Control of diabetes and cardiovascular risk factors in patients with type 2 diabetes: a nationwide French survey

Evaluation of the Addition of Pharmacist Management to a Medication Assistance Program in Patients with Hypertension and Diabetes Resistant to Usual Care

OBJECTIVE

To evaluate the effect of a medication assistance program and the addition of pharmacist management on clinical outcomes in patients with hypertension and diabetes through an Advanced Pharmaceutical Care program.

METHODS

This was a prospective quality improvement study on patients with hypertension and/or diabetes resistant to usual care. The primary outcomes were change in A1C, blood glucose, and blood pressure between 3 phases: usual care, free medications, and free medications plus pharmacist management. Secondary outcomes included achievement of A1C, blood glucose, and blood pressure goals as well as pharmacist interventions.

RESULTS

Seven patients were included in the study. The mean A1C decreased from 11.3% to 8.3% with free medications (p = 0.28) and from 8.3% to 6.4% with pharmacist management (p = 0.119). Mean blood pressure during usual care, free medications, and pharmacist intervention was 150/87 mm Hg, 148/85 mm Hg, and 125/78 mm Hg, respectively. After pharmacist management, 75% of patients with type 2 diabetes were able to achieve A1C and blood glucose goals, and 71% of patients with hypertension achieved blood pressure <130/80 mm Hg.

CONCLUSIONS

The Advanced Pharmaceutical Care program allowed pharmacists to identify and overcome patient-specific barriers to care, provide individualized disease state education, and optimize medication management. Medication assistance led to improvements in A1C and blood pressure, but did not affect achievement of disease state goals. Pharmacist involvement in hypertension and diabetes care led to clinically significant reductions in blood pressure and A1C and enabled patients to reach guideline-recommended blood pressure and glycemic goals.

The Impact of Coexistence of Smoking and Diabetes on the Coronary Artery Severity and Outcomes following Percutaneous Coronary Intervention: Results from the 1ST Jordanian PCI Registry

Introduction

Diabetes mellitus (DM) and smoking are highly prevalent among Middle Eastern patients admitted with acute coronary syndrome (ACS) or who undergo percutaneous coronary intervention (PCI).

Methods

This study used the analysis of the data from the first Jordanian PCI registry (JoPCR1) to determine the impact of coexistence of smoking and diabetes mellitus on the coronary artery severity and outcome following percutaneous coronary intervention in Middle Eastern patients.

Results

Of 2426 patients enrolled, 1300 (53.6%) and 1055 (43.5%) were diabetics and smokers, respectively. The patients' age was 59.0 ± 10.1 and ranged between 24 and 95 years. Males comprised 79.4% of all patients. The patients were divided into four groups: nondiabetic-nonsmokers (22.2%), diabetic-nonsmokers (34.3%), nondiabetic-smokers (24.2%), and diabetic-smokers (19.2%). Compared with the other three groups, patients in the diabetic-nonsmoker group were older, more likely to be females, and having a higher prevalence of hypertension, dyslipidemia, chronic renal disease, and history of CVD and revascularization. Consequently, the diabetic-nonsmoker patients (but not the diabetic-smokers) had a higher prevalence of multivessel CAD and PCI than the other three groups, highlighting the importance of other risk factors (age, gender, metabolic syndrome, and comorbidities) and not only smoking in predisposing for CAD. Furthermore, those patients had a higher incidence of ACS as an indication for PCI than the stable coronary disease (73% vs 27%) and the highest CRUSADE bleeding risk score (63.9%) among other groups. The in-hospital events including in-stent thrombosis and emergency CABG events did not significantly differ among groups (p = 0.5 and 0.22). Heart failure and major bleeding events occurred significantly higher among diabetic-nonsmokers compared to other groups. In-hospital deaths occurred significantly more among diabetic-nonsmokers. Moreover, the one-month and one-year follow-up outcome events (the mortality rate, in-stent thrombosis, readmission for ACS, coronary revascularization, and major bleedings) occurred more frequently in the diabetic-nonsmoker group. However, the difference was statistically significant only for major bleeding incidences.

Conclusions

In this analysis of a completed prospective Middle Eastern PCI registry, the majority of the diabetic-nonsmoker (and not the diabetic-smokers) patients (73%) presented with ACS. This group was the highest at risk for in-hospital PCI complications as well as the worst in outcomes after one year of follow-up. Those patients were more likely to be older, female, and have the worst cardiovascular baseline features, highlighting the importance of other risk factors (age, gender, metabolic syndrome, and comorbidities) and not only smoking in predisposing for CAD. Thus, more sufficient education about controlling CVD risk factors should be implemented in the Middle Eastern region.

Mortality and potential years of life lost attributable to non-optimal glycaemic control in men and women with diabetes in the United Arab Emirates: a population-based retrospective cohort study

OBJECTIVES

Numerous studies reported that achieving near-normal glycated haemoglobin (HbA1c) levels in patients with diabetes may delay or even prevent vascular complications. However, information regarding the impact of non-optimal HbA1c control on adverse health outcomes in an Arab population is unknown. The aim of this study was to estimate the fraction of deaths and potential years of life lost (PYLL) attributable to non-optimal HbA1c control among Emirati men and women with diabetes in the United Arab Emirates (UAE).

DESIGN

A retrospective cohort study.

SETTING

This study was conducted in outpatient clinics at a tertiary care centre in Al Ain, UAE, between April 2008 and September 2018.

PARTICIPANTS

The sample comprised of 583 adult UAE nationals, aged≥18 years, with diabetes. Overall, 57% (n=332) of the study participants were men and 43% (n=251) were women.

EXPOSURE

Non-optimal HbA1c control, defined as HbA1c≥6.5%.

PRIMARY OUTCOME MEASURE

All-cause mortality, defined as death from any cause.

RESULTS

At the end of the 9-year follow-up period, 86 (14.8%) participants died. Overall, up to 33% (95% CI 2% to 63%) of deaths were attributable to non-optimal HbA1c control among patients with diabetes mellitus (DM). Stratified by sex, the adjusted fraction of avoidable mortality was 17% (95% CI -23% to 57%) for men and 50% (95% CI 3% to 98%) for women. Both deaths and PYLL attributable to non-optimal HbA1c control were higher in women compared with men.

CONCLUSIONS

Up to one-third of all deaths in adult UAE nationals with DM could be attributed to non-optimal HbA1c control. Effective sex-specific interventions and healthcare quality-improvement programmes should urgently be implemented.

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

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

Evaluation of a Pharmacist-Managed Diabetes Program in a Primary Care Setting Within an Integrated Health Care System

BACKGROUND

Pharmacists have important roles in managing the therapy of patients with type 2 diabetes and improving patient care. Pharmacists titrate medications; reinforce patient education; and address care gaps, such as medication adherence, vaccinations, and overdue health screenings. Through these efforts and more, pharmacists help to improve patient care and achieve Healthcare Effectiveness Data and Information Set (HEDIS) measures. Thus, it is important to demonstrate improved health outcomes through pharmacist contributions to diabetes management, which can then provide an opportunity to expand the role of clinical pharmacists in other medical centers and practice settings within an integrated health care system.

OBJECTIVE

To evaluate the effect of a pharmacist-managed program within a primary care setting by determining the percentage of patients who reached the HEDIS goal of hemoglobin A1c (A1c) < 8.0%, the time needed to reach this goal, and A1c reduction in patients with type 2 diabetes.

METHODS

This retrospective cohort study identified patients aged 18-74 years who had uncontrolled A1c ≥ 8.0%. Patients in the Complete Care Program (CCP) had their diabetes therapy managed by a pharmacist and were propensity score matched to a comparison group of usual care (UC) patients. Multivariate regression analyses and a Cox proportional hazards model compared the change in A1c from baseline and the time to A1c goal between the 2 groups.

RESULTS

There were no significant differences in baseline characteristics between the CCP and UC patients (n = 980 patients per group). CCP patients were significantly more likely to achieve the HEDIS goal of A1c < 8% at 3 months (OR = 2.44, 95% CI = 1.93-3.10, P < 0.0001) and at 6 months (OR = 1.32, 95% CI = 1.08-1.61, P = 0.007) compared with the UC patients. CCP patients also reached the A1c goal significantly faster: 3.4 months versus 4.6 months (P < 0.0001), even after controlling for covariates (HR = 1.24, 95% CI = 1.09-1.41, P = 0.001). Change in baseline A1c was -0.95% versus -0.54% (P < 0.0001) at 3 months and -1.19% versus -0.99% (P = 0.008) at 6 months for CCP versus UC patients, respectively.

CONCLUSIONS

Type 2 diabetes therapy management by clinical pharmacists was associated with a greater percentage of patients achieving the HEDIS goal of A1c < 8.0%, reaching the A1c goal faster, and a greater A1c reduction from baseline at 3 and 6 months of follow-up compared with patients receiving usual care.

