State-of-the-Art Review on Diabetes Care in Italy

Improving outcomes with early and intensive metabolic control in patients with type 2 diabetes: a long-term modeling analysis of clinical and cost outcomes in Italy

Objectives

This analysis quantifies the potential long-term clinical and cost benefits of early and intensive metabolic control (EIMC) versus conventional management in patients newly diagnosed with type 2 diabetes in Italy.

Methods

The PRIME T2D Model was used to project clinical and cost outcomes over long-term time horizons for a newly diagnosed cohort of patients receiving EIMC or conventional management. EIMC was associated with a mean glycated hemoglobin reduction of 0.6% from baseline and a mean weight loss of 9.5 kg (8.2%) for a duration of 6 years, before gradually returning to the same levels as the conventional management arm over 6 years. Modifiable risk factors were assumed to progress over time based on published regression functions. Direct and indirect costs associated with diabetes-related complications were accounted in 2021 Euros (EUR), with unit costs and health state utilities derived from published sources. Future costs and clinical benefits were discounted at 3% annually.

Results

For the population diagnosed with type 2 diabetes in 2021 (estimated at 216,417 cases), EIMC was projected to add approximately 33,112 years of life and 55,403 quality-adjusted life years versus conventional management. Cost savings with EIMC were estimated at EUR 494 million, EUR 608 million and EUR 628 million in the incident population at 10- and 20- and 50-year time horizons, respectively.

Conclusions

According to this modeling study, early and intensive metabolic control has the potential to substantially improve clinical outcomes and reduce economic burden compared with conventional management of patients with type 2 diabetes in Italy.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40200-024-01553-w.

Metformin Treatment With or Without Mediterranean Diet for the Prevention of Age-Related Diseases in People With Metabolic Syndrome: The MeMeMe Randomized Trial

OBJECTIVE

The Metformin and Dietary Restriction to Prevent Age-Related Morbid Events in People With Metabolic Syndrome (MeMeMe) trial tested whether 1,700 mg/day metformin (MET) with or without a Mediterranean diet (MedDiet) intervention could reduce the cumulative incidence of major noncommunicable diseases in people with metabolic syndrome.

RESEARCH DESIGN AND METHODS

A total of 1,442 participants were randomly assigned to one of four interventions: 1) MET (1,700 mg/day) plus MedDiet intervention (MET+MedDiet); 2) placebo plus MedDiet intervention; 3) MET (1,700 mg/day) alone; and 4) placebo alone. Participants were followed up for 3 years on average. The primary outcome was the cumulative incidence of major noncommunicable diseases (including type 2 diabetes, cardiovascular diseases, and cancer). Secondary outcomes were the incidence of type 2 diabetes and the changing prevalence of metabolic syndrome.

RESULTS

The crude incidence of the major noncommunicable diseases was 6.7 cases per 100 person-years in the MET+MedDiet group, 6.9 in the MET alone group, 13.3 in the placebo plus MedDiet group, and 11.3 in the placebo group. The differences were fully explained by the reduction of type 2 diabetes, which was 80% and 92% lower in the MET and MET+MedDiet groups, respectively, compared with placebo.

CONCLUSIONS

The use of 1,700 mg/day MET is effective to prevent diabetes in people selected on the basis of metabolic syndrome.

National innovation system for diabetes and metabolic disorders can promote biomedical research accountability; a literature review and designing a conceptual framework

Objectives

Diabetes is one of the leading causes of death and health challenges in most countries and Iran. There is a domestic need to design an innovation system for healthcare through the integration of science and related industries in the country to overcome its specific challenges and complications. The present research aims to review the existing literature and experiences in designing a national innovation system in the field of diabetes and metabolic disorders to improve the research accountability in this field based on society's real needs.

Methods

Four steps were carried out as an examination of challenges and costs of diabetes, a thorough review of relevant literature and expert opinion, investigation of the status of research responsiveness to the real needs of society In Iran and the world, examination the types, components and the requirements of innovation systems and designing the National Innovation System for diabetes and metabolic disorders in Iran.

