Patterns of antihypertensive therapy among patients with diabetes

Diabetes Status and Pancreatic Cancer Survival in the Nationwide Veterans Affairs Healthcare System

BACKGROUND

Long-standing type 2 diabetes is a known risk factor for developing pancreatic cancer, however, its influence on cancer-associated outcomes is understudied.

AIMS

To examine the associations between diabetes status and pancreatic cancer outcomes.

METHODS

We identified patients diagnosed with pancreatic adenocarcinoma in the national Veterans Administration System from 2010 to 2018. We classified each patient by pre-cancer diagnosis diabetes status: no diabetes, new-onset diabetes (NOD) of ≤ 3 years duration, or long-standing diabetes of > 3 years duration. We used Cox proportional hazards models to examine the association between diabetes status and survival. We adjusted the models for age, race, sex, body mass index, tobacco, and alcohol use, coronary artery disease, hypertension, chronic kidney disease, year of cancer diagnosis, and cancer stage and treatment.

RESULTS

We identified 6342 patients diagnosed with pancreatic adenocarcinoma. Most had long-standing diabetes (45.7%) prior to their cancer diagnosis, 14.5% had NOD, and 39.8% had no diabetes. Patients with long-standing diabetes had 10% higher mortality risk compared to patients without diabetes after adjusting for sociodemographic factors and medical comorbidities (adjusted HR 1.10; 95% CI 1.03-1.16). This difference in mortality remained statistically significant after additionally adjusting for cancer stage and receipt of potentially curative treatment (adjusted HR 1.09; 95% CI 1.02-1.15). There was no significant difference in mortality between patients with NOD compared to those without diabetes.

CONCLUSIONS

Long-standing but not new-onset diabetes is independently associated with increased mortality among patients with pancreatic cancer. This information has implication for prognostication and risk stratification among pancreatic cancer patients.

The simultaneous quantification of Sitagliptin and Irbesartan in rat plasma using the validated LC-MS/MS method is applied to a pharmacokinetic study

Irbesartan (IRB), an angiotensin II receptor AT1 blocker, is an antihypertensive agent commonly used with Sitagliptin (STG), a novel antidiabetic agent in diabetes. A finalised and validated LC-MS/MS method was used for the bioanalytical quantification of STG and IRB to be applicable to studies on the P.K drug-drug interactions between STG and IRB. Using a YMC triart C18 column (50 mm × 4.6 mm i.d., 3 µm), both the drugs and the Tolbutamide were separated using a gradient mode with a flow rate of 1 ml/min with run time of 5 min. For analyte detection, an LC-MS/MS system with multiple reaction monitoring (MRM) was used. The technique was validated across a concentration range of 5-1000 ng/ml, with the LLOQ for both analytes being 5 ng/ml. At all QC levels accuracies from spiked samples were > 83% for both drugs and internal standards. The accuracy for STG within-batch and between-batch was found within 98.4-107.2%, and for IRB was found within 92.4-102.5%. The precision for STG within batch and between batches was less than 12.3% CV, and for IRB was less than 10.2% CV at all concentration levels. The pharmacokinetic profiles of STG and IRB were successfully applied on simultaneous oral administration to rats. This method applies to pharmacokinetic multidrug interaction studies.

Blood Pressure Control among Hypertensive Diabetic Patients on Follow-Up at Chronic Clinic of Nekemte Referral Hospital in West Ethiopia

Background

Hypertension is a prevalent comorbid condition in diabetes, affecting ∼20–60% of patients with diabetes, depending on obesity, ethnicity, and age. Adults with diabetes historically have two or three times higher rate of cardiovascular disease (CVD) than adults without diabetes.

Objective

The aim of this study was to assess blood pressure (BP) control and its predictors among hypertensive diabetic patients on follow-up at the chronic clinic of Nekemte Referral Hospital (NRH) in West Ethiopia.

