Survival as a function of HbA(1c) in people with type 2 diabetes: a retrospective cohort study

Association of Hemoglobin A1c Levels With All-Cause Mortality in Patients With Coronary Artery Disease: The Essen Coronary Artery Disease Registry

BACKGROUND

Hemoglobin A1c (HbA1c) as a marker of long-term glycemic control is used for the diagnosis and assessment of treatment of diabetes mellitus.

OBJECTIVES

The authors aimed to evaluate whether HbA1c levels would independently associate with long-term survival independent of the presence of other cardiovascular risk factors.

METHODS

The present retrospective analysis is based on the longitudinal the Essen Coronary Artery Disease registry of consecutive patients undergoing coronary revascularization therapy between 2004 and 2019. Cox regression analysis was used to determine the association of HbA1c with all-cause mortality. To assess for nonlinearity between HbA1c as a continuous variable and all-cause mortality, we fitted restricted cubic spline models. Kaplan-Meier analysis was used to depict the survival probability.

RESULTS

Overall, 4,700 patients (mean age 66.1 ± 11.4 years, 77.1% male) were included. Mean HbA1c was 6.3% ± 1.2%. During a median follow-up of 2.8 (IQR: 0.6-6.2) years, 558 patients (8.4%) died. In multivariable analysis, higher HbA1c levels, adjusted for other cardiovascular risk factors, were independently associated with all-cause mortality (HR: 1.16 [95% CI: 1.07-1.26] per 1 SD change in HbA1c, P < 0.001). Using HbA1c >5.3% to 5.6% as reference, we observed a U-shaped event rate for different HbA1c groups (≤5.3%: HR: 1.52 [95% CI: 1.01-2.28], P = 0.0044; >5.6%-5.9%: HR: 0.96 [95% CI: 0.65-1.41], P = 0.80; >5.9%-6.6%: HR: 1.26 [95% CI: 0.90-1.78], P = 0.20; >6.6-7.8: HR: 1.38 [95% CI: 0.93-2.04], P = 0.10; ≥7.8%: HR: 2.15 [95% CI: 1.43-3.19], P < 0.001).

CONCLUSIONS

In the present large registry of patients with established coronary artery disease (CAD) undergoing coronary revascularization therapy, HbA1c levels display a U-shaped association with all-cause mortality. In addition to patients with diabetes, also patients with CAD with very low HbA1c face increased mortality risk. Clinical trials, randomizing to different HbA1c targets are needed to define optimal HbA1c targets for patients with established CAD.

Models based on dietary nutrients predicting all-cause and cardiovascular mortality in people with diabetes

Dietary intervention plays a vital role in improving the prognosis of people with diabetes mellitus (DM). Currently, there is a lack of systematic analysis of the relation between dietary nutrients and long-term mortality risk in people with DM. The study aims to establish models predicting long-term mortality and explore dietary nutrients associated with reduced long-term events to guide daily dietary decisions in people with DM. The retrospective cohort study collected 5060 participants with DM from the National Health and Nutrition Examination Survey (NHANES) 1999-2018. The least absolute shrinkage and selection operator (LASSO) regression and random forest (RF) algorithm were applied to identify key mortality-related dietary factors, which were subsequently incorporated into risk prediction nomogram models. The receiver operating characteristic (ROC) curve, calibration plot and decision curve analysis (DCA) were utilized to evaluate the performance of the models. The association of key dietary nutrients with all-cause and cardiovascular mortality were visualized by restricted cubic spline (RCS) models both in the whole and subgroups by sex, age, drinking and smoking status. The overall median age of the cohort was 62.0 years (interquartile range (IQR) 52.0-70.0), 2564 (50.67%) being male. During a median follow-up period of 56.0 months, 997 (19.70%) all-cause deaths were recorded, with 219 (21.97%) of which being ascribed to cardiovascular disease. The nomogram models based on key dietary nutrients identified by LASSO and RF demonstrated a significant predicative value for all-cause and cardiovascular mortality. Dietary fiber and magnesium were the common predictive nutrients in the two nomogram models. The RCS curve revealed that dietary fiber and magnesium were negatively associated with long-term mortality in the whole and subgroups of people with DM after adjustment of potential confounders. The diet of people with DM is closely associated with mortality. The nomogram models based on dietary nutrients can predict long-term mortality of people with DM, and the higher intake of dietary fiber and magnesium was associated with reduced risks of both long-term all-cause and cardiovascular mortality.

Association of glycemic control with Long COVID in patients with type 2 diabetes: findings from the National COVID Cohort Collaborative (N3C)

INTRODUCTION

Elevated glycosylated hemoglobin (HbA1c) in individuals with type 2 diabetes is associated with increased risk of hospitalization and death after acute COVID-19, however the effect of HbA1c on Long COVID is unclear.

OBJECTIVE

Evaluate the association of glycemic control with the development of Long COVID in patients with type 2 diabetes (T2D).

RESEARCH DESIGN AND METHODS

We conducted a retrospective cohort study using electronic health record data from the National COVID Cohort Collaborative. Our cohort included individuals with T2D from eight sites with longitudinal natural language processing (NLP) data. The primary outcome was death or new-onset recurrent Long COVID symptoms within 30-180 days after COVID-19. Symptoms were identified as keywords from clinical notes using NLP in respiratory, brain fog, fatigue, loss of smell/taste, cough, cardiovascular and musculoskeletal symptom categories. Logistic regression was used to evaluate the risk of Long COVID by HbA1c range, adjusting for demographics, body mass index, comorbidities, and diabetes medication. A COVID-negative group was used as a control.

RESULTS

Among 7430 COVID-positive patients, 1491 (20.1%) developed symptomatic Long COVID, and 380 (5.1%) died. The primary outcome of death or Long COVID was increased in patients with HbA1c 8% to <10% (OR 1.20, 95% CI 1.02 to 1.41) and ≥10% (OR 1.40, 95% CI 1.14 to 1.72) compared with those with HbA1c 6.5% to <8%. This association was not seen in the COVID-negative group. Higher HbA1c levels were associated with increased risk of Long COVID symptoms, especially respiratory and brain fog. There was no association between HbA1c levels and risk of death within 30-180 days following COVID-19. NLP identified more patients with Long COVID symptoms compared with diagnosis codes.

CONCLUSION

Poor glycemic control (HbA1c≥8%) in people with T2D was associated with higher risk of Long COVID symptoms 30-180 days following COVID-19. Notably, this risk increased as HbA1c levels rose. However, this association was not observed in patients with T2D without a history of COVID-19. An NLP-based definition of Long COVID identified more patients than diagnosis codes and should be considered in future studies.

Blood Biomarker Signatures for Slow Gait Speed in Older Adults: An Explainable Machine Learning Approach

Maintaining physical function is crucial for independent living in older adults, with gait speed being a key predictor of health outcomes. Blood biomarkers may potentially monitor older adults' mobility, yet their association with slow gait speed still needs to be explored. This study aimed to investigate the relationship between blood biomarkers and gait speed using the Midlife in the United States (MIDUS) study biomarker dataset. A cross-sectional design was employed for analysis, involving 405 individuals aged 60 years and over. We used a machine learning framework, specifically the XGBoost algorithm, feature selection methods, and the Shapley Additive Explanations, to develop an explainable prediction model for slow gait speed. Our model demonstrated the highest cross-validation score with the six most important features among 35 variables, as elevated interleukin-6, C-reactive protein, glycosylated hemoglobin, interleukin-8, older age, and female sex were significantly associated with reduced gait speed (area under the curve = 0.75). Our findings suggest that blood biomarkers can play a critical role in integrated models to assess and monitor slow gait speed in older adults. Identifying key blood biomarkers provides valuable insights into the underlying physiological mechanisms of mobility decline and offers promising avenues for early intervention to preserve mobility in the aging population.

Diagnosis and management of type 2 diabetes mellitus in patients with ischaemic heart disease and acute coronary syndromes - a review of evidence and recommendations

Type 2 diabetes mellitus (T2DM) represents a major healthcare condition of the 21st century. It is characterised by persistently elevated blood glucose occurring as a result of peripheral insulin resistance and reduced insulin production which may lead to multiple long-term health conditions such as retinopathy, neuropathy, and nephropathy. The estimated number of individuals suffering from diabetes mellitus (DM) is expected to rise to 591 million by the year 2035 with 4.4 million in the United Kingdom (UK) alone, 90% of which is attributed to T2DM. Moreover, a significant proportion of individuals may have undetected diabetes mellitus, especially among those presenting with symptoms of ischaemic heart disease (IHD). This is particularly important in those individuals presenting with acute coronary syndromes (ACS) who are at the highest risk of complications and sudden cardiac death. Identifying abnormal levels of common biochemical markers of diabetes, such as capillary blood glucose or glycated haemoglobin (HbA1c) in these patients is important for early diagnosis, which will then allow for timely intervention to improve outcomes. However, a significant proportion of individuals who meet the criteria for the diagnosis of diabetes remain undiagnosed, representing missed opportunities for early intervention. This may result in a prolonged period of untreated hyperglycaemia, which can result resulting in significant further microvascular and macrovascular complications. There is an increased risk of IHD, heart failure, cerebrovascular accidents (CVA), and peripheral artery disease (PVD). These account accounting for 50% of deaths in patients with T2DM. Cardiovascular diseases in the context of diabetes particular represent a significant cause of morbidity and mortality with a two to three times higher risk of cardiovascular disease in individuals with T2DM than in those without the condition normo-glycaemia. In the United Kingdom UK alone, around 120 amputations, 770 CVA, 590 heart attacks, and more than 2300 presentations with heart failure per week are attributed to diabetes DM. with One 1 in six 6 hospital beds and around 10% of the healthcare budget may be being spent on managing diabetes DM or its complications. Therefore, it represents a significant burden on our healthcare system.