DISCLOSURES

No funding was provided to support this research study. The authors report no potential conflicts of interest relevant to this article. All authors contributed to the study concept and design. Benedict and Spence performed data analysis and interpretation. The manuscript was written by Benedict, with assistance from Spence and Rashid. All authors reviewed and contributed to manuscript revisions. Spence is the guarantor of this work and, as such, had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Parts of this study were presented at the AMCP Managed Care and Specialty Pharmacy Annual Meeting; San Francisco, California; April 19-22, 2016.

Pharmacological control of diabetes and hypertension comorbidity in the elderly: A study of "real world" data

AIMS

The study aimed to determine which drug combinations achieve better control in comorbid diabetes and hypertension in a pragmatic sample of primary health care patients.

METHODS

Cross-sectional study.

SETTING

251 primary health care centres in Catalonia, Spain.

PARTICIPANTS

individuals ≥65 years old with a dual diagnosis of hypertension and diabetes.

MAIN OUTCOME MEASURES

good control criteria were established as glycated haemoglobin ≤7% and blood pressure <140/90mmHg. Antihypertensive and hypoglycaemic drugs and treatment adherence were analysed in relation to their association with good control.

RESULTS

27,637 patients (58.0% women) had hypertension and diabetes and met selection criteria. Mean age was 75.9 years (standard deviation [SD]: 6.7). Both diseases were well controlled simultaneously in 34.2% of patients. The combination of biguanides and diuretics achieved the highest association with good control. Adherence to pharmacological treatment was more difficult in diabetes than in hypertension. Lack of control was associated significantly with non-adherence to treatment, 0-12 PHC visits, obesity and increasing number of diabetes prescriptions.

CONCLUSIONS

Good control of diabetes and hypertension comorbidity with pharmacological treatment in elderly patients is challenging. Some drug combinations achieved better control than others. The greatest effort should focus on improving the low adherence to diabetes treatment.

Trends in medical performance in diabetic patients in primary care clinics compared with those in hospitals: Shiga Diabetes Clinical Survey, Japan, 2000-2012

Aims

This study aimed to clarify trends in clinical performance in diabetic patients over a 12-year period in primary care clinics and hospitals in Japan.

Materials and methods

The Shiga Diabetes Clinical Survey records medical performance in diabetic patients in primary care clinics and hospitals in Shiga Prefecture, Japan. In this study, laboratory data, modality of treatment for diabetes, and status of examination for diabetic complications were examined using results of surveys in 2000, 2006, and 2012. The study included 17,870, 18,398, and 24,219 patients for those years, respectively.

Results

Mean glycated hemoglobin (HbA1_c) level significantly improved over 12 years and was significantly lower in the primary care clinics group than the hospitals group (7.3 ± 1.5 vs. 7.4 ± 1.4 % in 2000, 7.2 ± 1.2 vs. 7.4 ± 1.3 % in 2006, and 6.9 ± 1.0 vs. 7.1 ± 1.1 % in 2012). With regard to diabetic treatment modality, patients treated in hospitals used insulin more frequently than those in primary care clinics. The proportion of patients examined for diabetic complications increased but did not reach 50 % in 2012. Mean blood pressure and low-density lipoprotein cholesterol levels were lowered, but blood pressure control was worse than that of low-density lipoprotein cholesterol.

Conclusions

This study shows that glycemic control in both primary care clinics and hospitals has improved and was almost acceptable. However, examinations for diabetic complications and the control of blood pressure were still insufficient.

Pharmacist Interventions in the Management of Type 2 Diabetes Mellitus: A Systematic Review of Randomized Controlled Trials

BACKGROUND

Diabetes mellitus is a major health problem that is growing rapidly worldwide. A collaborative and integrated team approach in which pharmacists can play a pivotal role should be sought when managing patients with diabetes.

OBJECTIVE

To identify and summarize the main outcomes of pharmacist interventions in the management of type 2 diabetes.

METHODS

PubMed, Cochrane Central Register of Controlled Trials, and Web of Science were searched for randomized controlled trials evaluating the effectiveness of any pharmacist intervention directed at patients with type 2 diabetes in comparison with usual care. Outcome measures of interest included glycosylated hemoglobin (Alc), blood glucose, blood pressure, lipid profile, body mass index (BMI), 10-year coronary heart disease (CHD) risk, medication adherence, health-related quality of life (HRQoL), and economic outcomes. The risk of bias in included studies was assessed using the Cochrane risk of bias tool.

RESULTS

Thirty-six studies were included in this systematic review, involving 5,761 participants. The studies evaluated the effects of several pharmacist interventions carried out in various countries and in different health care facilities, such as community pharmacies, primary care clinics, and hospitals. The number of studies reporting each outcome of interest varied. Alc was evaluated in 26 studies, of which 24 reported a greater reduction in this outcome in the intervention group compared with the control group, with the difference in change between groups ranging from -0.18% to -2.1%. Eighteen studies assessed change in systolic blood pressure, of which 17 studies reported a greater improvement in this outcome in the intervention group, with the difference in change between groups varying between -3.3 mmHg and -23.05 mmHg. For diastolic blood pressure, a greater effect was also observed in the intervention group in 14 out of 15 studies, with the difference in change between groups varying between -0.21 mmHg and -9.1 mmHg. Thirteen studies described total cholesterol as an outcome measure, of which 10 reported a greater improvement in this outcome in the intervention group, with the difference in change between groups ranging from +18.95 mg dL(-1) to -32.48 mg dL(-1). With regard to low-density lipoprotein cholesterol, a greater reduction in this parameter in the intervention group was documented in 12 out of 15 studies, with the difference in change between groups varying between +7.35 mg dL(-1) and -30 mg dL(-1). Similarly, favorable data were reported on high-density lipoprotein cholesterol in the intervention group in 9 out of 12 studies that assessed this outcome, with the difference in change between groups ranging from -5.8 mg dL(-1) to +11 mg dL(-1). Data on triglycerides were also reported in 12 studies, of which 9 reported a greater reduction in triglycerides levels in the intervention group, with the difference in change between groups varying between +12 mg dL(-1) and -62 mg dL(-1). Overall, a beneficial effect on BMI was also described in the intervention group in 12 out of 14 studies. Of note, in all 6 studies that estimated the 10-year CHD risk among study patients, a greater improvement in the intervention group versus the control group was found. In addition, pharmacist interventions also had a positive impact on medication adherence and HRQoL in most studies that ascertained these outcomes. Finally, although only 3 studies conducted a cost-effectiveness analysis, pharmacist interventions proved to be cost-effective.

CONCLUSIONS

The findings from this review clearly support the involvement of pharmacists as members of health care teams in the management of patients with type 2 diabetes.

DISCLOSURES

This systematic review was not funded. The authors declare that they have no conflicts of interest. Concept and study design were created by Pousinho, Morgado, and Alves. Pousinho took the lead in data collection, along with Alves, and data interpretation was performed by Pousinho, Falcão, and Alves. The manuscript was primarily written by Pousinho, along with Alves, and revised by Alves, Morgado, and Falcão.

Current status of glucose, blood pressure and lipid management in type 2 diabetes clinic attendees in Isfahan, Iran

AIMS/INTRODUCTION

To estimate the prevalence of meeting American Diabetes Association clinical practice recommendations for hemoglobin A1c (HbA1c), blood pressure (BP) and low-density lipoprotein cholesterol (LDLC) among Iranian type 2 diabetes clinic attendees, and to identify the factors associated with therapeutic target achievement.

MATERIALS AND METHODS

A total of 2,640 patients with type 2 diabetes (944 men and 1,696 women) from Isfahan Endocrine and Metabolism Research Center outpatient clinics, Iran, were examined. The main outcome measures were HbA1c, BP and LDLC, in accordance with the American Diabetes Association recommendations. The mean (standard deviation) age of participants was 49.6 years (9.3 years) with a mean (standard deviation) duration of diabetes of 5.0 years (4.9 years) at initial registration.

RESULTS

The percentages of patients who had HbA1c <7%, BP <140/90 mmHg and LDLC <100 mg/dL was 37.4% (95% confidence interval [CI] 35.6-39.3), 35.3% (95% CI 33.5-37.3) and 48.9% (95% CI 47.0-50.8), respectively. The proportion of patients meeting all three goals was 7.7% (95% CI 6.7-8.8). Lower BP, cholesterol level and higher education at registration, and higher follow up but lower number of follow-up visits affected achievement of all three goals.

CONCLUSIONS

The present study highlights that a substantial proportion of Iranian type 2 diabetes clinic attendees did not meet the American Diabetes Association clinical practice recommendations, and shows the difficult challenges physicians face when treating patients with type 2 diabetes.

[Achievement of cardiovascular goals in patients diagnosed with type 2 diabetes with and without cardiovascular disease]

AIMS

To determine the proportion of patients with type 2 diabetes with and without cardiovascular disease achieving the main cardiovascular goals.

METHODS

DESIGN

Cross-sectional study.