Methods

A cross-sectional study was conducted among hypertensive adult patients comorbid with diabetes taking antihypertensive drugs for at least one year in NRH. Both bivariable and multivariable analyses were done. The odds ratio, along with 95% confidence level, was estimated to identify factors associated with uncontrolled BP by using multivariable logistic regression analysis. The level of statistical significance was declared at p value <0.05 levels. The patient's written informed consent was obtained after explaining the purpose and procedures of the study.

Results

A total of 186 study participants were included in this study. The mean age of the participants was 51.2 ± 12.2 years. Blood pressure and blood glucose were controlled in 104 (55.9%) and 106 (57.0%) study participants, respectively. In the multivariable analysis, age ≥60 years (AOR = 4.537, 95% CI = 1.142–18.024, p=0.032), duration with hypertension ≥5 years (AOR = 3.534, 95% CI = 1.062–11.760, p=0.040), cigarette smoking (AOR = 7.697, 95% CI = 2.356–25.146, p=0.001), nonadherence (AOR = 6.584, 95% CI = 2.337–18.553, p < 0.001), and uncontrolled glycaemia (AOR = 21.630, 95% CI = 8.057–58.070, p < 0.001) were independent predictors of uncontrolled blood pressure.

Conclusion

Compared to the previous studies, BP was better controlled among hypertensive diabetic patients in the present study. Older age, longer duration with hypertension, cigarette smoking, nonadherence, and uncontrolled glycaemia were predictors of uncontrolled BP. Thus, interventions on modifiable factors should be done to improve BP control of patients' comorbid with diabetes.

Real-world use of ACEI/ARB in diabetic hypertensive patients before the initial diagnosis of obstructive coronary artery disease: patient characteristics and long-term follow-up outcome

Background

Current guidelines recommend angiotensin-converting-enzyme inhibitors (ACEI)/angiotensin receptor blockers (ARB) as a first-line therapy in diabetic hypertensive patients and for secondary prevention in patients with obstructive coronary artery disease (OCAD). However, the effects of using ACEI/ARB before the initial diagnosis of OCAD on major adverse cardiac and cerebral event (MACCE) in diabetic hypertensive patients remain unclear. This study investigated whether using ACEI/ARB before the initial diagnosis of OCAD could be associated with improved clinical outcomes in diabetic hypertensive patients.

Methods

A total of 2501 patients with hypertension and diabetes, who were first diagnosed with OCAD by coronary angiography, were included in the analysis. Of the 2501 patients, 1300 did not used ACEI/ARB before the initial diagnosis of OCAD [the ACEI/ARB(-) group]; 1201 did [the ACEI/ARB(+) group]. Propensity score matching at 1:1 was performed to select 1050 patients from each group. Incidence of acute myocardial infarction (AMI), infarct size in patients with AMI, heart function, and subsequent MACCE during a median of 25.4-month follow-up were determined and compared between the 2 groups.

Results

Compared with the ACEI/ARB(-) group, the ACEI/ARB(+) group had significantly lower incidence of AMI (22.5% vs. 28.4%, p < 0.05), smaller infarct size in patients with AMI (pTNI: 5.7 vs. 6.8 ng/ml, p < 0.05; pCKMB: 21.7 vs. 28.7 ng/ml, p < 0.05), better heart function (LVEF: 60.0 vs. 58.5%, p < 0.05), and lower incidences of non-fatal stroke (2.4% vs. 4.6%, p < 0.05) and composite MACCE (23.1% vs. 29.7%, p < 0.05). No prior ACEI/ARB therapy was significantly and independently associated with non-fatal stroke and composite MACCE.

Conclusions

In diabetic hypertensive patients, treatment with ACEI/ARB before the initial diagnosis with OCAD was associated with decreased incidence of AMI, smaller infarct size, improved heart function, and lower incidences of non-fatal stroke and composite MACCE.