Matrix Metalloproteinase-9 as a Predictor of Healing in Diabetic Foot Ulcers

Background Wound healing in diabetic foot ulcers (DFUs) is hindered by several physiological and biochemical abnormalities, including prolonged inflammation, an imbalance in extracellular matrix (ECM) synthesis and degradation, insufficient neovascularization, and reduced macrophage activity. In DFUs, excessive and uncontrolled matrix metalloproteinases (MMPs) degrade the ECM and impede wound healing. Matrix metalloproteinase-9 (MMP-9) concentration plays a key role in inflammation and ECM degradation. This study explores the relationship between wound type in DFUs and MMP-9 levels, hypothesizing that a high MMP-9 environment may indicate inflammation and impaired wound healing. Materials and methods Forty individuals with type 2 diabetes and foot ulcers were recruited for the study. The participants were divided into two groups: nonhealing and healing, with 20 patients in each group. Biopsy samples were homogenized, and MMP-9 activity was measured using an ELISA. Results The MMP-9 concentration was significantly higher in nonhealing ulcers compared to healing ulcers. Receiver operating characteristic analysis revealed that MMP-9 measurement was the most accurate predictor of wound healing, with an area under the curve value of 0.945 and high sensitivity and specificity. Although there was a weak correlation between MMP-9 concentration and glycosylated hemoglobin, it was not statistically significant. Conclusions MMP-9 expression serves as a marker of poor wound healing. MMP-9 levels in the wound at the time of presentation may predict the healing trajectory and help tailor a specific treatment plan for each DFU patient.

The clinical importance of measuring glycaemic variability: Utilising new metrics to optimise glycaemic control

With the widespread use of continuous glucose monitoring (CGM), glycaemic variability (GV) is a glucose metric that has been gaining increasing attention. However, unlike other glucose metrics that are easily defined and have clear targets, GV has a large number of different measures given the complexity involved in assessment. While variabilities in HbA1c, fasting and postprandial glucose have been incorporated under the GV banner, short-term variability in glucose, within day and between days, is more in keeping with the correct definition of GV. This review is focused on short-term GV, as assessed by CGM data, although studies calculating GV from capillary glucose testing are also mentioned as appropriate. The different measures of GV are addressed, and their potential role in microvascular and macrovascular complications, as well as patient-related outcomes, discussed. It should be noted that the independent role of GV in vascular pathology is not always clear, given the inconsistent findings in different populations and the close association between GV and hypoglycaemia, itself an established risk factor for adverse outcomes. Therefore, this review attempts, where possible, to disentangle the contribution of GV to diabetes complications from other glycaemic parameters, particularly hypoglycaemia. Evidence to date strongly suggests an independent role for GV in vascular pathology but future large-scale outcome studies are required to fully understand the exact contribution of this metric to vascular complications. This can be followed by setting appropriate GV measures and targets in different diabetes subgroups, in order to optimise glycaemic management and limit the risk of complications.

Relationship between degree of risk factor control and all-cause mortality in individuals with type 2 diabetes: A prospective cohort study

AIMS

To assess whether and to what extent excess risk of all-cause death is reduced in individuals with type 2 diabetes by achieving optimal control of traditional cardiovascular risk factors.

METHODS

This observational, prospective, cohort study enrolled 15,773 Caucasian patients in 19 Italian centres in 2006-2008. Participants were stratified according to the number of the following risk factors outside target: haemoglobin A1c, blood pressure, micro/macroalbuminuria, current smoking, LDL cholesterol, and triglycerides. All-cause mortality was retrieved for 15,656 patients (99.3 %) on 31 October 2015.

RESULTS

Age-adjusted mortality rates and hazard ratios were significantly higher in the whole RIACE cohort (by ∼20 %) and in patients with (by ∼100 %) but not in those without prior cardiovascular disease (CVD), as compared with the coeval Italian general population. In all patients and in those without prior CVD, the relationship with mortality according to the number of risk factors outside target was J-shaped, an effect that was attenuated after either excluding "overtreated " patients, i.e., those with haemoglobin A1c ≤6.0 % on anti-hyperglycaemic agents causing hypoglycaemia and/or systolic blood pressure ≤120 mmHg on anti-hypertensive agents, or adjusting for "overtreatment". Conversely, in patients with prior CVD, mortality remained higher than in the general population in all categories and increased progressively from +70 % to +314 %, without J-effect.

CONCLUSIONS

In patients with type 2 diabetes, optimal treatment of traditional cardiovascular risk factors completely eliminated the excess mortality risk versus the general population, provided that they were not "overtreated". However, this effect was observed only in participants without history of CVD.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT00715481, retrospectively registered 15 July 2008.

Novel Insights into Diabetic Kidney Disease

Diabetic kidney disease (DKD) is a major complication of diabetes mellitus (DM), affecting over one-third of type 1 and nearly half of type 2 diabetes patients. As the leading cause of end-stage renal disease (ESRD) globally, DKD develops through a complex interplay of chronic hyperglycemia, oxidative stress, and inflammation. Early detection is crucial, with diagnosis based on persistent albuminuria and reduced estimated glomerular filtration rate (eGFR). Treatment strategies emphasize comprehensive management, including glycemic control, blood pressure regulation, and the use of nephroprotective agents such as angiotensin-converting enzyme (ACE) inhibitors, angiotensin II receptor blockers (ARBs), sodium-glucose cotransporter-2 (SGLT2) inhibitors, and glucagon-like peptide-1 (GLP-1) receptor agonists. Ongoing research explores novel therapies targeting molecular pathways and non-coding RNAs. Preventive measures focus on rigorous control of hyperglycemia and hypertension, aiming to mitigate disease progression. Despite therapeutic advances, DKD remains a leading cause of ESRD, highlighting the need for continued research to identify new biomarkers and innovative treatments.

Modern Challenges in Type 2 Diabetes: Balancing New Medications with Multifactorial Care

Type 2 diabetes mellitus (T2DM) is a prevalent chronic metabolic disorder characterized by insulin resistance and progressive beta cell dysfunction, presenting substantial global health and economic challenges. This review explores recent advancements in diabetes management, emphasizing novel pharmacological therapies and their physiological mechanisms. We highlight the transformative impact of Sodium-Glucose Cotransporter 2 inhibitor (SGLT2i) and Glucagon-Like Peptide 1 Receptor Agonist (GLP-1RA), which target specific physiological pathways to enhance glucose regulation and metabolic health. A key focus of this review is tirzepatide, a dual agonist of the glucose-dependent insulinotropic polypeptide (GIP) and GLP-1 receptors. Tirzepatide illustrates how integrating innovative mechanisms with established physiological pathways can significantly improve glycemic control and support weight management. Additionally, we explore emerging treatments such as glimins and glucokinase activators (GKAs), which offer novel strategies for enhancing insulin secretion and reducing glucose production. We also address future perspectives in diabetes management, including the potential of retatrutide as a triple receptor agonist and evolving guidelines advocating for a comprehensive, multifactorial approach to care. This approach integrates pharmacological advancements with essential lifestyle modifications-such as dietary changes, physical activity, and smoking cessation-to optimize patient outcomes. By focusing on the physiological mechanisms of these new therapies, this review underscores their role in enhancing T2DM management and highlights the importance of personalized care plans to address the complexities of the disease. This holistic perspective aims to improve patient quality of life and long-term health outcomes.

Glycemic control in diabetic patients improved overall lung cancer survival across diverse populations

BACKGROUND

The consequence of diabetes on lung cancer overall survival (OS) is debated. This retrospective study used 2 large lung cancer databases to assess comprehensively diabetes effects on lung cancer OS in diverse demographic populations, including health disparity.

METHODS

The University of Texas MD Anderson Cancer Center database (32 643 lung cancer patients with 11 973 patients with diabetes) was extracted from electronic health records (EHRs) using natural language processing (NLP). Associations were between diabetes and lung cancer prognostic features (age, sex, race, body mass index [BMI], insurance status, smoking, stage, and histopathology). Hemoglobin A1C (HgbA1c) and glucose levels assessed glycemic control. Validation was with a Louisiana cohort (17 768 lung cancer patients with 5402 patients with diabetes) enriched for health disparity cases. Kaplan-Meier analysis, log-rank test, multivariable Cox proportional hazard models, and survival tree analyses were employed.

