.00 [CI 1.022-3.090], P < 0.043) having lower PP than above knee bypasses. On multivariate adjustment, GV > 9.1% and level of bypass remained independent predictors of PP, HR 1.96 (95% CI: 1.12-3.42, P = 0.018) and HR 2.54 (95% CI: 1.24-5.22, P = 0.011), respectively.

CONCLUSIONS

GV is an independent predictor of PP following infrainguinal bypass, thus optimizing GV should be a therapeutic target.

Diabetic peripheral neuropathy and glycemic variability assessed by continuous glucose monitoring: A systematic review and meta-analysis

Continuous glucose monitoring (CGM)-derived metrics have been used to accurately assess glycemic variability (GV) to facilitate management of diabetes mellitus, yet their relationship with diabetic peripheral neuropathy (DPN) is not fully understood. We performed a systematic review and meta-analysis to evaluate the association between GV metrics and the risk of developing DPN. Nine studies totaling 3,649 patients with type 1 and type 2 diabetes mellitus were included. A significant association was found between increased GV, as indicated by metrics including standard deviation (SD) with OR and 95% CI of 2.58 (1.45-4.57), mean amplitude of glycemic excursions (MAGE) with OR and 95% CI of 1.90 (1.01-3.58), mean of daily difference (MODD) with OR and 95% CI of 2.88 (2.17-3.81) and the incidence of DPN. Our findings support a link between higher GV and an increased risk of DPN in patients with diabetes. These findings highlight the potential of GV metrics as indicators for the development of DPN, advocating for their inclusion in diabetes management strategies to potentially mitigate neuropathy risk. Longitudinal studies with longer observation periods and larger sample sizes are necessary to validate these associations across diverse populations.

Glycemic Variability and the Risk of Diabetic Peripheral Neuropathy: A Meta-Analysis

Glycemic variability (GV) has been related to complications in patients with diabetes. The aim of the systematic review and meta-analysis was to investigate whether GV is also associated with the incidence of diabetic peripheral neuropathy (DPN). A systematic search of Medline, Web of Science, Embase, and Cochrane Library database was conducted to identify relevant observational studies with longitudinal follow-up. The Newcastle-Ottawa Scale was used for study quality evaluation. A random-effects model was utilized to pool the results, accounting for heterogeneity. Ten observational studies including 72 565 patients with diabetes were included. The quality score was 8-9, indicating generally good quality of the included studies. With a mean follow-up duration of 7.1 years, 11 532 patients (15.9%) were diagnosed as DPN. Compared to patients with low GV, patients with high GV were associated with an increased risk incidence of DPN (risk ratio: 1.51, 95% confidence interval: 1.23 to 1.85, p<0.001; I2=78%). In addition, subgroup analysis showed consistent results in patients with type 1 and type 2 diabetes, and in studies evaluating the short-term and long-term GV (p for subgroup difference=0.82 and 0.53). Finally, results of subgroup analysis also suggested that the association between GV and risk of DPN were not significantly affected by study design, follow-up durations, diagnostic methods for DPN, adjustment of mean glycated hemoglobin A1c, or study quality scores (p for subgroup difference all>0.05). A high GV may be associated with an increased incidence of DPN.

Effects of long-term HbA1c variability on serious infection risks in patients with type 2 diabetes and the influence of age, sex and ethnicity: A cohort study of primary care data

AIMS

Long-term HbA1c (glycated haemoglobin) variability is associated with micro- and macrovascular complications in Type 2 diabetes (T2D). We explored prospective associations between HbA1c variability and serious infections, and how these vary by HbA1c level, age, sex and ethnicity.

METHODS

411,963 T2D patients in England, aged 18-90, alive on 01/01/2015 in the Clinical Practice Research Datalink with ≥ 4 HbA1c measurements during 2011-14. Poisson regression estimated incidence rate ratios (IRRs) for infections requiring hospitalisation during 2015-19 by HbA1c variability score (HVS) and average level, adjusting for confounders, and stratified by age, sex, ethnicity and average level. Attributable risk fractions (AF) were calculated using reference categories for variability (HVS < 20) and average level (42-48 mmol/mol).

RESULTS

An increased infection risk (IRR > 1.2) was seen with even modest variability (HVS ≥ 20, 73 % of T2D patients), but only at higher average levels (≥64 mmol/mol, 27 % patients). Estimated AFs were markedly greater for variability than average level (17.1 % vs. 4.1 %). Associations with variability were greater among older patients, and those with lower HbA1c levels, but not observed among Black ethnicities.

CONCLUSIONS

HbA1c variability between T2D patients' primary care visits appears to be associated with more serious infections than average level overall. Well-designed trials could test whether these associations are causal.