Results

We identified ten components for diabetes and metabolic disorders innovation system, which were classified under four categories.

Conclusions

The effective communication of 10 components, which are included in this study, is an essential element that can play a vital role in the effectiveness of diabetes and metabolic disorders innovation system in order to meet the community needs. Moreover, these components were categorized by experts in four groups of policymaking, financing, research and development, and education, as the functions of the National Innovation System for diabetes and metabolic disorders in Iran.

Continuous glucose monitoring (CGM) in a non-Icu hospital setting: The patient's journey

AIMS

Although consistent data support the outpatient use of continuous glucose monitoring (CGM) to improve glycemic control and reduce hypoglycemic burden, and clinical outcomes, there are limited data regarding its use in the hospital setting, particularly in the non-intensive care unit (non-ICU) setting. The emerging use of CGM in the non-critical care setting may be useful in increasing the efficiency of hospital care and reducing the length of stay for patients with diabetes while improving glycemic control.

DATA SYNTHESIS

The purpose of this Expert Opinion paper was to evaluate the state of the art and provide a practical model of how CGM can be implemented in the hospital.

SETTING

A patient's CGM journey from admission to the ward to the application of the sensor, from patient education on the device during hospitalization until discharge of the patient to maintain remote control.

CONCLUSIONS

This practical approach for the implementation and management of CGM in patients with diabetes admitted to non-ICUs could guide hospitals in their diabetes management initiatives using CGM, helping to identify patients most likely to benefit and suggesting how this technology can be implemented to maximize clinical benefits.

Penetration rates of new pharmaceutical products in Europe: A comparative study of several classes recently launched in type-2 diabetes

BACKGROUND

Different countries have their own systems for evaluating new medicines, and they make decisions as to when and how each new medicine is adopted.

PURPOSE

To compare the rate of uptake of new diabetes medicines (dipeptidyl peptidase-4 inhibitors [DPP-4Is], glucagon-like peptide-1 receptor agonists [GLP1-RAs], and sodium-glucose co-transporter-2 inhibitors [SGLT2Is]) in the five most populated European countries.

METHODS

The monthly volume of sales of antidiabetic drugs was extracted for each country from the IQVIA™ MIDAS® database for the period 2007 to 2016 and the defined daily doses (DDDs) were calculated. For each new drug, market shares were expressed as a percentage of the total market of non-insulin antidiabetic agents.

RESULTS

Sharp differences were observed between the countries. Overall, the highest and fastest rates of uptake were seen for Germany and Spain, compared to lower rates for the UK and Italy. This was especially marked for DPP-4Is, where the market share reached over 30% of non-insulin antidiabetic drugs in Germany and Spain, compared to around 10% in the UK and Italy. In France, there was an initial rapid uptake, which stabilized at around 20% after three years. Rates of uptake were lower for the other drugs, with the GLP1-RAs reaching a market share of 2.5-4.5% in Germany, Spain and France, compared to less than 2.5% in the UK and Italy. The SGLT2Is reached a market share of 5-8% in Spain and Germany, compared to less than 4% in the UK and Italy, and they were not launched at all in France in March 2020.

CONCLUSION

The differences in the uptake of new antidiabetic drugs may reflect different methods for assessing and introducing new medicines, as well as cultural factors. The uptake of the new medicines would appear to be more cautious in the UK and Italy, perhaps due to concerns about cost-effectiveness, whereas in Germany and Spain, and possibly also France, a new medicine's potential benefits may be prioritized.

Costs and where to find them: identifying unit costs for health economic evaluations of diabetes in France, Germany and Italy

BACKGROUND

Health economic evaluations require cost data as key inputs. Many countries do not have standardized reference costs so costs used often vary between studies, thereby reducing transparency and transferability. The present review provided a comprehensive overview of cost sources and suggested unit costs for France, Germany and Italy, to support health economic evaluations in these countries, particularly in the field of diabetes.