RESULTS

Lung cancer patients with diabetes exhibited marginally elevated OS or no statistically significant difference versus nondiabetic patients. When examining OS for 2 glycemic levels (HgbA1c > 7.0 or glucose > 154 mg/dL vs HgbA1c > 9.0 or glucose > 215 mg/dL), a statistically significant improvement in OS occurred in lung cancer patients with controlled versus uncontrolled glycemia (P < .0001). This improvement spanned sex, age, smoking status, insurance status, stage, race, BMI, histopathology, and therapy. Survival tree analysis revealed that obese and morbidly obese patients with controlled glycemia had higher lung cancer OS than comparison groups.

CONCLUSION

These findings indicate a need for optimal glycemic control to improve lung cancer OS in diverse populations with diabetes.

Fasting blood glucose and the risk of all-cause mortality in patients with diabetes mellitus undergoing hemodialysis

BACKGROUND

Glycemic control is particularly important in hemodialysis (HD) patients with diabetes mellitus (DM). Although fasting blood glucose (FBG) level is an important indicator of glycemic control, a clear target for reducing mortality in HD patients with DM is lacking.

METHODS

A total of 26,162 maintenance HD patients with DM were recruited from the National Health Insurance Database of Korea between 2002 and 2018. We analyzed the association of FBG levels at the baseline health examination with the risk of all-cause and cause-specific mortality.

RESULTS

Patients with FBG 80-100 mg/dL showed a higher survival rate compared with that of other FBG categories (p < 0.001). The risk of all-cause mortality increased with the increase in FBG levels, and adjusted hazard ratios (HRs) were 1.10 (95% confidence interval [CI], 1.04-1.17), 1.21 (95% CI, 1.13-1.29), 1.36 (95% CI, 1.26-1.46), and 1.61 (95% CI, 1.51-1.72) for patients with FBG 100-125, 125-150, 150-180, and ≥180 mg/dL, respectively. The HR for mortality was also significantly increased in patients with FBG <80 mg/dL (adjusted HR, 1.14; 95% CI, 1.05-1.23). The analysis of cause-specific mortality also revealed a J-shaped curve between FBG levels and the risk of cardiovascular deaths. However, the risk of infection or malignancy-related deaths was not linearly increased as FBG levels increased.

CONCLUSION

A J-shaped association was observed between FBG levels and the risk of all-cause mortality, with the lowest risk at FBG 80-100 mg/dL in HD patients with DM.

Associations of fasting plasma glucose with all-cause mortality and cardiovascular events in older Chinese diabetes patients: A population-based cohort study

AIMS/INTRODUCTION

Our aim was to investigate the optimal fasting glucose (FPG) range in Chinese older adults with type 2 diabetes, and to clarify whether the optimal range varies according to the control of risk factors.

MATERIALS AND METHODS

The baseline survey for the cohort study began in 2018, with follow up ending in 2022. Our study enrolled 59,030 older diabetes patients with no history of cardiovascular disease (CVD). Participants were divided into nine groups based on their baseline glycemic status. The association between FPG and the risk of adverse outcomes was mainly estimated by multivariate Cox proportional risk models and restricted spline analysis.

RESULTS

During the 4-year follow-up period, a total of 5,637 deaths and 4,904 CVD events occurred. The associations of FPG with mortality and CVD events showed J-shaped curves. Among all-cause deaths, the hazard ratios for FPG ≤4.50 and >11.50 mmol/L were 1.50 (95% confidence interval [CI] 1.31-1.71) and 1.84 (95% CI 1.67-2.02). Among CVD, the hazard ratios for FPG ≤4.50 and >11.50 mmol/L were 1.31 (95% CI 1.13-1.53) and 1.71 (95% CI 1.54-1.89), respectively. The optimal FPG ranges of all-cause mortality and CVD were 5.50-7.50 and 4.50-7.50 mmol/L, respectively. For participants with at least two risk factors, the optimal FPG levels were higher than those with fewer risk factors.

CONCLUSIONS

In older Chinese diabetes patients, the FPG ranges related to the minimum death and CVD event rates were 5.50-7.50 and 4.50-7.50 mmol/L, respectively. Patients with more cardiovascular risk factors had higher optimal blood glucose ranges than those with fewer risk factors.

A deprescribing programme aimed to optimise blood glucose-lowering medication in older people with type 2 diabetes mellitus, the OMED2-study: the study protocol for a randomised controlled trial

BACKGROUND

Older patients with type 2 diabetes mellitus (T2D) have an increased risk of hypoglycaemic episodes when using sulphonylureas or insulin. In the Netherlands, guidelines exist for reducing glucose-lowering medication in older patients. However, evidence is lacking that a medication reduction in older patients can be safely pursued. Here, we will examine if promoting the deprescribing of insulin/sulphonylureas with a deprescribing programme (DPP) in general practice affects T2D-complications in older overtreated patients.

METHODS

We will perform a 1:1 cluster randomised controlled trial in 86 general practices in the Netherlands. The DPP will consist of education sessions with general practitioners and practice nurses about reducing glucose-lowering medication in older patients (≥ 70 years). Topics of the sessions include the necessity of deprescribing, tools to initiate deprescribing and strategies to discuss deprescribing with patients (shared decision making). The DPP further includes a support programme with practice visits. The study will employ a selection tool to identify possibly overtreated older patients from the electronic medical records of the general practitioner. Eligibility for enrolment in the study will be based on HbA1c targets indicated by the Dutch guidelines, which depend on age, diabetes duration, presence of frailty, and life expectancy. The control group will provide usual care. We aim to include 406 patients. The follow-up period will be 2 years. For the primary outcome, the effect of the DPP on T2D-complications will be assessed by counting the cumulative incidence of events related to under- and overtreatment in T2D as registered in the electronic medical records. We shall perform an intention-to-treat analysis and an analysis including only patients for whom deprescribing was initiated. The implementation of the DPP in general practice will be evaluated quantitatively and qualitatively using the Extended Normalisation Process Theory (ENPT) and the Reach, Efficacy - Adoption, Implementation and Maintenance (RE-AIM) model. Other secondary outcomes include quality of life, cognitive functioning, events related to overtreatment or undertreatment, biomarkers of health, amount of blood glucose-lowering medication prescriptions, and cost-effectiveness.

DISCUSSION

This study will provide insight into the safety and feasibility of a programme aimed at deprescribing sulphonylureas/insulin in older people with T2D who are treated in general practice.

TRIAL REGISTRATION

ISRCTN Registry, ISRCTN50008265 , registered 09 March, 2023.

The association between previous use of anti-obesity medication and semaglutide weight loss outcomes

AIMS

To compare weight loss outcomes between patients starting semaglutide who had previously been on another anti-obesity medication (AOM) compared to those who were AOM-naïve.

MATERIALS AND METHODS

We performed a retrospective study in patients with overweight or obesity taking semaglutide for weight loss for a duration of 3 to 12 months. Our primary endpoint was assessment of percentage of total body weight loss (TBWL) in patients who started semaglutide as their first AOM (AOM-naïve) compared to those who started semaglutide and had previously taken another AOM (non-AOM-naïve). The secondary outcome was a comparison of the proportions of patients achieving ≥5%, ≥10%, ≥15% and ≥20% TBWL between the groups. Our endpoints were analysed using independent t-tests and ANOVA/ANCOVA for continuous variables and Pearson's test for categorical variables.

RESULTS

This study included 305 patients. Outcomes of semaglutide treatment were superior in AOM-naïve patients (n = 231) compared to non-AOM-naïve patients (n = 74) at 3 (6.3% vs. 3.8%), 6 (10.6% vs. 6.7%), 9 (14.0% vs. 9.1%) and 12 months (14.3% vs. 10.6%; p < 0.0001 at 3, 6 and 9 months, and p = 0.01 at 12 months). A greater proportion of patients in the AOM-naïve group achieved a TBWL ≥ 15% (48% vs 21%; p = 0.02) and ≥20% (27% vs 4% p < 0.01) at 12 months.

CONCLUSION

The use of semaglutide in patients with previous intake of other AOMs was associated with inferior weight loss outcomes in comparison to patients who were AOM-naïve.

Assessing Glycosylated Hemoglobin Thresholds for Development of Cardiovascular Disease by Racial and Ethnic Groups

BACKGROUND

Diabetes is the strongest risk factor for cardiovascular disease, and although glycosylated hemoglobin (HbA1c) levels are known to vary by race, no racial and ethnic-specific diagnostic thresholds exist for diabetes in prediction of cardiovascular disease events. The purpose of this study is to determine whether HbA1c thresholds for predicting major adverse cardiovascular events (MACEs) differ among racial and ethnic groups.