SETTING

A regional health district in a European country, Spain. Year: 2013.

PARTICIPANTS

Adult patients diagnosed with type 2 diabetes with and without cardiovascular disease.

MEASUREMENTS

Study using secondary data obtained from electronic records of clinical history. Haemoglobin A1c, blood pressure, LDL cholesterol, smoking and medication were covered. n=49,658 RESULTS: The proportion of patients with diabetes achieving cardiovascular goals (among those with recent measurement) was: haemoglobin A1c 68.8% (CI95%:68.2%-69.4%), blood pressure 74.3% (CI95%:73.9%-74.7%), LDL cholesterol 59.8% (CI95%:59.0%-60.6%), tobacco 80.2% (CI95%:79.6%-80.8%). Only 40%-67% of patients has recent measurement. Only 48.0% (CI95%: 46.6%-49.4%) of patients who needed statins were receiving them. Higher proportion of patients with cardiovascular disease were achiving goals. Differences were small but significant.

CONCLUSIONS

Cardiovascular goals were measured in around half of patients with diabetes. Proportion of patients achiving cardiovascular goals were similar to published and best in patients with cardiovascular disease but it could improve. This points to prioritising interventions in this group of patients at very high risk, improving the implementation of guidelines and patient adherence.

Arterial Plaques in Peripheral Arteries Diagnosed by Ultrasound in a Cohort of Patients With Type 2 Diabetes Mellitus

Macroangiopathy (eg, peripheral arterial disease) diagnosis in type 2 diabetes mellitus (T2DM) can be carried out by ultrasound. A surveillance study was performed in 366 consecutive patients (166 patients with T2DM and 200 non-T2DM) aiming to evaluate the frequency of single or multiple arterial plaques (Aplqs) in lower limbs and the relationship with different factors (age, duration of T2DM, glycemic balance, DM treatment, smoking habit, and microalbuminuria). Single and multiple Aplqs, respectively, were found in 10.2% and 38.6% among the patients with T2DM. Age, male gender ( P < .0002), duration of T2DM ( P < .009), insulin therapy ( P < .03), and mediocalcinosis ( P < .001) were risk factors in patients with T2DM. In conclusion, Aplqs of lower limbs are frequent in T2DM and several factors can play a determining role. Ultrasound is a helpful diagnostic tool.

[Control of cardiovascular risk factors among patients with diabetes with and without cardiovascular disease]

INTRODUCTION

There is evidence that cardiovascular goals are beneficial in diabetes.

OBJECTIVE

To determine the distribution of cardiovascular risk levels in patients with diabetes and the clinical interventions they have received.

DESIGN

Descriptive cross-sectional study.

SETTING

SERMAS (Madrid) 2010.

SUBJECTS

All patients with diabetes. (n=41,096).

MAIN MEASUREMENTS

Patients in primary or secondary prevention, metabolic and cardiovascular risk factors control, pharmacological and non-pharmacological interventions. Patient and professional variables.

RESULTS

Around one-fifth (21.5%) (95%CI: 21.1% -21.9%) in secondary prevention (very high cardiovascular risk). HbA1c was under control in 31% (95%CI: 30.1%-32%), with 49.9% (95%CI: 48.8%-50.9%) with BP under control, and 39.4% (95% CI: 38.4%-40.4%) with LDL controlled. Only 8.9% (95%CI: 8.3%-9.5%) had a well-controlled HdA1c, BP and LDL, and in 19.8% (95%CI: 19%-20.6%) none of these were under control. Of those with an uncontrolled BP, 23.6% (95% CI: 23.2%-24%) had antihypertensive drugs. There was better control in patients older than 70 years, and those who lived in an urban center, or a lower number of patients per day.

CONCLUSION

In diabetic patients with very high cardiovascular risk (secondary prevention), just half of them had good control of cardiovascular risk factors (BP and LDL). An association was found between better control and older than 70, urban center or lower number of patients per day. This suggests developing strategies to promote a comprehensive control of cardiovascular risk factors in diabetic patients in secondary prevention.

Primacy of the 3B approach to control risk factors for cardiovascular disease in type 2 diabetes patients

BACKGROUND

Individually, diabetes mellitus, hypertension, and dyslipidemia have been shown to increase the risk of cardiovascular disease. While traditional management of Type 2 diabetes has focused mainly on glycemic control, robust evidence supports the integration of hypertension and dyslipidemia management to reduce the risk of cardiovascular disease. The primary objective of this study was to assess the level of control of blood glucose, blood pressure, and blood lipids (3Bs) among patients with type 2 diabetes. An additional objective was to investigate the impact of hospital type, physician specialty, treatment pattern, and patient profile on clinical outcomes.

METHODS

This was a cross-sectional, multicenter observational study. A nationally representative sample of outpatients with established type 2 diabetes were enrolled at hospitals representative of geographic regions, tiers, and physician specialties in China. Main clinical measurements were the levels of glycosylated hemoglobin (HbA1c), blood pressure, and total serum cholesterol in reference to target goals.

RESULTS

A total of 25,817 adults with type 2 diabetes (mean age 62.6 years, 47% male) were enrolled at 104 hospitals. Seventy-two percent reported comorbid hypertension, dyslipidemia, or both. Patients with concurrent type 2 diabetes, hypertension, and dyslipidemia were 6 times more likely to report a prior history of cardiovascular disease compared with those with type 2 diabetes alone. The mean HbA1c level was 7.6%. While 47.7%, 28.4%, and 36.1% of patients achieved the individual target goals for control of blood glucose (HbA1c <7%), blood pressure (systolic blood pressure <130 mm Hg, diastolic blood pressure <80 mm Hg), and blood lipids (total cholesterol <4.5 mmol/L), respectively, only 5.6% achieved all 3 target goals. Lower body mass index (<24 kg/m(2)), no active smoking or drinking, higher education, and diabetes duration <5 years were independent predictors of better cardiovascular disease risk control.

CONCLUSION

Achieving adequate control of risk factors for cardiovascular disease in patients with type 2 diabetes remains a clinical challenge. Interventions to achieve control of 3Bs coupled with modification of additional cardiovascular disease predictors are crucial for optimization of clinical outcomes in patients with type 2 diabetes.

Glycemic control in diabetic patients in King Khalid University Hospital (KKUH) - Riyadh - Saudi Arabia

OBJECTIVES

To evaluate glycemic control of diabetic patients at the King Khalid University Hospital (KKUH) in Riyadh, Saudi Arabia.

METHODS

A cross sectional study was conducted among diabetic patients attending KKUH, Riyadh. Patients were identified through the hospital pharmacy records, over a one year period (January-December, 2009). A total of 20,000 patients were identified, and 1520 patients were selected by a simple random method. Medical charts were reviewed, the data were collected in a specially designed data sheet: and entered in a computer, and finally analyzed using a SPSS program.

RESULTS

About 90% of patients were older than 40 years old and 90% were overweight or obese. Fasting blood sugar was above 7.2 mmol/L in 60% of the patients and random blood sugar was more than 10 mmol/L in about 70% of patients. The overall glycemic control as evaluated by HBA1C was acceptable in about 40% of the patients. Cholesterol level was normal in more than 70% of patients while triglyceride was normal in 56% of patients. In about half of the patients systolic blood pressure was not controlled, while in 27% the diastolic blood pressure was above the target level.

CONCLUSION

The control of diabetes and its associated cardiovascular risk factors in this hospital - based survey, in Riyadh is far from optimal. Further studies are needed to find out the possible causes for this defective care of diabetic patients.

[Characteristics of the association type 2 diabetes and hypertension in the elderly aged 65 and over]

Introduction

L'HTA du diabétique âgé est particulière par sa fréquence et sa gravité. Cette association HTA-diabète type 2 (DT2) est particulièrement fréquente chez la personne âgée, et responsable d'une majoration du risque cardiovasculaire et d'une accélération de l'atteinte dégénérative du diabète.

Méthodes

Etude descriptive, concernant 100 patients diabétiques de type 2 hypertendus âgés de 65 ans ou plus, suivis au service d'endocrinologie-diabétologie du CHU de Marrakech, du mois de Novembre 2010 au mois de Juillet 2011. Le logiciel SPSS version 18 a été utilisé pour l'analyse statistique.

Résultats

Le sex-ratio des patients étudiés était de 0,26, l’âge moyen était de 69,2 ±; 4,3 ans, l'ancienneté du diabète était de 9,3 ±; 6,7 ans. Le diagnostic du diabète précédait celui de l'HTA dans 67,7% des cas. Seulement 4,2% avaient une HbA1c ≤ 6,5%. 60% des patients avaient une HTA de grade I. L'IMC moyen était de 28,1 ±; 4,6 kg/m². La dyslipidémie était présente chez 59,6% de nos patients avec essentiellement une hypoHDLémie (75,9%). La macroangiopathie était observée chez 40% des patients avec essentiellement une cardiopathie ischémique (29%). Elle était significativement plus fréquente chez les patients ayant une HbA1c supérieure à 9%, LDL-c ≥ 1 g/l et une hypoHDLémie. La microangiopathie présente dans 82% des cas était significativement en relation avec l'HbA1c, le DFG et le taux des triglycérides.