Trial registration Retrospectively registered

A nationwide assessment of blood pressure control and the associated factors in Chinese type 2 diabetes mellitus patients

A subgroup analysis of the nationwide, cross-sectional 3B STUDY was performed to understand the current blood pressure (BP) control status and treatment patterns in Chinese diabetes patients as well as to identify factors associated with BP control. The demographic data, anthropometric parameters, and laboratory results were collected from 24 512 type 2 diabetes patients. The BP goal was a systolic BP <130 mm Hg and a diastolic BP <80 mm Hg regardless of a history of hypertension or current antihypertensive treatment. The overall prevalence of hypertension was 59.9% with geographical differences. Among the diabetes patients with hypertension, 76.9% received antihypertensive medicines. Calcium channel blockers (39.3%), angiotensin II receptor antagonists (26.6%), and then β-blockers (14.0%) or angiotensin-converting enzyme inhibitors (13.6%) were frequently used for BP control. Only 17.5% (n = 2658) of diabetes patients with hypertension reached the recommended target BP. Body mass index <24 kg/m² , urban resident, frequent physical activity, good adherence to medication, comorbidity with cardiovascular disease, achieving glycemic goal (HbA1c <7.0%), achieving lipid goal (low-density lipoprotein cholesterol <2.59 mmol/L) were independent factors that predicted achievement of target BP goal. On the contrary, comorbidity with chronic kidney disease predicted failure to achieve target BP goal. Patients who were treated in a cardiology department or lived in the North were more likely to achieve BP goals. A considerable proportion of diabetic patients failed to achieve guideline-recommended BP targets. More aggressive efforts should be made to overcome the diverse barriers and facilitate the optimization of diabetes management.

Management and control of type 2 diabetes mellitus in Lebanon: Results from the International Diabetes Management Practices Study Wave 6

BACKGROUND

Diabetes mellitus is a worldwide public health problem associated with significant complications. There is lack of data on the quality of care of patients with diabetes, specifically among the non-Western countries. Efforts have been made in Lebanon to better study the characteristics of patients with diabetes mellitus in order to improve glycemic control and prevent late-term complications.

AIM

To investigate control and therapeutic management of patients with diabetes mellitus in the current medical practice in Lebanon.

METHODS

Wave 6 of the International Diabetes Management Practice Study in Lebanon is an international and multicenter study involving selected countries.

RESULTS

Only 1 patient with type 1 diabetes and 595 patients with type 2 diabetes were included in Wave 6. Average age was around 60 years, with a mean body mass index of 30. The mean fasting serum glucose was 159.42 mg/dL, and the mean glycosylated hemoglobin (HbA1c) level was 7.98 with around 30% achieving an HbA1c target of < 7%. More patients were on oral anti-diabetic medications. Screening of diabetic complications has improved over the years. A large percentage is diagnosed with hypertension and dyslipidemia, the majority of whom were treated but only a small percentage were controlled.

CONCLUSION

Diabetes, with its associated dyslipidemia and hypertension, is still not very well controlled. Screening for diabetes complications has improved over the years. Patients need to have more proper care, and physicians need to follow diabetes guidelines, and to have a larger number of patients who have appropriate treatment of diabetes, hypertension and lipids.

Renin angiotensin-aldosterone system (RAAS) blockers usage among type II diabetes mellitus patients-A Retrospective Study

AIMS

Recent data showed an alarming rise of new dialysis cases secondary to diabetic nephropathy despite the growing usage of RAAS blockers. Primary objective of this study is to explore the prevalence of RAAS blockers usage among type II diabetic patients, secondary objectives are to compare the prescribing pattern of RAAS blocker between primary and tertiary care center and to explore if the dose of RAAS blocker prescribed was at optimal dose as suggested by trials.

MATERIALS AND METHODS

This is a retrospective study conducted at one public tertiary referral hospital and one public health clinic in Sungai Petani, Kedah, Malaysia.