METHODS AND RESULTS

This is a retrospective cohort study of Kaiser Permanente Northern California adult members (n=309 636) with no history of cardiovascular disease who had HbA1c values and race and ethnicity data available between 2014 and 2019. Multivariable logistic regression was used to evaluate the odds of MACEs by the following racial and ethnic groups: Filipino, South Asian, East Asian, Black, White, and Hispanic. A Youden index was used to calculate HbA1c thresholds for MACE prediction by each racial and ethnic group, stratified by sex. Among studied racial and ethnic groups, South Asian race was associated with the greatest odds of MACEs (1.641 [95% CI, 1.456-1.843]; P<0.0001). HbA1c was a positive predictor for MACEs, with an odds ratio of 1.024 (95% CI, 1.022-1.025) for each 0.1% increment increase in HbA1c. HbA1c values varied between 6.0% and 7.6% in MACE prediction by race and ethnicity and sex. White individuals, South Asian individuals, East Asian women, and Black men had HbA1c thresholds for MACE prediction in the prediabetic range, between 6.0% and 6.2%. Black women, Hispanic men, and East Asian men had HbA1c thresholds of 6.2% to 6.6%, less than the typical threshold of 7.0% that is used as a treatment goal.

CONCLUSIONS

Findings suggest that the use of race and ethnic- and sex-specific HbA1c thresholds may need to be considered in treatment goals and cardiovascular disease risk estimation.

Cardiovascular risk reduction in older people with type 2 diabetes mellitus-a comprehensive narrative review

Metabolic targets are controversial in older people with type 2 diabetes due to functional heterogeneity and morbidity burden. Tight blood pressure and metabolic control appears beneficial in fit individuals who are newly diagnosed with type 2 diabetes and have fewer comorbidities. The benefits of low blood pressure and tight metabolic control is attenuated with the development of comorbidities, especially frailty. Guidelines consider frail older people as one category and recommend relaxed targets. However, sarcopenic obese frail individuals may benefit from tight targets and intensification of therapy due to their unfavourable metabolic profile, accelerated diabetes trajectory and high cardiovascular risk. In addition, the early use of sodium glucose transporter-2 inhibitors and glucagon like peptide-1 receptor agonists may be beneficial in this frailty phenotype due to their cardio-renal protection, which is independent of glycaemic control, provided they are able to engage in resistance exercise training to avoid loss of muscle mass. In the anorexic malnourished frail individual, early use of insulin, due to its weight gain and anabolic properties, is appropriate. In this phenotype, targets should be relaxed with deintensification of therapy due to significant weight loss, decelerated diabetes trajectory and increased risk of medication side effects.

Optimal Coefficient of Variance Threshold to Minimize Hypoglycemia Risk in Individuals with Well-Controlled Type 1 Diabetes Mellitus

BACKGRUOUND

This study investigated the optimal coefficient of variance (%CV) for preventing hypoglycemia based on real-time continuous glucose monitoring (rt-CGM) data in people with type 1 diabetes mellitus (T1DM) already achieving their mean glucose (MG) target.

METHODS

Data from 172 subjects who underwent rt-CGM for at least 90 days and for whom 439 90-day glycemic profiles were available were analyzed. Receiver operator characteristic analysis was conducted to determine the cut-off value of %CV to achieve time below range (%TBR)<54 mg/dL <1 and =0.

RESULTS

Overall mean glycosylated hemoglobin was 6.8% and median %TBR<54 mg/dL was 0.2%. MG was significantly higher and %CV significantly lower in profiles achieving %TBR<54 mg/dL <1 compared to %TBR<54 mg/dL ≥1 (all P<0.001). The cut-off value of %CV for achieving %TBR<54 mg/dL <1 was 37.5%, 37.3%, and 31.0%, in the whole population, MG >135 mg/dL, and ≤135 mg/dL, respectively. The cut-off value for %TBR<54 mg/dL=0% was 29.2% in MG ≤135 mg/dL. In profiles with MG ≤135 mg/dL, 94.2% of profiles with a %CV <31 achieved the target of %TBR<54 mg/dL <1, and 97.3% with a %CV <29.2 achieved the target of %TBR<54 mg/ dL=0%. When MG was >135 mg/dL, 99.4% of profiles with a %CV <37.3 achieved %TBR<54 mg/dL <1.

CONCLUSION

In well-controlled T1DM with MG ≤135 mg/dL, we suggest a %CV <31% to achieve the %TBR<54 mg/dL <1 target. Furthermore, we suggest a %CV <29.2% to achieve the target of %TBR<54 mg/dL =0 for people at high risk of hypoglycemia.

Mortality in the Glycemia Reduction Approaches in Diabetes: A Comparative Effectiveness Study (GRADE)

OBJECTIVE

We report mortality outcomes in the Glycemia Reduction Approaches in Diabetes: A Comparative Effectiveness Study (GRADE) among people with type 2 diabetes diagnosed within 10 years and no recent history of cardiovascular events or cancer.

RESEARCH DESIGN AND METHODS

Overall mortality rates and major causes of death were assessed over an average of 5 years of follow-up. Cause of death was adjudicated centrally by a committee masked to treatment assignment. We examined baseline covariates and the 10-year Framingham Risk Score for associations.

RESULTS

Mortality rate was low (0.59 per 100 participant-years). Participants who died during follow-up were likely to be older, be male, have a history of hypertension, have a history of smoking, and have moderate albuminuria. The two most common underlying causes of death were "cardiovascular-cause" (a composite of underlying causes) (38.6%) and cancer (26.8%). There were no differences by treatment group.

CONCLUSIONS

Among people with diabetes of relatively short duration, cause of death was varied. Attention to health risks beyond cardiovascular diseases is warranted.

Glycemic control and dementia risk in patients aged above and below 75 years

Background

There is a lack of data about the treatment effect of glycemic control on incident dementia in patients with advanced age.

Methods

In a nationwide Korean cohort of 79,076 diabetic patients 75 years or older and a representative cohort of 74,672 diabetics aged 50 to 74 years, multivariable-adjusted incidence of overt dementia was estimated across yearly-averaged on-treatment fasting blood glucose (FBG) levels.

Results

During 9-year follow-up, overt dementia was noted in 24,710 (31.2%) patients 75 years or older and in 5237 (7.0%) patients aged 50 to 74 years. For dementia risk, J-shaped associations were observed across on-treatment FBG levels (80-99, 100-109, 110-125, 126-139, 140-159, 160-179, and 180-900 mg/dl) in patients 75 years or older (respective incidence: 49.3, 45.7, 45.9, 45.7, 48.5, 51.5, and 57.9 per 1000 person-years) and in those aged 50 to 74 years (respective incidence: 8.9, 8.3, 7.7, 7.6, 8.0, 8.6, and 10.6 per 1000 person-years) with a significant interaction of FBG level and age group (P = 0.001). For all-cause mortality, the J-shaped association curve was left-shifted in patients 75 years or older (respective incidence: 64.9, 59.1, 57.6, 60.4, 64.0, 70.9, and 90.4 per 1000 person-years) relative to that in patients aged 50 to 74 years (respective incidence: 15.7, 13.4, 12.3, 12.2, 13.4, 15.7, and 21.8 per 1000 person-years; P < 0.001 for interaction).

Conclusion

The achieved glycemic level with the lowest risk for dementia and mortality was lower in older patients, and absolute risk increase related to poorly controlled glucose was greater in the elderly compared with younger patients.

Supplementary Information

The online version contains supplementary material available at 10.1007/s13340-023-00684-4.

Combined-task deep network based on LassoNet feature selection for predicting the comorbidities of acute coronary syndrome

Acute coronary syndrome (ACS) is a multifaceted cardiovascular condition frequently accompanied by multiple comorbidities, which can have significant implications for patient outcomes and treatment approaches. Precisely predicting these comorbidities is crucial for providing personalized care and making well-informed clinical decisions. However, there is a shortage of research investigating the identification of risk factors associated with ACS comorbidities and accurately predicting their likelihood of occurrence beyond heart failure. In this study, an approach called Combined-task Deep Network based on LassoNet feature selection (CDNL) is presented for predicting ACS comorbidities, including hypertension, diabetes, hyperlipidemia, and heart failure. In order to identify crucial biomarkers associated with ACS comorbidities, the proposed framework first incorporates LassoNet, which extends Lasso regression to the deep network by adding a skip (residual) layer. Additionally, a correlation score calculation method across tasks is introduced based on measuring the overlap of identified biomarkers and their assigned importance. This method enables the development of an optimal combined-task prediction model for each ACS comorbidity, addressing the challenge of limited representations in traditional multi-task learning. Our evaluation, conducted through a meticulous cross-sectional study at a tertiary hospital in China, involved a dataset of 2941 samples with 42 clinical features. The results demonstrate that CDNL facilitates the identification of significant biomarkers and achieves an average improvement in AUC of 4.93% and 8.58% compared to deep learning multi-layer neural network (DNN) and SVM, respectively. Additionally, it shows an average improvement of 2.64% and 1.92% compared to two state-of-the-art multi-task models.

What are the consequences of over and undertreatment of type 2 diabetes mellitus in a frail population? A systematic review

AIMS

This review aims to identify the evidence base for the consequences of over and undertreatment of type 2 diabetes mellitus in a frail population.