Conclusion

Une prise en charge complète du risque cardio-vasculaire chez les sujets âgés se heurte à des problèmes objectifs en pratique courante, en particulier, la polymédication, source d'une mauvaise compliance et donc de mauvais résultats. Mots clés: Complications dégénératives, Diabète type 2, Dyslipidémie, Hypertension artérielle, Sujet âgé.

Achievement of cardiometabolic goals among diabetic patients in Spain. A nationwide population-based study

BACKGROUND

No previous study has reported a comprehensive assessment of the attainment of cardiometabolic goals in the diabetic population of a European country. We examined the achievement of cardiometabolic goals among diabetics in Spain.

METHODS AND FINDINGS

A cross-sectional survey was performed in 2008-2010 among 12,077 individuals representative of the Spanish population aged ≥18 years. Information on cardiometabolic characteristics was collected at the participants' homes through structured questionnaires, physical examination, and fasting blood samples. Attainment of cardiometabolic goals was evaluated according to the most well-known guidelines. A total of 834 individuals had diabetes (fasting serum glucose ≥126 mg/dl, or glycosylated hemoglobin ≥6.5%,) or were being treated with oral antidiabetic drugs or insulin). Among diabetic patients, 661 (79.2%) were aware of their condition. Among the aware diabetic patients, only 11.4% had neither general (body mass index <25 kg/m(2)) nor abdominal obesity (waist circumference ≤102 cm in men and ≤88 cm in women), 8.6% consumed <7% of calories daily from saturated fats, and 41.1% achieved the recommendation on weekly physical activity. About 71% had glycosylated hemoglobin <7%, 22% had blood pressure <130/80 mmHg, and 36% reached the LDL-cholesterol goal of <100 mg/dl. Although a large proportion of aware diabetic individuals received lifestyle medical advice, only 38% of overweight individuals and 20% of daily smokers were offered a specific strategy for weight loss or quitting smoking, respectively.

CONCLUSIONS

In a European country with universal healthcare coverage, achievement of many cardiometabolic goals, in particular lifestyle, among aware diabetic individuals is poor. This suggests a need for improvement in both clinical guidelines' implementation and patients' adherence.

Importance of Prandial Glucose Regulation in the Management of Cardiovascular Complications in Type 2 Diabetes Mellitus

There is a worldwide epidemic increase in the number of type 2 diabetes (T2DM)patients who frequently associate with cardiovascular disease (CVD). There are datasuggesting that glycemic control does not substantially reduce CVD risk buthyperglycemia increases the risk of CVD. This apparent paradox could be explainedby the role of post-prandial hyperglycemia in the pathogenesis of cardiovascularcomplications in T2DM. There is numerous evidences, both experimental andclinical, for this association but controversies on this topic persist. The aim of thispaper was to review the current literature regarding the role of postprandial glucosein the genesis of CVD in T2DM.

Predicting Changes in Cardiovascular Risk Factors in Type 2 Diabetes in the Post-UKPDS Era: Longitudinal Analysis of the Swedish National Diabetes Register

The aim of the current study was to provide updated time-path equations for risk factors of type-2-diabetes-related cardiovascular complications for application in risk calculators and health economic models. Observational data from the Swedish National Diabetes Register were analysed using Generalized Method of Moments estimation for dynamic panel models (N = 5,043, aged 25-70 years at diagnosis in 2001-2004). Validation was performed using persons diagnosed in 2005 (n = 414). Results were compared with the UKPDS outcome model. The value of the risk factor in the previous year was the main predictor of the current value of the risk factor. People with high (low) values of risk factor in the year of diagnosis experienced a decreasing (increasing) trend over time. BMI was associated with elevations in all risk factors, while older age at diagnosis and being female generally corresponded to lower levels of risk factors. Updated time-path equations predicted risk factors more precisely than UKPDS outcome model equations in a Swedish population. Findings indicate new time paths for cardiovascular risk factors in the post-UKPDS era. The validation analysis confirmed the importance of updating the equations as new data become available; otherwise, the results of health economic analyses may be biased.

Long-term changes of the prevalence and control rate of hypertension among Korean adults with diagnosed diabetes: 1998-2008 Korean National Health and Nutrition Examination Survey

AIMS

We investigated the long-term changes in the prevalence and the control rate of hypertension among Korean adults diagnosed with diabetes.

METHODS

Using data from the Korean National Health and Nutrition Examination Survey (1998-2008), including 1384 adults diagnosed with diabetes, we analyzed changes in the prevalence of hypertension (mean SBP ≥ 140 mmHg, DBP ≥ 90 mmHg, or use of antihypertensive medication) and the control rate of hypertension (BP < 130/80 mmHg).

RESULTS

The prevalence of hypertension in diabetic adults was 50.9% in 1998 and 51.7% in 2008 (P = 0.563). The mean blood pressure decreased from 138.1 ± 1.1/80.0 ± 0.6 mmHg to 124.7 ± 0.8/76.0 ± 0.5 mmHg (P < 0.001); awareness (37.4 to 85.2%, P < 0.001), treatment (37.4 to 81.8%, P < 0.001), and the control rate (20.1 to 34.7%, P = 0.001) steadily increased. The prevalence of hypertension increased significantly more in the obese group compared with the non-obese group (53.3% vs. 49.0% in 1998, P = 0.784; 64.3% vs. 42.0% in 2008, P < 0.0001, respectively, P for trend = 0.0001).

CONCLUSIONS

Although the rates of hypertension treatment have significantly improved, the control rate remains inadequate, and intensive intervention is urgently needed.

Study of Once Daily Levemir (SOLVE™): insights into the timing of insulin initiation in people with poorly controlled type 2 diabetes in routine clinical practice

AIMS

The aim of this analysis is to determine the timing of insulin initiation in routine clinical practice, especially in relation to glycaemic control and use of oral antidiabetic drugs (OADs).

METHODS

Study of Once Daily Levemir was a 24-week international observational study involving 10 countries which evaluated the safety and effectiveness of initiating once-daily insulin detemir in people with type 2 diabetes mellitus (T2DM) being treated with one or more OADs (clinical trial number NCT00825643 and NCT00740519).

RESULTS

A total of 17 374 participants were enrolled in the study: aged 62 ± 12 years, 53% male, T2DM duration 10 ± 7 years, body mass index 29.3 ± 5.4 kg/m(2) . Pre-insulin HbA1c was 8.9 ± 1.6%. The proportion of patients with HbA1c ≥9.0% ranged from 64% (UK) to 23% (Poland). Pre-insulin OAD treatment included metformin (81%), sulphonylureas (59%), glinides (16%), thiazolidinediones (TZD) (12%), α-glucosidase inhibitors (12%) and dipeptidyl peptidase (DPP)-IV inhibitors (7%). The mean starting dose of insulin detemir for the total cohort was 0.16 ± 0.09 U/kg. Differences in OAD use and insulin doses at initiation were evident among participating countries. The largest proportional changes in OAD prescribing at insulin initiation were seen with glinides (+15%), sulphonylureas (-19%), TZD (-31%) and DPP-IV inhibitors (-28%).

CONCLUSIONS

Despite well-documented benefits of timely glycaemic control and consensus guidelines encouraging earlier use of insulin, considerable clinical inertia exists with respect to initiating appropriate insulin therapy in people with T2DM. Considerable regional differences exist in the timing of insulin initiation and in the use of OADs.

Blood pressure and lipid management fall far short in persons with type 2 diabetes: results from the DIAB-CORE Consortium including six German population-based studies

Background

Although most deaths among patients with type 2 diabetes (T2D) are attributable to cardiovascular disease, modifiable cardiovascular risk factors appear to be inadequately treated in medical practice. The aim of this study was to describe hypertension, dyslipidemia and medical treatment of these conditions in a large population-based sample.

Methods

The present analysis was based on the DIAB-CORE project, in which data from five regional population-based studies and one nationwide German study were pooled. All studies were conducted between 1997 and 2006. We assessed the frequencies of risk factors and co-morbidities, especially hypertension and dyslipidemia, in participants with and without T2D. The odds of no or insufficient treatment and the odds of pharmacotherapy were computed using multivariable logistic regression models. Types of medication regimens were described.