METHODS

A literature review was conducted across multiple databases to identify published unit costs and cost data sources for resource items commonly used in health economic evaluations of antidiabetic therapies. The quality of unit cost reporting was assessed with regard to comprehensiveness of cost reporting and referencing as well as accessibility of cost sources from published cost-effectiveness analyses (CEA) of antidiabetic medications.

RESULTS

An overview of cost sources, including tariff and fee schedules as well as published estimates, was developed for France, Germany and Italy, covering primary and specialist outpatient care, emergency care, hospital treatment, pharmacy costs and lost productivity. Based on these sources, unit cost datasets were suggested for each country. The assessment of unit cost reporting showed that only 60% and 40% of CEAs reported unit costs and referenced them for all pharmacy items, respectively. Less than 20% of CEAs obtained all pharmacy costs from publicly available sources.

CONCLUSIONS

This review provides a comprehensive account of available costs and cost sources in France, Germany and Italy to support health economists and increase transparency in health economic evaluations in diabetes.

Sex-Gender Differences in Diabetic Retinopathy

Diabetic retinopathy (DR) is one of the main causes of visual loss in individuals aged 20–64 years old. The aim of this study was to investigate, in a multicenter retrospective cross-sectional study, sex-gender difference in DR in a large sample of type 2 diabetic patients (T2DM). 20,611 T2DM regularly attending the units for the last three years were classified as having: (a) No DR (NDR), (b) nonproliferative DR (NPDR), or (c) preproliferative/proliferative DR (PPDR). DR of all grades was present in 4294 T2DM (20.8%), with a significant higher prevalence in men as compared to women (22.0% vs. 19.3% p < 0.0001). Among DR patients, both NPDR and PPDR were significantly more prevalent in men vs. women (p = 0.001 and p = 0.0016, respectively). Women had similar age and BMI, but longer diabetes duration, worse glycemic metabolic control, and more prevalence of hypertension and chronic renal failure (CRF) of any grade vs. men. No significant differences between sexes were evident in term of drug therapy for diabetes and associate pathologies. Conclusions: In this large sample of T2DM, men show higher prevalence of DR vs. women, in spite of less represented risk factors, suggesting that male sex per se might be a risk factor for DR development.

The burden of type 2 diabetes in Europe: Current and future aspects of insulin treatment from patient and healthcare spending perspectives

Due to the progressive nature of type 2 diabetes (T2DM), initiation of insulin therapy is very likely in the disease continuum. This article aims at highlighting the current situation with regard to insulin therapy in people with T2DM in Europe and at presenting the associated unmet need. Challenges for both people with T2DM and healthcare professionals include clinical inertia also derived from fear of hypoglycaemia, weight gain and injections as well as increased need for a comprehensive diabetes management. We compare national and international guidelines and recommendations for the initiation and intensification of insulin therapy with the real-world situation in six European countries, demonstrating that glycaemic targets are only met in a minority of people with T2DM on insulin therapy. Furthermore, this work evaluates currently recorded numbers of people with T2DM treated with insulin in Europe, the proportion not achieving the stated glycaemic targets and thus in need to enhance insulin therapy e.g. by a change in means of insulin delivery including, but not limited to, insulin pens, wearable mealtime insulin delivery patches, patch pumps, and conventional insulin pumps with continuous subcutaneous insulin infusion.

Patient Preferences and Health State Utilities Associated with Mealtime Insulin Concentrations Among Patients with Diabetes in Italy

INTRODUCTION

Standard concentration (100 units/mL) mealtime insulin is frequently used to treat patients with type 1 (T1D) and type 2 diabetes (T2D). A more concentrated version of the medication (200 units/mL) has been available in Italy since 2016. This concentrated version is bioequivalent to the standard version and delivers the same amount of medication but in half the volume of liquid. The purpose of this study was to examine patient preferences and estimate health state utilities associated with standard and concentrated rapid-acting mealtime analog insulin.