METHOD

In this systematic review, we searched MEDLINE, Embase, PubMed, CINAHL and the Cochrane Library for studies from January 2001 to 15th August 2022. We included a variety of study types that assessed and reported frailty including patients ≥18 years old. Studies included those that reported the prevalence of over or undertreatment of diabetes mellitus in a frail population and those examining outcomes related to glucose control in frail older people living with diabetes. Data were extracted using a bespoke extraction table using a narrative synthesis approach.

RESULTS

A total of 4114 articles were identified with 112 meeting inclusion criteria. These included 15,130 participants across the 11 studies with sample sizes ranging from 101 to 11,140. Several areas were identified in the included studies where under or overtreatment of diabetes impacted outcomes for patients. These included hospital admissions, readmissions, length of stay, falls, mortality, cognitive impairment and cardiovascular disease outcomes.

CONCLUSION

The results showed that there was a high heterogeneity of outcomes between the studies and that many examined small numbers of participants. In this review, both over and undertreatment were shown to increase adverse outcomes in frail older people. Further research around optimal glycaemic control for frail older people living with diabetes is required with the aim to identify ideal target ranges and produce practical clinical guidelines to promote attainment of these.

Impact of two COVID-19 lockdowns on HbA1c levels in patients with type 2 diabetes and associations with patient characteristics: a multicentre, observational cohort study over three years

Introduction

Glycemic effects of COVID-19 lockdowns on patients with type 2 diabetes (T2D) are controversial. In this long-term observation, we aimed (1) to analyze changes in HbA1c levels during lockdowns in Germany, and (2) to investigate whether diabetes medication, comorbidities, and sociodemographic data influenced these changes.

Materials and methods

This cohort study observed 1,089 patients aged ≥18 years over the years 2019 to 2021. Patients were recruited from 14 physicians specialized on diabetes. As dependent variable, 7,987 HbA1c values were analyzed by multivariable linear regression adjusted for random effects of physicians and patients.

Results

Patients had a median age of 68 (60/76) years and 623 (57.2%) were male. Before the pandemic, median HbA1c level (in %) was 6.9 (6.3/7.7). Average HbA1c level increased during first lockdown (0.21,0.11/0.31,p < 0.001), after first lockdown (0.23,0.18/0.28,p < 0.001), during second lockdown (0.40,0.33/0.47,p < 0.001) and after second lockdown (0.27,0.18/0.36,p < 0.001). The increase of HbA1c levels was more pronounced in male patients (0.08,0.01/0.15,p = 0.019), if patients did not have German as native language (0.12,0.01/0.23,p = 0.041) and if they were widowed (0.19,0.05/0.32,p = 0.008). End organ damages (0.12,0.01/0.23,p = 0.039), atherosclerotic cardiovascular disease (ASCVD; 0.23,0.10/0.36,p = 0.001) and cardiovascular events (0.25,0.10/0.40,p = 0.001) as well as oral medication (0.09,0.03/0.15,p = 0.002), intermediate- or long-acting insulins (0.24,0.16/0.32,p < 0.001), and fast-acting or mixed insulins (0.30,0.23/0.36,p < 0.001) were also related to a greater increase in HbA1c levels.

Conclusion

Both lockdowns resulted in a significant increase in HbA1c levels. In particular, patients with ASCVD, cardiovascular events, and insulin therapy appear to be at risk for worsening glycemic control in crisis and thus require special medical attention.

Clinical Trial Registration

ClinicalTrials.gov (NCT04821921).

Old and Novel Predictors for Cardiovascular Risk in Diabetic Foot Syndrome—A Narrative Review

Diabetic foot syndrome (DFS) is a complication associated with diabetes that has a strong negative impact, both medically and socio-economically. Recent epidemiological data show that one in six patients with diabetes will develop an ulcer in their lifetime. Vascular complications associated with diabetic foot have multiple prognostic implications in addition to limiting functional status and leading to decreased quality of life for these patients. We searched the electronic databases of PubMed, MEDLINE and EMBASE for studies that evaluated the role of DFS as a cardiovascular risk factor through the pathophysiological mechanisms involved, in particular the inflammatory ones and the associated metabolic changes. In the era of evidence-based medicine, the management of these cases in multidisciplinary teams of “cardio-diabetologists” prevents the occurrence of long-term disabling complications and has prognostic value for cardiovascular morbidity and mortality among diabetic patients. Identifying artificial-intelligence-based cardiovascular risk prediction models or conducting extensive clinical trials on gene therapy or potential therapeutic targets promoted by in vitro studies represent future research directions with a modulating role on the risk of morbidity and mortality in patients with DFS.

Association of hemoglobin A1c stability with mortality and diabetes complications in older adults with diabetes

INTRODUCTION

Hemoglobin A1c (A1c) treatment goals in older adults should be individualized to balance risks and benefits. It is unclear if A1c stability over time within unique target ranges also affects adverse outcomes.

RESEARCH DESIGN AND METHODS

We conducted a retrospective observational cohort study from 2004 to 2016 of veterans with diabetes and at least four A1c tests during a 3-year baseline. We generated four distinct categories based on the percentage of time that baseline A1c levels were within patient-specific target ranges: ≥60% time in range (TIR), ≥60% time below range (TBR), ≥60% time above range (TAR), and a mixed group with all times <60%. We assessed associations of these categories with mortality, macrovascular, and microvascular complications.

RESULTS

We studied 397 634 patients (mean age 76.9 years, SD 5.7) with an average of 5.5 years of follow-up. In comparison to ≥60% A1c TIR, mortality was increased with ≥60% TBR, ≥60% TAR, and the mixed group, with HRs of 1.12 (95% CI 1.11 to 1.14), 1.10 (95% CI 1.08 to 1.12), and 1.06 (95% CI 1.04 to 1.07), respectively. Macrovascular complications were increased with ≥60% TBR and ≥60% TAR, with estimates of 1.04 (95% CI 1.01 to 1.06) and 1.06 (95% CI 1.03 to 1.09). Microvascular complications were lower with ≥60% TBR (HR 0.97, 95% CI 0.95 to 1.00) and higher with ≥60% TAR (HR 1.11, 95% CI 1.08 to 1.14). Results were similar with higher TIR thresholds, shorter follow-up, and competing risk of mortality.

CONCLUSIONS

In older adults with diabetes, mortality and macrovascular complications are associated with increased time above and below individualized A1c target ranges. Higher A1c TIR may identify patients with lower risk of adverse outcomes.

The association of glycated hemoglobin A1c with coronary artery disease, myocardial infarction, and severity of coronary lesions

Glycated hemoglobin A1c (HbA1c) has been recognized as a predictor of cardiovascular events. However, the relationship between HbA1c and coronary artery disease (CAD) in the Chinese population has yet to be systematically explored. In addition, factors associated with HbA1c were generally analyzed linearly, thereby failing to appreciate more complex nonlinear associations. The study aimed to evaluate the relationship between the HbA1c value and the presence and severity of coronary artery stenosis. A total of 7192 consecutive patients who underwent coronary angiography were enrolled. Their biological parameters, including HbA1c, were measured. The severity of coronary stenosis was evaluated using Gensini score. After correcting for baseline confounding factors, a multivariate logistic regression analysis was used to evaluate the relationship between HbA1c and CAD severity. Restricted cubic splines were applied to explore the relation of HbA1c with the presence of CAD, myocardial infarction (MI), and the severity of coronary lesions. HbA1c was significantly associated with the presence and severity of CAD in patients without diagnosed diabetes (odds ratio: 1.306, 95% confidence interval: 1.053-1.619, p = 0.015). Spline analysis showed a U-shaped association of HbA1c with the presence of MI. Both HbA1c > 7.2% and HbA1c < 5.7% were associated with the presence of MI. In conclusion, HbA1c value was highly associated with the severity of coronary artery stenosis in the whole study population, and in CAD patients without diagnosed diabetes. Compared with patients with HbA1c levels between 6.0% and 7.0%, HbA1c < 5.7% and HbA1c > 7.2% were associated with higher presence of MI.

Narrative Review of glycaemic management in people with diabetes on peritoneal dialysis

There is an increasing number of people with diabetes on peritoneal dialysis (PD) worldwide. However, there is a lack of guidelines and clinical recommendations for managing glucose control in people with diabetes on PD. The aim of this review is to provide a summary of the relevant literature and highlight key clinical considerations with practical aspects in the management of diabetes in people undergoing PD. A formal systematic review was not conducted because of the lack of sufficient and suitable clinical studies. A literature search was performed using PubMed, MEDLINE, Central, Google Scholar and ClinicalTrials.gov., from 1980 through February 2022. The search was limited to publications in English. This narrative review and related guidance have been developed jointly by diabetologists and nephrologists, who reviewed all available current global evidence regarding the management of diabetes in people on PD.We focus on the importance of individualized care for people with diabetes on PD, the burden of hypoglycemia, glycemic variability in the context of PD and treatment choices for optimizing glucose control. In this review, we have summarized the clinical considerations to guide and inform clinicians providing care for people with diabetes on PD.