Results

The pooled data set comprised individual data of 15, 071 participants aged 45–74 years, including 1287 (8.5%) participants with T2D. Subjects with T2D were significantly more likely to have untreated or insufficiently treated hypertension, i.e. blood pressure of > = 140/90 mmHg (OR = 1.43, 95% CI 1.26-1.61) and dyslipidemia i.e. a total cholesterol/HDL-cholesterol ratio > = 5 (OR = 1.80, 95% CI 1.59-2.04) than participants without T2D. Untreated or insufficiently treated blood pressure was observed in 48.9% of participants without T2D and in 63.6% of participants with T2D. In this latter group, 28.0% did not receive anti-hypertensive medication and 72.0% were insufficiently treated. In non-T2D participants, 28.8% had untreated or insufficiently treated dyslipidemia. Of all participants with T2D 42.5% had currently elevated lipids, 80.3% of these were untreated and 19.7% were insufficiently treated.

Conclusions

Blood pressure and lipid management fall short especially in persons with T2D across Germany. The importance of sufficient risk factor control besides blood glucose monitoring in diabetes care needs to be emphasized in order to prevent cardiovascular sequelae and premature death.

Prevalence, awareness and treatment of type 2 diabetes mellitus in Switzerland: the CoLaus study

AIMS

To assess the prevalence, awareness and treatment levels of Type 2 diabetes in a Swiss city.

METHODS

Population-based cross-sectional study of 6181 subjects (3246 women) aged 35-75 years living in Lausanne, Switzerland. Type 2 diabetes was defined as fasting plasma glucose ≥ 7 mmol/l and/or oral hypoglycaemic treatment and/or insulin.

RESULTS

Total prevalence of Type 2 diabetes was 6.3% (95% confidence interval: 5.7-7.0%), higher in men (9.1%) than in women (3.8%, P < 0.001) and increased with age. Two-thirds (65.3%; 60.4-70.0%) of participants with Type 2 diabetes were aware of their status and among those aware 86.0% (81.5-90.3%) were treated. Treatment was more frequent in men (91.3%) than in women (75.9%, P < 0.001). Two-thirds of those treated for Type 2 diabetes were on monotherapy. Biguanides were prescribed in 65.0% of Type 2 diabetes patients and represented 48% of all antidiabetic drugs. Multivariable analysis showed male gender, increasing age, waist or BMI to be positively associated with prevalence of Type 2 diabetes, while leisure-time physical activity and alcohol consumption were negatively associated. Among participants presenting with Type 2 diabetes, increasing age was positively associated with awareness of Type 2 diabetes. Among subjects diagnosed with Type 2 diabetes, male gender and increasing age were positively associated with treatment.

CONCLUSION

Prevalence of Type 2 diabetes in Switzerland is estimated to be between 5.7% and 7.0%. Two-thirds of patients with Type 2 diabetes are aware of their status, and over three quarters of those aware are treated.

A longitudinal study examining adherence to guidelines in diabetes care according to different definitions of adequacy and timeliness

BACKGROUND

Performance indicators assessing quality of diabetes care often look at single processes, e.g. whether an HbA1c test was conducted. Adequate care, however, consists of consecutive processes which should be taken in time (clinical pathways). We assessed quality of diabetes care by looking at single processes versus clinical pathways. In addition, we evaluated the impact of time period definitions on this quality assessment.

METHODOLOGY

We conducted a cohort study in 2007-2008 using the GIANTT (Groningen Initiative to Analyse type 2 diabetes Treatment) database. Proportions of patients adequately managed for HbA1c, systolic blood pressure (SBP), LDL-cholesterol (LDL-C), and albumin/creatinine ratio (ACR) were calculated for the pathway of (1) risk factor level testing, (2) treatment intensification when indicated, (3) response to treatment evaluation. Strict and wide time periods for each step were defined. Proportions of patients adequately managed regarding the overall pathway and single steps, using strict or wide time periods were compared using odds ratios (OR) with 95% confidence intervals.

FINDINGS

Of 11,176 patients diagnosed with type 2 diabetes, 9439 with complete follow-up were included. The majority received annual examination of HbA1c (86%) and SBP (86%), whereas this was 67% for LDL-C and 49% for ACR. Adequate management regarding the three-step pathway was observed in 73%, 53%, 46%, 41% of patients for HbA1c, SBP, LDL-C, and ACR respectively. Quality scores reduced significantly due to the second step (OR 0.43, 0.18, 0.44, 0.74), but were not much further reduced by the third step. Timely treatment evaluation occurred in 88% for HbA1c, 87% for SBP, 83% for LDL-C, and 76% for ACR. The overall score was not significantly changed by using strict time windows.

CONCLUSION

Quality estimates of glycemic, blood pressure and cholesterol management are substantially reduced when looking at clinical pathways as compared to estimates based on commonly used simple process measures.

Underutilization of statins in patients with type 2 diabetes in US clinical practice: a retrospective cohort study

OBJECTIVES

To estimate the proportion of patients with type 2 diabetes who were eligible for statin treatment per American Diabetes Association (ADA) recommendations and the proportion who were actually prescribed a statin in US clinical practice. Factors associated with receiving a statin prescription were also determined.

METHODS

Patients ≥ 25 years diagnosed with type 2 diabetes or had received prescriptions for antihyperglycemic agents between 7/2006 and 6/2008 were identified within a large electronic medical record database. Eligibility for statin therapy was determined according to 2008 ADA recommendations. Statin use was assessed based on prescription records during a 12-month follow-up period. An adjusted logistic regression analysis was performed to estimate the likelihood of statin use in relation to selected baseline characteristics.

RESULTS

Of the 125,464 patients identified, 98.5% were eligible for statin therapy. Only 62.9% received a statin prescription during follow-up period. In an adjusted logistic regression, factors associated with increased likelihood of statin use were older age, male gender, smoking, history of cardiovascular conditions, and receiving an antihyperglycemic, antihypertensive, or anticoagulant prescription at baseline (all p < 0.05).

LIMITATIONS

Of the patients who did not receive statin during follow-up, 13% of them were previously on a statin during the baseline period. The reasons for discontinuing therapy are not known. It cannot be excluded that some of these patients were intolerant or had contraindications to statin. The data on prescription dispensing and compliance were not recorded.

CONCLUSIONS

Nearly all patients with type 2 diabetes were eligible for statin therapy, but less than two-thirds received statin therapy in US clinical practice. Efforts to minimize this gap are warranted.

Diagnosing microalbuminuria and consequences for the drug treatment of patients with type 2 diabetes: a European survey in primary care

AIMS

To assess general practitioners (GPs) knowledge of guideline recommendations on diagnosing microalbuminuria (MA) and to evaluate how this diagnosis influences drug treatment of diabetes patients.

METHODS

A postal case-history based questionnaire describing a male patient (previously not tested for MA) with type 2 diabetes who had several risk markers for cardiovascular disease.

RESULTS

2078GPs from nine European countries were included, with response rates varying from 7% to 43%. Almost all GPs recommended annual testing for MA. Forty-five to 77% (depending on country) of GPs required more than one positive test to diagnose MA. The absolute increase in the percentages of GPs who would supplement the patient's drug treatment if MA developed was: for anginotensin converting enzyme inhibitors (ACEIs) or angiotensin II receptor blockers (ARBs) 23-50% (depending on country), for statins 0-19%, for acetylsalicylic acid 2-13%, and for hypoglycemic agents (tablets and insulin) 0-33%. The proportion of GPs recommending all four possible treatment modalities was low.

CONCLUSIONS

Guidelines for diagnosing MA were partly followed. ACEIs and ARBs were recommended when MA was present, but the recommended multifactorial treatment of cardiovascular risk markers was not implemented.

Evaluation of control of diabetes mellitus in a subspecialty clinic

OBJECTIVE

To determine whether patients with diabetes under follow-up surveillance in a subspecialty clinic are receiving care that meets the guidelines recommended by the American Diabetes Association and American Association of Clinical Endocrinologists.

METHODS

We abstracted 2 years of medical records of patients sampled from 2 academic diabetes clinics, managed by board-certified endocrinologists. Information regarding the testing for and results of hemoglobin A1c (A1C), lipids, blood pressure, and microalbuminuria was recorded and analyzed.

RESULTS

The data on 499 patients were analyzed. More than 90% of patients had the recommended A1C, lipid, and blood pressure testing. Approximately 25% of patients had A1C levels >7%, and about 14% had A1C levels >6.5%. Total cholesterol, low-density lipoprotein cholesterol, and triglyceride levels were at target in approximately 82%, 65%, and 68% of patients, respectively. Approximately 55% of male and 50% of female patients had high-density lipoprotein cholesterol levels at target. Blood pressure was controlled in approximately a third of the patients. Approximately 30% of patients tested had microalbuminuria. Only 6.8% of patients in year 1 and 3.5% of patients in year 2 had all these risk factors (A1C, lipids, and blood pressure) at target levels.

CONCLUSION

The results indicate that in our subspecialty clinics, although testing for "risk factors" is being done at a high frequency, the targets for these risk factors are being met by only a limited number of patients. We believe that this result may be due to patient- or system-related factors but not due to physician knowledge. Therefore, emphasis should be placed on patient and system factors to improve the outcomes of the care of patients with diabetes.