Chronic hyperglycemia and intracranial meningiomas

Meningiomas are among the most common primary tumors of the central nervous system. Previous research into the meningioma histological appearance, genetic markers, transcriptome and epigenetic landscape has revealed that benign meningiomas significantly differ in their glucose metabolism compared to aggressive lesions. However, a correlation between the systemic glucose metabolism and the metabolism of the tumor hasn't yet been found. We hypothesized that chronic levels of glycaemia (approximated with glycated hemoglobin (HbA1c)) are different in patients with aggressive and benign meningiomas. The study encompassed 71 patients with de novo intracranial meningiomas, operated on in three European hospitals, two in Croatia and one in Spain. Our results show that patients with WHO grade 2 meningiomas had significantly higher HbA1c values compared to patients with grade 1 lesions (P = 0.0290). We also found a significant number of patients (19/71; 26.7%) being hyperglycemic, harboring all the risks that such a condition entails. Finally, we found a significant correlation between our patients' age and their preoperative HbA1c levels (P = 0.0008, ρ(rho) = 0.388), suggesting that older meningioma patients are at a higher risk of having their glycaemia severely dysregulated. These findings are especially important considering the current routine and wide-spread use of corticosteroids as anti-edematous treatment. Further research in this area could lead to better understanding of meningiomas and have immediate clinical impact.

Prognostic value of longitudinal HbA1c variability in predicting the development of diabetic sensorimotor polyneuropathy among patients with type 2 diabetes mellitus: A prospective cohort observational study

AIMS/INTRODUCTION

This prospective cohort study aims to identify the optimal measure of glycated hemoglobin (HbA1c) variability and to explore its relationship with the development of new diabetic sensorimotor polyneuropathy (DSPN) in individuals with type 2 diabetes mellitus, building upon previous cross-sectional studies that highlighted a significant association between HbA1c visit-to-visit variability and DSPN.

MATERIALS AND METHODS

In a prospective study, 321 participants diagnosed with type 2 diabetes mellitus underwent comprehensive clinical assessments, neurophysiologic studies, and laboratory evaluations at enrollment and follow-up. Various indices, including HbA1c standard deviation (HbA1c SD), coefficient of variation (HbA1c CV), HbA1c change score (HbA1c HVS), and average real variability (HbA1c ARV), were employed to calculate the visit-to-visit variability HbA1c based on 3 month intervals. The investigation focused on examining the associations between these indices and the development of new DSPN.

RESULTS

The average follow-up duration was 16.9 ± 6.9 months. The Cox proportional hazards model identified age (P = 0.001), diabetes duration (P = 0.024), and HbA1C ARV (P = 0.031) as the sole factors associated with the development of new DSPN. Furthermore, the cumulative risk of developing DSPN over 1 year demonstrated a significant association with HbA1C ARV (P = 0.03, log-rank test).

CONCLUSIONS

Apart from age and diabetes duration, HbA1c variability emerged as a robust predictor for the occurrence of new DSPN. Among the various measures of HbA1c variability evaluated, HbA1c ARV demonstrated the highest potential as a reliable indicator for anticipating the onset of new DSPN.

Is eGFR Slope a Novel Predictor of Chronic Complications of Type 2 Diabetes Mellitus? A Systematic Review and Meta-Analysis

Background

Diabetic kidney disease affects approximately 40% of patients with type 2 diabetes mellitus (T2DM) and is associated with an increased risk of end-stage kidney disease (ESKD) and cardiovascular (CV) events, as well as increased mortality. Among the indicators of decline in renal function, the eGFR slope is acquiring an increasing clinical interest. The aim of this study was to evaluate, through a systematic review of the literature and meta-analysis of the collected data, the association between the decline of the eGFR slope, chronic complications, and mortality of T2DM patients, in order to understand whether or not the eGFR slope can be defined as a predictive indicator of complications in T2DM.

Methods

The review and meta-analysis were conducted according to PRISMA guidelines considering published studies on patients with T2DM. A scientific literature search was carried out on PubMed from January 2003 to April 2023 with subsequent selection of scientific papers according to the inclusion criteria.

Results

Fifteen studies were selected for meta-analysis. Risk analysis as hazard ratio (HR) indicated a significant association between all events considered (all-cause mortality, CV events, ESKD, and microvascular events) for patients with steeper eGFR slope decline than subjects with stable eGFR. Calculated HRs (with 95% CI) were as follows: for all-cause mortality, 2.31 (1.70-3.15); for CV events, 1.73 (1.43-2.08); for ESKD, 1.54 (1.45-1.64); and for microvascular events, 2.07 (1.57-2.73). Overall HR was 1.82 (1.72-1.92).

Conclusions

An association between rapid eGFR decline and chronic diabetes complications was demonstrated, suggesting that eGFR slope variability significantly impacts the course of T2DM and that eGFR slope should be considered as a predictor for chronic complications in patients with T2DM. According to the obtained results, the therapeutic management of the patient with diabetes should not focus exclusively on glycaemic control, and particular attention should be paid to preserve renal function.