METHODS

Participants with T1D and T2D in Italy valued two health states in time trade-off interviews. The descriptions of diabetes and treatment in the two health states were identical, differing only in terms of insulin concentration (e.g., half as much liquid for the same dose, less effort needed to press the injection button, and fewer injection pens required with concentrated insulin). To ensure participants understood the health states, they were shown a short video illustrating the differences between concentrations.

RESULTS

A total of 217 participants completed the interviews (49.8% male; mean age 56.1 years; 109 from Milan; 108 from Rome; 12.0% T1D; 88.0% T2D). When asked which health state they preferred, 98.2% responded the concentrated version, 0.9% said the standard version, and 0.9% had no preference. Mean [standard deviation (SD)] utilities rounded to three decimals were 0.892 (0.099) for the concentrated version and 0.884 (0.101) for the standard version. The mean (SD; p value) utility difference between the standard and concentrated rapid-acting insulin was 0.007 (0.019; p < 0.0001).

CONCLUSIONS

Findings from this study provide insight into patient preferences associated with concentration of rapid-acting insulin. Although the difference in utility is small, patients consistently preferred the concentrated formulation over the standard insulin, and for some patients this difference had an impact on utility valuations. These results suggest that the concentration of rapid-acting insulin should be considered because it could affect treatment preference and quality of life.

FUNDING

Eli Lilly and Company.

Diabetes Prevention: Knowledge and Perception of Risk among Italian Population

The risk perception for developing diabetes has not been well established. The aim of this study is to evaluate knowledge and perception of risk for developing diabetes. A cross-sectional study was conducted among a sample of 527 parents of children attending public schools in Naples (Italy). A self-administered anonymous questionnaire was used to collect the data. In total, 97.3% of participants have heard about diabetes, but only 16.7% knew the main risk and protective factors. This knowledge was statistically significantly higher in those who had close relatives with diabetes. Moreover, those who had middle school or lower and high school education, compared with those who had a college degree or higher, were less knowledgeable. The mean total value of the risk perception for developing diabetes was 1.9. Females those who had more than 40 years of age, those who needed of additional information, those who had a higher BMI, those who had close relatives with diabetes, those who had at least one chronic disease, and those who reported a lower value of self-rated health status were more likely to perceive a higher risk for developing diabetes. Moreover, this perception was statistically significantly lower among those who had a middle school or lower and high school education, compared with those who had a college degree or higher. The knowledge about diabetes needs to be improved, and the low risk perception for developing diabetes among the sample is worrying given the severity of the disease and the preventive measures available.

Outcomes of integrated management versus specialized care for patients with type 2 diabetes: An observational study

AIMS

To compare type 2 diabetes (T2D) patients included in a Diabetes Integrated Management (DIM) program with those followed in Diabetes Specialized Care (DSC), investigating differences in general characteristics, changes in clinical outcomes, and factors related with the inclusion in the DIM program.

METHODS

T2D patients living in the ASLTO3 district and included into the DIM program, a shared disease management between general practitioners and diabetes specialists, from 2008 to 2014 were compared with T2D patients living in the same district and in charge of the local DSC. Demographic, anthropometric and clinical data for both groups of patients were obtained from the electronic records of DSC.

RESULTS

1326 DIM patients were compared with 3494 DSC patients. A higher proportion of females was observed among DIM patients than among DSC patients. DIM patients were older, more frequently in therapy with diet only or with oral hypoglycemic, and had HbA1c and creatinine lower than DSC patients. The analyses of changes in clinical parameters during the study period showed a good and statistically significant improvement of most parameters, independently of the inclusion in DIM or DSC, with the exception of creatinine level.

CONCLUSIONS

Integrated Management is an efficient and effective way to achieve good long-term clinical outcomes for patients with diabetes.

Utilization Patterns of Glucagon-Like Peptide-1 Receptor Agonists in Patients with Type 2 Diabetes Mellitus in Italy: A Retrospective Cohort Study

INTRODUCTION

Real-world evidence on glucagon-like peptide-1 receptor agonist (GLP-1 RAs) usage is emerging in different European countries but is lacking in Italy. This retrospective cohort study aimed to describe the real-world drug utilization patterns in patients initiating GLP-1 RAs for treating T2DM in Italy.