Trends from 1995 to 2006 in the prevalence of self-reported cardiovascular risk factors among elderly Spanish diabetics

AIM

In this study, we examined the trends from 1995 to 2006 in cardiovascular risk factors (CVRF) in Spaniards aged 65 years or older with diabetes.

METHODS

We looked at the individual data from adults aged > or =65 years from the Spanish National Health Surveys of 1995 (n=1117), 1997 (n=1111), 2001 (n=4328), 2003 (n=6134) and 2006 (n=7835). Those classified as having diabetes had answered the two following questions in the affirmative: Has your doctor told you that you currently have diabetes? Have you taken any medication to treat diabetes in the last two weeks? The CVRF of interest included high blood pressure (HBP), high cholesterol levels, obesity (BMI > or =30 kg/m(2)), smoking and sedentarity, which were estimated and compared for prevalence by survey year, age group and gender. Progression over time was analyzed using logistic-regression models.

RESULTS

During the study period, the prevalences of all of the CVRF of interest were significantly higher among the elderly with diabetes compared with those without diabetes, except for current smoking, which was less frequent. The percentages of diabetic patients with HBP and obesity increased from 49.6 and 17.1%, respectively, in 1995 to 64 and 30.6%, respectively, in 2006 (adjusted ORs: 1.95 for HBP; 2.22 for obesity).

CONCLUSION

Overall, the self-reported prevalence of CVRF among elderly patients with diabetes did not improve during 1995-2006 but, instead, showed significant increases in self-reported obesity and HBP. This lack of improvement calls for further investigations, and the dedicated attention of both healthcare providers and the diabetic patients themselves.

Trends in cardiovascular risk factors and lifestyle behaviors among Spanish adults with diabetes (1993-2003)

Previous studies have observed high prevalences of high blood pressure (HBP), high blood cholesterol (HBC), obesity, and sedentary lifestyle among Spanish diabetic adults. These cardiovascular risk factors and unhealthy lifestyle behaviors occur more often in subjects with diabetes than in the general population. The aim of this study was to examine the trends in cardiovascular risk factors and lifestyle behaviors among Spanish adults with diabetes over the decade 1993-2003.

METHODS

We used individualized data drawn from the 1993 (N=20,880) and 2003 (N=21,650) Spanish National Health Surveys. Subjects were classified as diabetes sufferers if they answered affirmatively to either or both of the following questions: "Has your doctor told you that you are currently suffering from diabetes?" and/or, "Have you taken any medication to treat diabetes in the last two weeks?" Cardiovascular risk factors analyzed included self-reported HBP and HBC. Lifestyle behaviors included obesity (body mass index >or=30), smoking status, and physical activity. We estimated and compared the prevalences and analyzed the time trends using logistic regression models.

RESULTS

In both years studied, the prevalence of obesity and sedentary lifestyle was significantly higher among persons with than among those without diabetes, and current smoking was less frequent. The proportions of diabetes patients with HBP and obesity increased significantly from 39.5% and 20.1% in 1993 to 46.7% and 29.8% in 2003, with adjusted odds ratios of 1.32 (95% CI 1.07-1.62) for HBP and 1.88 (95% CI 1.44-2.46) for obesity.

CONCLUSIONS

The overall prevalence of cardiovascular risk factors and unhealthy lifestyle behaviors among diabetes patients has shown no improvement in the decade 1993-2003, and there have been significant setbacks, in particular the rise in obesity and HBP.

Improved care of type 2 diabetes patients as a result of the introduction of a practice nurse: 2003-2007

OBJECTIVE

The main objective is to examine the effect of the introduction of a practice nurse (PN) on the quality of type 2 diabetes care.

METHODS

Retrospective cohort study in 397 type 2 diabetes patients recruited from five general practices in the Netherlands. Measurements were performed in 2003, 2005 and 2007, to estimate the effects before (2003) and after the introduction of the PN (2005) as well as the changed diabetes guidelines (2007). Process measures indicated whether measurements of HbA(1c), systolic blood pressure, lipid profile, funduscopy, foot examination and annual check-ups were carried out. Outcome measures comprised actual levels of HbA(1c), systolic blood pressure, lipid levels and BMI.

RESULTS

All process measures - except performance of funduscopy - improved significantly. Mean HbA(1c) decreased from 6.8% to 6.5% (2003-2007: ns, 2005-2007: p<0.01), mean LDL-cholesterol from 3.2 to 2.7 mmol/L (p<0.0001) and mean total cholesterol/HDL-cholesterol ratio from 4.5 to 3.7 (p<0.0001). For systolic blood pressure, the number of patients reaching targets increased considerably in 2007. Analyses for both study populations at different time points as well as for patients present at all time points showed comparable results.

CONCLUSIONS

Delegating diabetes care to a PN leads to significant improvements in diabetes care. General practitioners should seriously consider close collaboration with PNs to delegate diabetes care tasks.

ABC control of diabetes: survey data from National Diabetes Health Promotion Centers in Taiwan

We undertook nationwide surveys to evaluate the status of diabetes control in 7541 diabetes subjects among 114 accredited Diabetes Health Promotion Centers in Taiwan in 2006, focusing on characteristics of those who attained the "ABC" goals (n=310). The mean age was 62.8+/-12.4 years (mean+/-SD), BMI 25.9+/-0.4 kg/m(2) and HbA1c levels 7.9+/-1.7%. The percentage of subjects whose HbA1c levels met ADA goals was less than 7% (A), and both SBP and DBP less than 130/80 mmHg (B), total cholesterol less than 160 mg/dl or LDL cholesterol levels less than 100mg/dl (C) were 32.4%, 30.9% and 35.3%, respectively. Overall, the percentage of examined diabetic subjects who fulfilled current recommended ABC goals was 4.1% (95% CI, 3.66-4.56%). Results of logistic regression analysis that indicated factors significantly associated with ABC goals are diagnosis of type 1 diabetes (p=0.025), BMI less than 23 kg/m(2) (p=0.022) and subjects not requiring insulin (p=0.006). In conclusion, only 4.1% of subjects reached all ABC goals. Diabetic individuals with diagnosis of type 1 diabetes, lesser BMI and those not using insulin were more likely to attain all ABC goals.

Factors of cardiovascular risk in patients with type 2 diabetes and incipient nephropathy

BACKGROUND

Microalbuminuria was originally established as a predictor of renal failure and an independent risk factor for cardiovascular disease in patients with diabetes mellitus as well as in general population. The aim of our study is to assess the relationship between microalbuminuria and the other risk factors in diabetics and their prevalence.

METHODS

Sixty five patients, 22 men and 43 women with mean age 58.6+/-10.09, with type 2 diabetes, were hospitalized in the Department of Internal Medicine in the University Hospital Center "Mother Teresa" in Tirana, Albania, between March 2007 and February 2008. These patients with a mean duration of diabetes 6.09+/-5.41 were divided in two groups: with (Group A: 24 patients) and without (Group B: 41 patients) microalbuminuria and each group was evaluated for left ventricular mass index (LVMI), body mass index (BMI), glycosylated hemoglobin (HbA1C), lipid profile and intima media thickness (IMT).

RESULTS

The prevalence of microalbuminuria in our study was 32.3%. The prevalence of microalbuminuria in males was 37.5 and in females 62.5%. The microalbuminuric patients were older ( 59.71+/-9.87 vs 57.07+/-10.32) and had a longer duration of diabetes (7.74+/-5.74 vs 4.45+/-5.08) compared with normoalbuminuric patients (p=0.01). The Group A had significantly higher LVMI compared with Group B ( p=0.02). The prevalence of obesity (BMI>30 kg/m2) in our sample was 44.6%. In Group A the mean BMI (30.13+/-4.98) was significantly higher compared with Group B (28.00+/-3.72, p=0.04). Diabetic retinopathy was more frequent in Group A compared with Group B ( 33.3% vs 14.6%, p=0.05). The mean value of IMT was higher in Group A compared with Group B (1.28+/-0.35 vs 1.09+/-0.28, p=0.03).

CONCLUSION

In patients with type 2 diabetes and microalbuminuria LVMI, IMT, BMI, duration of diabetes was significantly higher compared with patients with type 2 diabetes and normoalbuminuria.

Albuminuria, cardiovascular risk factors and disease management in subjects with type 2 diabetes: a cross sectional study

BACKGROUND

Epidemiological studies have shown that microalbuminuria is an important risk factor for arteriosclerosis, coronary heart disease and other vascular diseases in persons with type 2 diabetes. In the present study we examined the prevalence and risk factors for micro- and macroalbuminuria and examined glycemic control as well as treatment of modifiable cardiovascular risk factors in persons with known type 2 diabetes in Germany.

METHODS

The presented data were derived from the 'KORA Augsburg Diabetes Family Study', conducted between October 2001 and September 2002. Participants were adults aged 29 years and older with previously diagnosed type 2 diabetes (n = 581). Microalbuminuria was defined as an albumin-creatinine ratio of 30 to 300 mg/g, and macroalbuminuria as an albumin-creatinine ratio of more than 300 mg/g.