Association of dietary magnesium intake and glycohemoglobin with mortality risk in diabetic patients

BACKGROUND

Dietary magnesium intake inversely correlated to risk of death in general population. However, it is relatively unknown whether the beneficial effect remains significant in individuals with diabetes. Our study purpose is to evaluate the association of dietary magnesium intake with mortality risk in diabetic population.

METHODS

The study population is recruited from 2003-2014 National Health and Nutrition Examination Survey, totaling 2,045 adults with diabetes being included. Participants were divided based on glycohemoglobin (HbA1c < 7% and ≥ 7%) and daily dietary magnesium intake (≤ and > 250mg/day) ascertained by 24-hour dietary recall interviews.

RESULTS

The average age of the study population was 52.9±10.1 years, with 49.1% being male. During a median follow-up of 77.0 months (interquartile range: 45.0-107.0 months), a total of 223 participants died (1.5 per 1000 person-months). Our results showed that individuals with lower dietary magnesium intake (≤250mg/day) had higher risk of all-cause (HR: 1.56, 95% CI: 1.13-2.16) and other-cause (non-cardiovascular and non-cancer) mortality (HR: 1.68, 95% CI: 1.09-2.60), while cardiovascular and cancer-related mortality were similar compared with individuals with magnesium intake > 250mg/day. We also showed that the risk of all-cause (HR: 1.86, 95% CI: 1.33-2.60) and other-cause mortality (HR: 2.03, 95% CI: 1.29-3.19) were higher in individuals with poorly controlled diabetes (HbA1c ≥7.0%) compared with HbA1c <7.0%; however, the association attenuated in the subgroup of higher magnesium intake (>250mg/day). When combining HbA1c and dietary magnesium intake, we showed that individuals with HbA1c ≥ 7% and dietary magnesium intake ≤ 250 mg/day had higher all-cause and other-cause (non-cardiovascular and non-cancer) mortality risk compared with those with HbA1c < 7% and/or dietary magnesium intake > 250 mg/day.

CONCLUSION

Higher magnesium intake may help reduce mortality risk in individuals with diabetes and attenuate mortality risk of poor diabetic control.

Admission glucose as a prognostic marker for all-cause mortality and cardiovascular disease

BACKGROUND

Diabetes and prediabetes are known risk factors for cardiovascular disease and associated with increased mortality risk. Whether patients with a random elevated blood glucose level but no history of diabetes are at a higher mortality and cardiovascular risk is not entirely known.

METHODS

A retrospective cohort study where patients (18-80 years) with no history of diabetes between 2006 and 2016 attending the emergency department (ED) in Sweden were included. Based on the first (index) blood glucose level patients were categorized into four groups: hypoglycemia (< 3.9 mmol/L), normal glucose tolerance (NGT) (3.9-7.8 mmol/L), dysglycemia (7.8-11.1 mmol/L), and hyperglycemia (> 11.1 mmol/L). Data was collected from four nationwide registers (National Patient Register, National Cause of Death Register, Prescribed Drug Register and Statistics Sweden). Cox regression was used to calculate adjusted hazard ratios (HR) with 95% confidence intervals (CI) for all-cause mortality and cardiovascular outcomes using NGT as reference.

RESULTS

618,694 patients were included during a mean follow-up time of 3.9 years. According to the index blood glucose level: 1871 (0.3%) had hypoglycemia, 525,636 (85%) had NGT, 77,442 (13%) had dysglycemia, and 13,745 (2%) patients had hyperglycemia, respectively. During follow-up 44,532 (7.2%) deaths occurred. After multiple adjustments, mortality risk was highest in patients with hypoglycemia HR 2.58 (2.26-2.96) followed by patients with hyperglycemia HR 1.69 (1.63-1.76) and dysglycemia HR 1.16 (1.13-1.19). Risk for cardiovascular events: i.e., myocardial infarction, stroke and heart failure, were highest among patients with hyperglycemia HR 2.28 (2.13-2.44), HR 1.62 (1.51-1.74) and HR 1.60 (1.46-1.75), respectively.

CONCLUSION

Patients with disturbed blood glucose level at ED admission have a higher mortality risk than patients with NGT. Patients with hyperglycemia have almost a two folded increased long-term mortality risk and more than a doubled risk for cardiovascular events compared to patients with NGT.

[Integrating hypertension and diabetes management in primary health care settings: HEARTS as a toolIntegrando o manejo da hipertensão e do diabetes na atenção primária à saúde: uso do HEARTS como instrumento]

Hypertension and diabetes are modifiable cardiovascular disease (CVD) risk factors that contribute to nearly one-third of all deaths in the Americas Region each year (2.3 million deaths). Despite advances in the detection and clinical management of hypertension and diabetes, there are substantial gaps in their implementation globally and in the Region. The considerable overlap in risk factors, prognosis, and treatment of hypertension and diabetes creates a unique opportunity for a unified implementation model for management at the population level. This report highlights one such high-profile effort, the Pan American Health Organization's "HEARTS in the Americas" program, based on the World Health Organization's HEARTS Technical Package for Cardiovascular Disease Management in Primary Health Care. The HEARTS program aims to improve the implementation of preventive CVD care in primary health systems using six evidence-based, pragmatic components: Healthy-lifestyle counseling, Evidence-based protocols, Access to essential medicines and technology, Risk-based CVD management, Team-based care, and Systems for monitoring. To date, HEARTS implementation projects have focused primarily on hypertension given that it is the leading modifiable CVD risk factor and can be treated cost-effectively. The objective of this report is to describe opportunities for integration of diabetes clinical care and policy within the HEARTS hypertension framework. A substantial global burden of disease could be averted with integrated primary care management of these conditions. Thus, there is an urgency in applying lessons from HEARTS to close these implementation gaps and improve the integrated detection, treatment, and control of diabetes and hypertension.

Prevalence and predictors of clinical inertia in patients with type 2 diabetes who were treated with a single oral antidiabetic drug

AIMS/INTRODUCTION

Clinical inertia, defined as a failure of healthcare providers to initiate or intensify treatment when indicated, is one of the challenges in achieving glycemic targets in type 2 diabetes patients.

MATERIALS AND METHODS

Using a Japanese medical database compiled from Diagnostic Procedure Combination hospitals, this retrospective study investigated clinical inertia in type 2 diabetes patients treated with a single oral antidiabetic drug. We analyzed predictors of clinical inertia, measured the time to treatment intensification, and monitored patients' glycemic control and renal function for 2 years. The index date was defined as the first date of hemoglobin A1c ≥7.0% during the 180 (±60) days after the first oral antidiabetic drug was prescribed.

RESULTS

Clinical inertia was identified in 35.3% of patients. The median time to treatment intensification from the index date was 75.5 days. The proportion of patients achieving hemoglobin A1c <7.0% within 2 years was 33.8% with clinical inertia, and 47.9% without clinical inertia. Multivariate logistic regression analysis showed that Charlson Comorbidity Index score and an interval between visits of ≥6 weeks significantly increased the risk of developing clinical inertia, and hyperlipidemia and higher hemoglobin A1c at baseline significantly decreased the risk.

CONCLUSIONS

This study showed that clinical inertia in type 2 diabetes patients treated with a single oral antidiabetic drug might have a lasting effect on long-term glycemic control. Our findings will inform clinicians of the characteristics of patients associated with clinical inertia and the importance of providing appropriate treatment under clinical practice guidelines.

American Association of Clinical Endocrinology Clinical Practice Guideline: Developing a Diabetes Mellitus Comprehensive Care Plan-2022 Update

OBJECTIVE

The objective of this clinical practice guideline is to provide updated and new evidence-based recommendations for the comprehensive care of persons with diabetes mellitus to clinicians, diabetes-care teams, other health care professionals and stakeholders, and individuals with diabetes and their caregivers.

METHODS

The American Association of Clinical Endocrinology selected a task force of medical experts and staff who updated and assessed clinical questions and recommendations from the prior 2015 version of this guideline and conducted literature searches for relevant scientific papers published from January 1, 2015, through May 15, 2022. Selected studies from results of literature searches composed the evidence base to update 2015 recommendations as well as to develop new recommendations based on review of clinical evidence, current practice, expertise, and consensus, according to established American Association of Clinical Endocrinology protocol for guideline development.

RESULTS

This guideline includes 170 updated and new evidence-based clinical practice recommendations for the comprehensive care of persons with diabetes. Recommendations are divided into four sections: (1) screening, diagnosis, glycemic targets, and glycemic monitoring; (2) comorbidities and complications, including obesity and management with lifestyle, nutrition, and bariatric surgery, hypertension, dyslipidemia, retinopathy, neuropathy, diabetic kidney disease, and cardiovascular disease; (3) management of prediabetes, type 2 diabetes with antihyperglycemic pharmacotherapy and glycemic targets, type 1 diabetes with insulin therapy, hypoglycemia, hospitalized persons, and women with diabetes in pregnancy; (4) education and new topics regarding diabetes and infertility, nutritional supplements, secondary diabetes, social determinants of health, and virtual care, as well as updated recommendations on cancer risk, nonpharmacologic components of pediatric care plans, depression, education and team approach, occupational risk, role of sleep medicine, and vaccinations in persons with diabetes.