METHODS

Adults aged ≥ 20 years and with ≥ 1 oral antidiabetic drug (alone or in combination with insulin) other than GLP-1 RAs in the 6 months prior to initiating exenatide twice daily (exBID), exenatide once weekly (exQW), dulaglutide once weekly (DULA), liraglutide once daily (LIRA) or lixisenatide once daily (LIXI) between March and July 2016 were retrospectively identified in the Italian IMS LifeLink™ longitudinal prescriptions database (retail pharmacy data). Patients with ≥ 6-month follow-up (defined as evidence of any prescription activity) were included. Proportions of patients who remained persistent (continued treatment until discontinuation/switch) in the first 6 months and of those who discontinued or switched to a different GLP-1 RA over the entire follow-up were recorded. For each treatment, the average daily/weekly dosage (ADD/AWD) while persistent during the available follow-up was calculated.

RESULTS

We identified 7319 patients: 92 exBID, 970 exQW, 3368 DULA, 2573 LIRA and 316 LIXI. Across treatments, 89% patients were ≥ 50 years old, 54% were males, and the median follow-up duration ranged between 8.1 and 8.7 months. At 6 months, 35% exBID, 47% exQW, 62% DULA, 50% LIRA and 40% LIXI patients remained persistent. Over the entire follow-up, median persistence days varied from 73 (exBID) to > 300 days (DULA). The mean ± SD ADD/AWD was exBID: 17.7 ± 2.1 µg/day; exQW: 2.1 ± 0.1 mg/week; DULA: 1.5 ± 0.2 mg/week; LIRA: 1.5 ± 0.2 mg/day; LIXI: 21.0 ± 5.5 µg/day.

CONCLUSIONS

This real-world analysis suggests differences exist in persistence between patients treated with various GLP-1 RAs. Among the investigated treatments, patients prescribed exBID recorded the lowest and those prescribed DULA the highest persistence with therapy.

FUNDING

Eli Lilly and Co., Indianapolis, IN, USA.

Efficacy and Renal Safety of Dapagliflozin in Patients with Type 2 Diabetes Mellitus Also Receiving Metformin: A Real-Life Experience

INTRODUCTION

This study aimed at evaluating the efficacy and safety of dapagliflozin in patients with type 2 diabetes (T2D) who also received metformin in clinical practice in Italy.

METHODS

This was a retrospective observational study and it included data from patients who received dapagliflozin 10 mg once daily in conjunction with metformin for 12 months (DAPA + MET). In those with inadequate glycemic control, insulin or glimepiride was added after 30 days (DAPA + MET + other glucose-lowering drugs). Efficacy assessments included glycosylated hemoglobin (HbA_1c) levels at 6 and 12 months, as well as body mass index (BMI) and lipid parameters at 12 months. Safety was also assessed.

RESULTS

Data on 66 patients were included. In both groups, HbA_1c was significantly reduced at 6 and 12 months compared with baseline and significant reductions in HbA_1c were observed at 12 months compared with 6 months. Over the 12-month treatment period, dapagliflozin significantly reduced BMI in both groups. No significant changes in lipid parameters were observed in either group and no detrimental effects on renal function were detected.

CONCLUSIONS

Dapagliflozin is effective and safe in patients with T2D also receiving metformin. Glycemic control was already achieved with dapagliflozin + metformin, and add-on therapy was not associated with further improvements.

Familial diabetes of adulthood: A bin of ignorance that needs to be addressed

AIMS

The aim of this article was to share with a wide readership some data and related reasoning about a multigenerational form of diabetes mellitus of adulthood.