RESULTS

Microalbuminuria was revealed in 27.2% and macroalbuminuria in 9.0% of the 581 included diabetic persons. Multivariable regression analysis identified HBA1c, duration of diabetes, systolic blood pressure, serum creatinine, smoking and waist circumference as independent risk factors associated with albuminuria (micro- or macroalbuminuria). Relatively few persons with type 2 diabetes achieved treatment targets of HbA1c < 7% (46.6%), total cholesterol < 200 mg/dl (44.1%), and LDL cholesterol < 100 mg/dl (16.0%). Optimal HDL cholesterol values (> 45 mg/dl in men, > 55 mg/dl in women) were found in 55.8%, and blood pressure values < 130 and < 85 mmHg in 31.3% of the persons

CONCLUSION

Albuminuria is common among German persons with known type 2 diabetes. Despite evidence-based guidelines, only a small proportion of type 2 diabetic persons achieved the recommended levels of glycemic control and control of cardiovascular risk factors.

A multinational, multi-centre, observational, cross-sectional survey assessing diabetes secondary care in Central and Eastern Europe (DEPAC Survey)

AIMS

The objective of this study was to assess diabetes care in outpatient diabetes clinics in the Czech Republic, Estonia, Hungary, Latvia, Lithuania, Poland, Slovakia and Slovenia.

METHODS

Questionnaires for each randomly enrolled patient were completed by an endocrinologist or diabetologist. Data concerning age, sex, diabetes duration, diabetes type, treatment type, glycated haemoglobin (HbA(1c)), total cholesterol (TC), low-density lipoprotein cholesterol (LDL-C), triglycerides (TG) and high-density lipoprotein cholesterol (HDL-C), blood pressure (BP) and short- and long-term diabetes complications were recorded. Questionnaires were analysed centrally for each country and stratified for Type 1 diabetes (T1D), Type 2 diabetes (T2D) and other types of diabetes.

RESULTS

Data on 10 950 individuals were analysed (mean population age 56.2 years; females 52%; T1D 22.9%; T2D 75.3%; mean time from diagnosis 11 years). Patients with HbA(1c) within target (< 6.5%): T1D 13.1%, T2D 21.4%; for TC levels (< 4.5 mmol/l): T1D 37%, T2D 20%; for TG levels (< 1.7 mmol/l): T1D 78%, T2D 44%; for HDL-C (> 1.1 mmol/l): T1D 81%, T2D 60%; for LDL-C (< 2.5 mmol/l): T1D 36%, T2D 23%; for BP (< 130/80 mm Hg): T1D 42%, T2D 9%. The prevalence of severe hypoglycaemia (within the last 6 months) was 12% in T1D and 2% in T2D. Prevalence of diabetic ketoacidosis was 0.3-6.6%, blindness 0.15-1.3% and diabetic nephropathy 19-42%.

CONCLUSIONS

The data show the current quality of care and potential areas for improvement. The quality of care is generally comparable with that in Western Europe.

Good glycaemic control: an international perspective on bridging the gap between theory and practice in type 2 diabetes

BACKGROUND

Good glycaemic control is crucial in reducing the risk of diabetes-related complications. Despite the availability of evidence-based treatment guidelines, glycaemic control appears to remain suboptimal in most countries.

OBJECTIVES

In this commentary we outline the extent to which diabetes guideline targets on HbA(1c) are being met in clinical practice and--where targets are being missed--to identify potential reasons for this shortfall. Furthermore, we discuss possible actions that may improve glycaemic control.

METHODS

A literature search of MEDLINE using 20 core terms was conducted to help assess the state of glycaemic control in patients with type 2 diabetes worldwide.

RESULTS

Despite clinical guidelines, evidence suggests that glycaemic control is suboptimal in most parts of the world, with average HbA(1c) values varying from 7.0% to 12.6% and thus above virtually all HbA(1c) recommendations. The potential reasons for this shortfall are numerous. However, lack of diabetes education and awareness of HbA(1c) appear to be particularly important. A number of education initiatives from around the world have been shown to improve HbA(1c) levels significantly and thus improve standards of care.

CONCLUSIONS

Poor glycaemic control in patients with type 2 diabetes appears to be a worldwide problem. As the global rise in diabetes (and its complications) seems destined to affect many less affluent countries, it is essential that appropriate steps are taken to address the barriers to good glycaemic control and ultimately improve outcomes for all people with type 2 diabetes.

Hypoglycaemia in patients with type 2 diabetes treated with a combination of metformin and sulphonylurea therapy in France

CONTEXT

Hypoglycaemia from antihyperglycaemic drugs may have a significant impact on patients' health-related quality of life. Combination use of metformin and a sulphonylurea has become increasingly common; yet, the impact of hypoglycaemia on quality of life in these patients is not well documented.

OBJECTIVE

To examine patient-reported experience of hypoglycaemia, worry about hypoglycaemic symptoms and the impact of hypoglycaemia on patients' quality of life associated with use of sulphonylurea co-administered with metformin.

DESIGN

This was an observational, cross-sectional, multi-centre study.

SETTING

A total of 98 primary care centres in France during October to December 2005.

PATIENTS

A total of 400 patients with type 2 diabetes, who were > or = 35 years old and who had been treated with metformin and a sulphonylurea for at least 6 months, completed questionnaires during their usual primary care office visit.

MAIN OUTCOME MEASURES

Frequency and severity of hypoglycaemic symptoms in the past 6 months, the Worry subscale of the Hypoglycaemic Fear Survey-II (HFS-II) and the EuroQol-5 Dimensions (EQ-5D) questionnaire.

RESULTS

A total of 136 (34%) patients reported experiencing hypoglycaemia, of whom 78 (58%) experienced mild, 40 (30%) experienced moderate and 16 (12%) experienced severe or very severe symptoms. Mean score on the HFS-II Worry scale was higher for patients who reported having hypoglycaemia than for those who did not (19.0 vs. 10.2; p < 0.0001) and increased with severity of hypoglycaemic symptoms. In linear regression analyses, more severe symptoms of hypoglycaemia were significantly associated with higher scores on the HFS-II Worry scale (p = 0.0162) among patients with hypoglycaemic symptoms. Summary scores on the EQ-5D were lower for patients who reported hypoglycaemia than for those who did not (p = 0.0001) and, in multivariate analysis, the experience of hypoglycaemia was negatively associated with the EQ-5D summary score (p < 0.0001).

CONCLUSION

The occurrence and severity of hypoglycaemic symptoms were associated with increased patient worry about hypoglycaemia and lower health-related quality of life among type 2 diabetic patients being treated with both metformin and a sulphonylurea.

Evaluation of a diabetes management system based on practice guidelines, integrated care, and continuous quality management in a Federal State of Germany: a population-based approach to health care research

OBJECTIVE

The aim of this study was to evaluate the Saxon Diabetes Management Program (SDMP), which is based on integrated practice guidelines, shared care, and integrated quality management. The SDMP was implemented into diabetes contracts between health insurance providers, general practitioners (GPs), and diabetes specialized practitioners (DSPs) unified in the Saxon association of Statutory Health Insurance Physicians.

RESEARCH DESIGN AND METHODS

The evaluation of the SDMP in Germany represents a real-world study by using clinical data collected from participating physicians. Between 2000 and 2002 all DSPs and about 75% of the GPs in Saxony participated. Finally, 291,771 patients were included in the SDMP. Cross-sectional data were evaluated at the beginning of 2000 (group A1) and at the end of 2002 (group A2). A subcohort of 105,204 patients was followed over a period of 3 years (group B).

RESULTS

The statewide implementation of the SDMP resulted in a change in therapeutic practice and in better cooperation. The median A1C at the time of referral to DSPs decreased from 8.5 to 7.5%, and so did the overall mean. At the end, 78 and 61% of group B achieved the targets for A1C and blood pressure, respectively, recommended by the guidelines compared with 69 and 50% at baseline. Patients with poorly controlled diabetes benefited the most. Preexisting regional differences were aligned.

CONCLUSIONS

Integrated care disease management with practicable integrated quality management including collaboration between GPs and specialist services is a significant innovation in chronic care management and an efficient way to improve diabetes care continuously.

Undertreatment of cardiovascular risk factors among persons with diabetes in the United States

OBJECTIVE

We examined the extent of control of cardiovascular risk factors and distance from goal for those with uncontrolled levels in a recent sample of U.S. adults with diabetes.

METHODS

In the cross-sectional National Health and Nutrition Examination Survey 2001-2002, 532 (projected to 15.2 million) or 7.3% of adults aged >/=18 years had diabetes. Use of antihypertensive, antidiabetic and antidyslipidemic medications was examined. We determined the proportion of subjects not at goal for blood pressure (BP), lipids and glycosylated hemoglobin (A1C) and examined the distance from goal for those not under control.