CONCLUSIONS

This updated clinical practice guideline provides evidence-based recommendations to assist with person-centered, team-based clinical decision-making to improve the care of persons with diabetes mellitus.

Association between the Diabetes Drug Cost and Cardiovascular Events and Death in Korea: A National Health Insurance Service Database Analysis

BACKGRUOUND

This study aimed to investigate the long-term effects of diabetes drug costs on cardiovascular (CV) events and death.

METHODS

This retrospective observational study used data from 2009 to 2018 from the National Health Insurance in Korea. Among the patients with type 2 diabetes, those taking antidiabetic drugs and who did not have CV events until 2009 were included. Patients were divided into quartiles (Q1 [lowest]-4 [highest]) according to the 2009 diabetes drug cost. In addition, the 10-year incidences of CV events (non-fatal myocardial infarction, stroke, hospitalization for heart failure, and coronary revascularization) and CV death (death due to CV events) were analyzed.

RESULTS

A total of 441,914 participants were enrolled (median age, 60 years; men, 57%). CV events and death occurred in 28.1% and 8.36% of the patients, respectively. The 10-year incidences of CV events and deaths increased from Q1 to 4. After adjusting for sex, age, income, type of diabetes drugs, comorbidities, and smoking and drinking status, the risk of CV events significantly increased according to the sequential order of the cost quartiles. In contrast, the risk of CV death showed a U-shaped pattern, which was the lowest in Q3 (hazard ratio [HR], 0.953; 95% confidence interval [CI], 0.913 to 0.995) and the highest in Q4 (HR, 1.266; 95% CI, 1.213 to 1.321).

CONCLUSION

Diabetes drug expenditure affects 10-year CV events and mortality. Therefore, affording an appropriate diabetes drug cost at a similar risk of CV is an independent protective factor against CV death.

The Importance of Continuous Glucose Monitoring-derived Metrics Beyond HbA1c for Optimal Individualized Glycemic Control

CONTEXT

Current guidelines recommend assessing glycemic control using continuous glucose monitoring (CGM) and hemoglobin A1c (HbA1c) measurement.

OBJECTIVE

This study aimed to clarify the characteristics of patients who might benefit from CGM metrics in addition to HbA1c monitoring.

METHODS

CGM metrics, specifically time in range (TIR), time below range (TBR), and time above range (TAR), were determined in 999 outpatients with type 2 diabetes and compared between HbA1c categories (HbA1c < 53 mmol/mol [7.0%, HbA1c <  53], HbA1c 53-63 mmol/mol [7.0-7.9%, HbA1c 53-63], HbA1c 64-74 mmol/mol [8.0-8.9%, HbA1c 64-74], and HbA1c ≥ 75 mmol/mol [9.0%, HbA1c ≥  75]) and between patients with identical HbA1c categories who were stratified by age, types of antidiabetic agents, and renal function.

RESULTS

For HbA1c <  53 category, patients aged ≥ 65 years had a significantly higher nocturnal TBR than those aged < 65 years. For HbA1c <  53 and HbA1c 53-63 categories, patients receiving insulin and/or sulfonylureas had a significantly higher TAR and TBR, and a lower TIR than those not receiving these drugs, and for HbA1c 64-74 category, they had a significantly higher TBR. For HbA1c <  53, HbA1c 53-63, and HbA1c 64-74 categories, patients with an estimated glomerular filtration rate (eGFR) < 60 mL/min/1.73 m2 had a significantly higher TBR during some periods than those with an eGFR ≥ 60.

CONCLUSION

Higher HbA1c levels do not always protect against hypoglycemic episodes. Our data demonstrate that using CGM metrics to complement HbA1c monitoring is beneficial, especially in older people, users of insulin and/or sulfonylureas, and patients with chronic kidney disease.

Relationship among Insulin Therapy, Insulin Resistance, and Severe Coronary Artery Disease in Type 2 Diabetes Mellitus

Objectives

The effect of insulin therapy on coronary artery disease (CAD) remains controversial. This study aimed to analyze the association between insulin resistance and the morbidity of severe CAD in type 2 diabetes mellitus (T2DM).

Methods

A total of 2044 T2DM patients aged ≥40 years were included in this cross-sectional observational study. Clinical information and laboratory results were collected from the medical records. Those who underwent percutaneous coronary intervention (PCI) were classified as severe CAD, while those who did not have a history of and were not suffering from CAD were classified as patients without CAD.

Results

T2DM patients with severe CAD and without CAD had no significant differences in glycosylated hemoglobin A1c (8.55% ± 2.10% vs. 8.39% ± 1.77%, P=0.234). The proportion of insulin treatment was also similar between the two groups (56.85% vs. 53.65%, odds ratio = 1.138, P=0.310). In the patients without insulin treatment, the levels of fasting C peptide (FCP) correlated with severe CAD prevalence. FCP was categorized into 3 tertiles (<1.5 ng/mL, 1.5 ng/mL- 3 ng/mL, and ≥3 ng/mL), and the prevalence rates of severe CAD were 7.88%, 14.31%, and 18.28%, respectively (P < 0.05). In the patients with insulin treatment, the body mass index (BMI) was the significant risk factor of severe CAD. The prevalence of severe CAD according to BMI tertiles (<24 kg/m², 24 kg/m²–28 kg/m², and ≥28 kg/m²) was 11.22%, 14.61%, and 24.62%, respectively (P < 0.01).

Conclusions

Our results showed that insulin resistance, rather than insulin therapy, increases the risk of severe CAD in T2DM patients with inadequate glycemic control. Non-insulin treated patients with high FCP and insulin-treated patients with high BMI are at higher risk of severe CAD.

Association of poorly controlled HbA1c with increased risk of progression to end-stage kidney disease and all-cause mortality in patients with diabetes and chronic kidney disease

Glycosylated hemoglobin (HbA1c) targets for patients with chronic kidney disease (CKD) and type 2 diabetes remain controversial. To evaluate whether baseline HbA1c and HbA1c trajectories are associated with the risk of end-stage kidney disease (ESKD) and all-cause mortality, we recruited adult patients with CKD and type 2 diabetes from a "Pre-ESKD Program" at a medical center in Taiwan from 2003 to 2017. Group-based trajectory modeling was performed to identify distinct patient groups that contained patients with similar longitudinal HbA1c patterns. Cox proportional hazard models were used to estimate hazard ratios (HRs) of ESKD and mortality associated with baseline HbA1c levels and HbA1c trajectories. In the analysis related to baseline HbA1c (n = 4543), the adjusted HRs [95% confidence interval (CI)] of all-cause mortality were 1.06 (0.95-1.18) and 1.25 (95% CI, 1.07-1.46) in patients with an HbA1c level of 7%-9% (53-75 mmol/mol) and >9% (>75 mmol/mol), respectively, as compared with those with an HbA1c level < 7% (<53 mmol/mol). In the trajectory analysis (n = 2692), three distinct longitudinal HbA1c trajectories were identified: nearly optimal (55.9%), moderate to stable (34.2%), and poor control (9.9%). Compared with the "nearly optimal" HbA1c trajectory group, the "moderate-to-stable" group did not have significantly higher mortality, but the "poorly controlled" group had 35% higher risk of mortality (adjusted HR = 1.35, 95% CI = 1.06-1.71). Neither baseline levels of HbA1c nor trajectories were associated with ESKD risk. In conclusion, in patients with CKD and type 2 diabetes, poor glycemic control was associated with an elevated risk of mortality but not associated with a risk of progression to ESKD.

Longitudinal Adherence to Diabetes Quality Indicators and Cardiac Disease: A Nationwide Population-Based Historical Cohort Study of Patients With Pharmacologically Treated Diabetes

Background Evidence of the cardiovascular benefits of adherence to quality indicators in diabetes care over a period of years is lacking. Methods and Results We conducted a population-based, historical cohort study of 105 656 people aged 45 to 80 with pharmacologically treated diabetes and who were free of cardiac disease in 2010. Data were retrieved from electronic medical records of the 4 Israeli health maintenance organizations. The association between level of adherence to national quality indicators (2006-2010: adherence assessment) and incidence of cardiac outcome; ischemic heart disease or heart failure (2011-2016: outcome assessment) was estimated using Cox proportional hazards models. During 529 551 person-years of follow-up, 19 246 patients experienced cardiac disease. An inverse dose-response association between the level of adherence and risk of cardiac morbidity was shown for most of the quality indicators. The associations were modified by age, with stronger associations among younger patients (<65 years). Low adherence to low-density lipoprotein cholesterol testing (≤2 years) during the first 5 years was associated with 41% increased risk of cardiac morbidity among younger patients. Patients who had uncontrolled low-density lipoprotein cholesterol in all first 5 years had hazard ratios of 1.60 (95% CI, 1.49-1.72) and 1.23 (95% CI, 1.14-1.32), among patients aged <65 and ≥65 years, respectively, compared with those who achieved target level. Patients who failed to achieve target levels of glycated hemoglobin or blood pressure had an increased risk (hazard ratios, 1.50-1.69) for cardiac outcomes. Conclusions Longitudinal adherence to quality indicators in diabetes care is associated with reduced risk of cardiac morbidity. Implementation of programs that measure and enhance quality of care may improve the health outcomes of people with diabetes.