The Impact of Modern Anti-Diabetic Treatment on Endothelial Progenitor Cells

Diabetes is one of the leading chronic diseases globally with a significant impact on mortality. This condition is associated with chronic microvascular and macrovascular complications caused by vascular damage. Recently, endothelial progenitor cells (EPCs) raised interest due to their regenerative properties. EPCs are mononuclear cells that are derived from different tissues. Circulating EPCs contribute to regenerating the vessel's intima and restoring vascular function. The ability of EPCs to repair vascular damage depends on their number and functionality. Diabetic patients have a decreased circulating EPC count and impaired EPC function. This may at least partially explain the increased risk of diabetic complications, including the increased cardiovascular risk in these patients. Recent studies have confirmed that many currently available drugs with proven cardiovascular benefits have beneficial effects on EPC count and function. Among these drugs are also medications used to treat different types of diabetes. This manuscript aims to critically review currently available evidence about the ways anti-diabetic treatment affects EPC biology and to provide a broader context considering cardiovascular complications. The therapies that will be discussed include lifestyle adjustments, metformin, sulphonylureas, gut glucosidase inhibitors, thiazolidinediones, dipeptidyl peptidase 4 inhibitors, glucagon-like peptide 1 receptor analogs, sodium-glucose transporter 2 inhibitors, and insulin.

Key indices of glycaemic variability for application in diabetes clinical practice

Near normal glycaemic control in diabetes consists to target daily glucose fluctuations and quarterly HbA1c oscillations in addition to overall glucose exposure. Consequently, the prerequisite is to define simple, and mathematically undisputable key metrics for the short- and long-term variability in glucose homeostasis. As the standard deviations (SD) of either glucose or HbA1c are dependent on their means, the coefficient of variation (CV = SD/mean) should be applied instead as it that avoids the correlation between the SD and mean values. A CV glucose of 36% is the most appropriate threshold between those with stable versus labile glucose homeostasis. However, when near normal mean glucose concentrations are achieved a lower CV threshold of <27 % is necessary for reducing the risk for hypoglycaemia to a minimal rate. For the long-term variability in glucose homeostasis, a CVHbA1c < 5 % seems to be a relevant recommendation for preventing adverse clinical outcomes.

Expression analysis of ABCA1 in type 2 diabetic Pakistani patients with and without dyslipidemia and correlation with glycemic index and lipid profile

Diabetes Mellitus type II, earlier considered as an endocrinological disorder is now more regarded as an inflammatory disorder along with lipid aberrations. It demands for regular monitoring, healthy dietary habits and lifestyle modification. This study was focused on gene expression of ATP binding cassette protein 1 (ABCA1) in diabetic dyslipidemia patients in comparison with control groups of only diabetics and healthy individuals. Blood samples and data were collected from recruited 390 patients who were further divided into three groups (130 each). Glycemic index and lipid profile was assessed. Delta Delta Ct method was used that revealed downregulation of the studied gene more in diabetic dyslipidemia patients as compared to only diabetics and healthy controls. The Ct values of ABCA1 were associated with glycemic index and lipid profile using Pearson's correlation. A negative correlation with fasting blood sugar and a positive correlation with HbA1cwas observed in only diabetics group. While in diabetic dyslipidemia and normal healthy controls, a negative correlation was found with both. As far as the lipid profile is concerned a positive correlation was observed among only diabetics with whole lipid profile. In diabetics with dyslipidemia, a negative correlation with all parameters except the TAGs was observed. A positive correlation with all except HDL was observed in healthy controls. The Ct values and fold change were compared among diseased and healthy individuals by applying independent t test. The cycle threshold in only diabetics was p = 0.000018 and in diabetic dyslipdemia individuals was p = 0.00251 while fold change in only diabetics (p = 0.000230) and in diabetics with dyslipidemia (p = 0.001137) was observed to be as statistically significant.

Reducing Hemoglobin A1C Levels in Type II Diabetes: A Retrospective Analysis of the Renew Procedure

INTRODUCTION

Periodontal disease and type 2 diabetes are interrelated, with inflammation playing a significant role in the progression of both conditions. Previous research has demonstrated the potential of various treatments, such as diet, exercise, and periodontal therapies, to improve glycemic control in diabetic patients.

METHOD

This study proposed a novel surgical approach, the Renew Procedure, as a potential solution to enhance glycemic control in type 2 diabetic patients with periodontal issues. The procedure involves the removal of all teeth, the elimination of oral and maxillofacial infections, the placement of dental implants, and the provision of implant-supported and implant-retained removable dentures.

RESULTS

Preliminary findings indicated a significant reduction in HbA1c levels post-surgery, suggesting that this approach may improve overall oral health, reduce inflammation, and consequently lower HbA1c levels.

CONCLUSION

Further research is necessary to confirm the efficacy of the proposed solution, but these initial results highlight the importance of addressing oral health through comprehensive strategies for diabetic and periodontitis patients.