RESULTS

Overall, 50.2% of subjects with diabetes were not at goal for A1C, 64.6% for low density lipoprotein-cholesterol (LDL-C), 52.3% for high density lipoprotein-cholesterol (HDL-C), 48.6% for triglycerides and 53.0% BP. Only 5.3% of men and 12.7% of women with diabetes were simultaneously at goal for A1C, LDL-C and BP. Even among those on treatment, most were not at goal for these parameters. Women were more likely to have LDL-C and HDL-C not at goal than men. Non-Hispanic Blacks were more often not at goal for BP and LDL-C. Mean distances from targets were 36mg/dL for LDL-C, 18mmHg for systolic BP, 6mmHg for diastolic BP and 2.0% for A1C in patients not at goal.

CONCLUSIONS

Many U.S. adults with diabetes have sub-optimal control of cardiovascular risk factors and remain far from target goals for BP, lipids and A1C, even if on treatment.

Control of diabetes and cardiovascular risk factors in patients with type 2 diabetes in primary care. The gap between guidelines and reality in Spain

To evaluate the level and factors affecting control of diabetes and cardiovascular risk factors in type 2 diabetes (TYPE 2 DM) patients. Multicentre cross-sectional study: a sample of 430 primary care practices across Spain selected 1907 type 2 diabetic patients. The first five consecutive ambulatory patients with TYPE 2 DM were eligible for the inclusion into the survey. Patients were free of known cardiovascular disease (CVD). Control criteria were defined based on 2002 American Diabetes Association (ADA) clinical practice recommendations. A total of 1907 patients (51% women) aged 63 +/- 9 years. Smoking prevalence was 22.6%, 50.6% had levels of A1c < 7%. Mean blood pressure (BP) was 148 +/- 17/86 +/- 10 mmHg. Only 7.8% have achieved the target of BP < 130/80 mmHg. Among the 1180 patients (65%) treated for hypertension, this target was attained in only 4.4% of patients. A measurement for low-density lipoprotein (LDL) cholesterol was available in 1669 patients (88%). Only 5.9% of patients achieved the target of LDL < 100 mg/dl. Among the 638 patients (41.6%) on drug treatment for dyslipidaemia, this target was attained in only 5.6% of patients. Among type 2 diabetic patients in Spain the prevalence of cardiovascular risk factors is high. Control of glycaemia, smoking, BP and LDL are far from optimal despite the widespread use of guidelines for the management of diabetes and CVD. The application of published recommendations needs to be reinforced.

Difficulties of smoking cessation in diabetic inpatients benefiting from a systematic consultation to help them to give up smoking

AIM

To assess the value of systematic smoking cessation consultations for diabetic smokers admitted to hospital.

METHODS

All diabetic smokers admitted to the Diabetes Department of Georges Pompidou European Hospital between February 2003 and February 2004 were systematically offered a consultation with a physician specialised in tobacco cessation. Follow-up visits at three, six and nine months were planned.

RESULTS

Of the 306 diabetic patients admitted, 38 (12.4%) were smokers. There were more men than women in the group of smokers and the diabetic smokers were younger than the non-smokers. The smokers had fewer micro-angiopathic complications than the non-smokers, but there was no difference in the frequency of macro-angiopathic complications. The level of nicotine physical dependence was moderate or high for 60% of the smokers. Although all the smokers agreed to the consultation, less than half agreed to drug-based treatments to help them to give up smoking and only 15% returned for the six-month visit. Only one patient had stopped smoking at the six-month visit.

CONCLUSION

This study demonstrates the difficulties in systematic interventions to help diabetic patients to stop smoking. Diabetic smokers probably constitute a specific population for which the barriers to giving up smoking should be explored.

Cost-consequence analysis in a French setting of screening and optimal treatment of nephropathy in hypertensive patients with type 2 diabetes

AIM

Forty percent of hypertensive type 2 diabetes patients develop nephropathy (microalbuminuria/overt nephropathy), indicating end organ damage, increased risk of cardiovascular disease (CVD), and death. In France, screening rates and nephropathy treatment are suboptimal. We assessed the health economic impact of nephropathy screening in hypertensive patients with type 2 diabetes followed by optimal antihypertensive/nephroprotective therapy in those who have nephropathy in France.

METHODS

A Markov/Monte Carlo model simulated lifetime impacts of screening for albuminuria (microalbuminuria/overt nephropathy) using semi-quantitative urine dipsticks in a primary care setting, and subsequent addition of irbesartan 300 mg to conventional therapy in hypertensive type 2 diabetes patients identified as having nephropathy. Progression from no renal disease to end-stage renal disease (ESRD) was simulated. Probabilities, utilities and costs of CVD events, medications and ESRD treatment came from published sources. Cumulative incidence of ESRD, life expectancy, quality-adjusted life years (QALYs) and direct costs were projected. Second-order Monte Carlo simulation accounted for uncertainty in multiple parameters. Costs and QALYs were discounted at 3% annually.

RESULTS

Screening and optimized treatment led to a 42% reduction in the cumulative incidence of ESRD from 10.1 +/- 9.9% without screening to 5.8 +/- 5.7%, improvements in life expectancy of 0.38 +/- 0.59 years, improvements of 0.29 +/- 0.32 QALYs, and decreased costs of Euro 4,812 +/- 7,882/patient over 25 years. Sensitivity analysis showed that the results were robust. Screening was most beneficial when performed in younger patients.

CONCLUSION

In hypertensive patients with type 2 diabetes, screening for albuminuria followed by optimal antihypertensive/nephroprotective treatment improves patient outcomes and leads to cost savings in France.

Subcutaneous insulin: pharmacokinetic variability and glycemic variability

The therapeutic goal in insulin-treated diabetic patients is to maintain on the long-term a tight glucose control (HbA1, < 6.5-7% or less) through an insulin regimen which "mimic" the physiological insulin profile: a basal insulin secretion to maintain glucose homeostasis and an acute post-prandial secretion in response to meal intake. Such goal represents a challenge for the clinician as conventional human insulins have major drawbacks: slow absorption and too late peak with regular insulins, delayed peak and often occuring at an unwanted time with intermediate and long-acting insulins. Furthermore, these insulins are characterised by a large within- and between-subjects variability, which complicate patients' task to self-adapt their daily doses, even for those well educated and compliants. These limitations and unpredictable variations in insulin action are responsible for an increased risk of hypoglycemic events, between meals as well as during the night period. As a consequence, glucose control is frequently insufficient in type 1 diabetic patients, and these limitations may contribute also to the delayed initiation of insulin therapy in type 2 diabetics when oral antidiabetic agents fail. This variability and the non-reproducibility of the conventional insulin pharmacodynamics are explained by several exogenous and endogenous factors describe in this review. Availability of new short-acting (lispro, aspart and glulisine) and long-acting analogs (glargine, detemir) of human insulin, with improved pharmacokinetic characteristics, and a lesser variability and better reproducibility, should facilitate a tight glucose control in insulin-treated patients. The main pharmacokinetic and pharmacodynamic characteristics of these new insulin analogs are presented and discussed in the light of there intra- and inter-individual variability. Their reduced variability should permit to reinforce near "physiological" insulin regimen such as "basal-bolus" technique and to consider new approaches and therapeutic strategies in type 1 and type 2 diabetic patients.

Utilization of oral antihyperglycemic drugs over a 7–year period (1998–2004) in a Hungarian population and adherence to drug therapy

OBJECTIVE

To describe the quantitative and qualitative changes in the utilization of oral antihyperglycemic drugs (OAHDs) between 1998 and 2004 and to analyze patients' adherence to OAHD therapy.

METHODS

We conducted a retrospective analysis of the electronic database of the Hungarian National Health Fund Administration for the years 1998 through 2004. All 912,620 prescriptions for OAHDs dispensed for the 38,855 patients in Csongrád County (430,000 inhabitants) were retrieved and analyzed according to the ATC/DDD (World Health Organization) methodology. Nonadherence was set as medication possession ratio <80%.

RESULTS

The number of patients using OAHDs significantly increased (P<0.001); the yearly prevalence of 2.88% in 1998 increased to 4.32% in 2004. The overall consumption of OAHDs increased by 76%, from 20.85 defined daily doses per 1,000 inhabitants per day (DDD/TID) in 1998 to 36.83 DDD/TID in 2004. While in 1998 glibenclamide was the most often prescribed agent, received by 61.7% of patients, its share dropped to 16.1% in 2004, and metformin became the leading agent prescribed for 43.0% of patients. During the study period, the adherence rate varied between 47.9% and 49.2%. Women had a significantly better (P<0.001) adherence rate than men, 51.3% vs. 45.5%. The adherence rate peaked in patients between 60 and 79 years and was lowest in patients in their 30s.

CONCLUSIONS

The utilization pattern of OAHDs considerably changed, but there were no significant changes in patients' adherence. The significant increase in the utilization of OAHDs is not the result of increased adherence but of increased patient number.