Integrating hypertension and diabetes management in primary health care settings: HEARTS as a tool

Hypertension and diabetes are modifiable cardiovascular disease (CVD) risk factors that contribute to nearly one-third of all deaths in the Americas Region each year (2.3 million deaths). Despite advances in the detection and clinical management of hypertension and diabetes, there are substantial gaps in their implementation globally and in the Region. The considerable overlap in risk factors, prognosis, and treatment of hypertension and diabetes creates a unique opportunity for a unified implementation model for management at the population level. This report highlights one such high-profile effort, the Pan American Health Organization's "HEARTS in the Americas" program, based on the World Health Organization's HEARTS Technical Package for Cardiovascular Disease Management in Primary Health Care. The HEARTS program aims to improve the implementation of preventive CVD care in primary health systems using six evidence-based, pragmatic components: Healthy-lifestyle counseling, Evidence-based protocols, Access to essential medicines and technology, Risk-based CVD management, Team-based care, and Systems for monitoring. To date, HEARTS implementation projects have focused primarily on hypertension given that it is the leading modifiable CVD risk factor and can be treated cost-effectively. The objective of this report is to describe opportunities for integration of diabetes clinical care and policy within the HEARTS hypertension framework. A substantial global burden of disease could be averted with integrated primary care management of these conditions. Thus, there is an urgency in applying lessons from HEARTS to close these implementation gaps and improve the integrated detection, treatment, and control of diabetes and hypertension.

The association between long-term glycemic control and all-cause mortality is different among older versus younger patients with diabetes mellitus and maintenance hemodialysis treatment

AIMS

Knowledge about association between glycated hemoglobin (HbA1c) and risk of all-cause mortality in patients with diabetes mellitus on maintenance hemodialysis (HD)-treatment is sparse. The study aims to investigate association between HbA1c and all-cause mortality in patients with diabetes and maintenance HD-treatment, separately for two age groups- above and below 75 years.

METHODS

2487 patients (mean age 66 years, 66 % men) were separated in two age groups: ≤75 years (n = 1810) and > 75 years (n = 677) and followed up between 2008 and 2018. Hazard ratios (HR) and 95 % confidence intervals (CI) for associations between HbA1c and all-cause mortality were calculated using Cox-regression-models.

RESULTS

1295 (52 %) patients died and 473 (70 %) among the patients above 75 years old. In the multivariate analysis, HbA1c5-6 % was used as reference. In patients ≤ 75 years old, only increased HbA1c > 9.7 %, HR2.03(CI1.43-2.89) was associated with increased risk of all-cause mortality. In patients > 75 years, HbA1c ≤ 5 %, HR1.67(CI1.16-2.40); HbA1c6.9-7.8 %, HR1.41(CI1.03-1.93) and HbA1c8.7-9.7 %, HR1.79 (CI1.08-2.96) were associated with increased risk of all-cause mortality.

CONCLUSIONS

We found a J-shaped association between HbA1c and mortality only in diabetic HD-patients > 75 years. This probably indicates that in an old population of diabetic HD-patients, both intensive glucose control and hyperglycemia could be harmful and associated with higher risk of death.

European Stroke Organisation (ESO) guideline on pharmacological interventions for long-term secondary prevention after ischaemic stroke or transient ischaemic attack

Recurrent stroke affects 9% to 15% of people within 1 year. This European Stroke Organisation (ESO) guideline provides evidence-based recommendations on pharmacological management of blood pressure (BP), diabetes mellitus, lipid levels and antiplatelet therapy for the prevention of recurrent stroke and other important outcomes in people with ischaemic stroke or transient ischaemic attack (TIA). It does not cover interventions for specific causes of stroke, including anticoagulation for cardioembolic stroke, which are addressed in other guidelines. This guideline was developed through ESO standard operating procedures and the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) methodology. The working group identified clinical questions, selected outcomes, performed systematic reviews, with meta-analyses where appropriate, and made evidence-based recommendations, with expert consensus statements where evidence was insufficient to support a recommendation. To reduce the long-term risk of recurrent stroke or other important outcomes after ischaemic stroke or TIA, we recommend: BP lowering treatment to a target of <130/80 mmHg, except in subgroups at increased risk of harm; HMGCoA-reductase inhibitors (statins) and targeting a low density lipoprotein level of <1.8 mmol/l (70 mg/dl); avoidance of dual antiplatelet therapy with aspirin and clopidogrel after the first 90 days; to not give direct oral anticoagulant drugs (DOACs) for embolic stroke of undetermined source and to consider pioglitazone in people with diabetes or insulin resistance, after careful consideration of potential risks. In addition to the evidence-based recommendations, all or the majority of working group members supported: out-of-office BP monitoring; use of combination treatment for BP control; consideration of ezetimibe or PCSK9 inhibitors when lipid targets are not achieved; consideration of use of low-dose DOACs in addition to an antiplatelet in selected groups of people with coronary or peripheral artery disease and aiming for an HbA1c level of <53 mmol/mol (7%) in people with diabetes mellitus. These guidelines aim to standardise long-term pharmacological treatment to reduce the burden of recurrent stroke in Europe.

Effect of glycated hemoglobin A1c on the survival of patients with oral squamous cell carcinoma: A multi-institutional database cohort study

Objectives

Few studies have evaluated the impact of blood glucose levels on cancer prognosis. We investigated the association between hemoglobin A1c (HbA1c) and survival in oral squamous cell carcinoma (OSCC) patients.

Materials and Methods

A 19-year retrospective cohort study of OSCC patients was performed using the Chang Gung Research Database to identify and enroll 7279 patients diagnosed with OSCC between January 2001 and June 2020. A total of 3600 patients were recruited after performing 1:2 frequency-matching between patients with DM and non-DM. A Cox’s regression model was used to evaluate the relative hazards of all-cause mortality (ACM) and disease-specific mortality (DSM) in relation to HbA1c.

Results

An unadjusted Cox’s regression model indicated that DM, in addition to high levels of HbA1c, were statistically prognostic of poor survival. An adjusted hazard ratio (aHR) of HbA1c ≥ 8% interval at the initial diagnosis of OSCC was statistically higher for DSM (1.25 to 2.24) compared to the non-DM group in different regression models. Considering the effect of sustained HbA1c control in 699 patients, the aHR of mean HbA1c ≥ 9% interval was statistically higher for ACM (1.78 to 2.13) compared to the reference group (7% ≤ HbA1c< 8%). In addition, increased hazards of ACM (2.09 to 2.18) and DSM (2.20 to 2.41) were consistently observed in the highest quartiles of average real variability of HbA1c.

Conclusion

Poor and unstable control of HbA1c could strongly predict the risks of mortality in OSCC patients with DM.

Low mean HbA1c does not increase all-cause and cardiovascular mortality in patients with diabetes: Effect-modifications by anemia and chronic kidney disease stages

Background

Previous studies reported that low levels of glycated hemoglobin A1c (HbA1c) were associated with increased mortality. We investigated rates and risks of all-cause and cardiovascular mortality in association with mean HbA1c levels with stratification of anemia and chronic kidney disease (CKD) stages, major causes of low HbA1c.

Methods

47,145 patients with prescription of antidiabetic agents >6 months in the outpatient visits (2003–2018) were linked to Taiwan’s National Death Registry to identify all-cause and cardiovascular mortality. Poisson assumption was used to estimate the mortality rates, and the Cox proportional hazard regression model was used to evaluate the relative hazards of respective mortality in relation to mean HbA1c in different statuses of anemia and CKD stages.

Results

All-cause and cardiovascular mortality rates were the lowest in non-anemic stages 1–2 CKD patients, and the highest in anemic stages 3–5 CKD patients. In stages 1–2 CKD, excessive HRs observed in those with mean HbA1c <6.0% (Hazard Ratio [HR]) 1.58; 95% Confidence Interval [CI] 1.18–2.12) became inconsequential after adjustment of medications and laboratory results (HR: 1.26; 95% CI 0.89–1.79). The similar patterns were observed in anemic stages 1–2 CKD, anemic or non-anemic stages 3–5 CKD. Low HbA1c was not related to cardiovascular mortality in any anemia status or CKD staging.

Conclusions

Higher risks associated with low mean HbA1c and all-cause mortality were attenuated by adjustment of medications and comorbidities. It is imperative for the diabetologists to consider confounding effects of underlying illness before concluding low HbA1c associated higher mortality.