DATA SYNTHESIS

We have recently described a familial form of diabetes mellitus, which in the routine clinical setting of adult individuals is simplistically diagnosed as type 2 diabetes. Such misdiagnosis involves as much as 3% of adult unrelated diabetic patients with no evidence of autoimmune disease. More recent data, obtained by means of a next-generation sequencing, indicate that approximately 25% of such patients carry mutations in the genes involved in monogenic diabetes, thus leaving unraveled the molecular causes of the remaining 75% individuals.

CONCLUSIONS

Our proposal is to define the latter patients as being affected by familial diabetes of adulthood (FDA), a clear admission of ignorance and a limbo where adult patients with multigenerational diabetes with no genetic definition of their hyperglycemia have to wait for better times.

Insulin regimens and glycemic control in different parts of Europe over 4years after starting insulin in people with type 2 diabetes: Data from the CREDIT non-interventional study

AIMS

A number of insulin regimens are used in type 2 diabetes. This analysis aims to better understand the evolution of insulin therapy in different regions of Europe.

METHODS

Data from people starting any insulin were collected in eastern Europe (EEur: Croatia, Russia, Ukraine), northern Europe (NEur: Finland, Germany, UK) and southern Europe (SEur: France, Italy, Portugal, Spain). Retrospective data on starting insulin and prospective follow-up data were extracted from clinical records.

RESULTS

At 4years, 1699 (76.0%) of 2236 eligible people had data. EEur participants were mostly female, younger and had shorter diabetes duration on starting insulin, yet had highest baseline HbA1c and more micro-/macrovascular disease. A majority (60%-64%) in all regions started on basal insulin alone, declining to 30%-38% at 4years, with most switching to basal+mealtime insulin regimen (24%-40%). Higher baseline (28%) and 4-year use (34%) of premix insulin was observed in NEur. Change in HbA1c (SD) ranged from -1.2 (2.1)% (-13 [23]mmol/mol) in NEur to -2.4 (2.0)% (-26 [22]mmol/mol) in EEur. Weight change ranged from +1.9 (8.3) kg in NEur to +3.2 (7.0) kg in SEur. Overall documented hypoglycemia ranged from 0.3 (1.3) to 1.3 (4.4) events/person/6-months (NEur vs. EEur, respectively) and was stable with time. Severe hypoglycemia rates remained low.

CONCLUSION

When starting insulin, HbA1c and prevalence of complications were higher in EEur. Regional differences exist in choice of insulin regimens in Europe. However, people starting insulin improved and sustained their glycemic control regardless of regional differences or insulin regimens used.

Transcultural Endocrinology: Adapting Type-2 Diabetes Guidelines on a Global Scale

Type-2 diabetes (T2D) needs to be prevented and treated effectively to reduce its burden and consequences. White papers, such as evidence-based clinical practice guidelines (CPG) and their more portable versions, clinical practice algorithms and clinical checklists, may improve clinical decision-making and diabetes outcomes. However, CPG are underused and poorly validated. Protocols that translate and implement these CPG are needed. This review presents the global dimension of T2D, details the importance of white papers in the transculturalization process, compares relevant international CPG, analyzes cultural variables, and summarizes translation strategies that can improve care. Specific protocols and algorithmic tools are provided.

Diabetic Retinopathy in Italy: Epidemiology Data and Telemedicine Screening Programs

In Italy, the number of people living with diabetes is about 3.5 million (5.5% of the population), with an increase by about 60% in the last 20 years and with 1 person out of 3 older than 65 years. The Italian Health Service system estimates that 10 billion euros is spent annually on caring for patients with diabetes, a figure that increases yearly. No national data on prevalence and incidence of legal blindness in patients with diabetes and no national registry of patients with diabetic retinopathy (DR) are currently available. However, the available epidemiological data (in several locations throughout the country) are consistent with those reported in other European countries. The use of telemedicine for the screening of DR in Italy is confined to geographically limited locations. The available data in the literature on implementation and use of telematic screening proved to be successful from patient, caregiver, and authorities point of view. This review addresses the available epidemiological data on DR and telematic screening realities in Italy and thus may help in establishing a national screening program.