RESULTS

RAAS blockers in T2DM patients was found to be 65%. In primary care, 14.3% of the RAAS blockers prescribed was ARB. Tertiary care had higher utilization of ARB, which was 42.9%. In primary care setting, the most commonly used ACEI were perindopril (92.4%) followed by enalapril (7.6%), meanwhile perindopril was the only ACEI being prescribed in tertiary care. The most prescribed ARB was irbesartan (63.6%) and telmisartan (54.2%) respectively in primary and tertiary care. Overall, 64.9% of RAAS blockers prescribed by both levels of care were found to be achieving the target dose as recommended in landmark trials. Crude odd ratio of prescribing RAAS blocker in primary care versus tertiary care was reported as 2.70 (95% CI: 1.49 to 4.91).

CONCLUSION

RAAS blockers usage among T2DM patients was higher in primary care versus tertiary care settings. Majority of the patients did not receive optimal dose of RAAS blockers.

Angiotensin-converting enzyme inhibitors and angiotensin II receptor blockers reduced dementia risk in patients with diabetes mellitus and hypertension

OBJECTIVE

The effects of angiotensin-converting enzyme inhibitors (ACEI) and angiotensin II receptor blockers (ARB) on dementia risk in patients with type 2 diabetes mellitus (DM) and hypertension remain unknown. We investigated the effects of ACEIs and ARBs on dementia risk in patients with type 2 DM and hypertension.

METHODS

We conducted a cohort study by using the Taiwan National Health Insurance Research Database. We included 2377 patients receiving ACEIs and 1780 patients receiving ARBs in the ACEI and ARB cohorts, respectively. We included a comparable number of patients not receiving ACEIs and ARBs as controls in the non-ACEI and non-ARB cohorts through propensity score matching. The effect of ACEIs and ARBs on dementia risk was estimated through multivariate Cox proportional hazard regression after adjustment for several confounding factors.

RESULTS

During the 12-year follow-up period, compared with the non-ACEI cohort, all-cause dementia risk decreased by 26% in the ACEI cohort [hazard ratio (HR)=0.74, 95% confidence interval (CI)=0.56-0.96]. The all-cause dementia risk was nearly 40% lower in the ARB cohort than in the non-ARB cohort (HR=0.60, 95% CI=0.37-0.97). These drugs prevented the occurrence of vascular dementia (VD), however, this effect was nonsignificant for Alzheimer's dementia (AD). Treatment duration- and dosage-related protection effects on dementia occurrence were observed.

CONCLUSIONS

ACEIs and ARBs may effectively prevent all-cause dementia, particularly VD, in patients with type 2 DM and hypertension. Moreover, compared with ACEIs, ARBs appear to be more advantageous in dementia prevention.

Pharmacokinetic Interaction Between Amlodipine and Lobeglitazone, a Novel Peroxisome Proliferator-activated Receptor-γ Agonist, in Healthy Subjects

PURPOSE

Lobeglitazone, a peroxisome proliferator-activated receptor-γ agonist, was developed for the treatment of diabetes mellitus. Because the prevalence of hypertension is high among patients with diabetes mellitus, lobeglitazone is likely to be used with the antihypertensive drug amlodipine. We evaluated the pharmacokinetic interactions between lobeglitazone and amlodipine in healthy male Korean subjects.

METHODS

The study used a randomized, open-label, multiple-dose, 3-treatment, 3-period, 6-sequence crossover design. A total of 24 healthy subjects were enrolled. Blood samples for pharmacokinetic analysis were collected according to a planned schedule after 0.5 mg of lobeglitazone and 10 mg of amlodipine were administered alone or concomitantly once per day for 10 days.

FINDINGS

A total of 24 healthy male subjects participated in the study (mean [SD] age, 26.6 [3.9] years; weight, 67.8 [5.7] kg; and height, 173.6 [6.4] cm). Three participants voluntarily withdrew after the second period, and 1 participant dropped out because of increased creatinine kinase levels caused by strenuous exercise before the start of the third period. Thus, 21 participants completed the study schedule to compare the pharmacokinetic parameters of lobeglitazone, and 22 participants completed the study of amlodipine. The geometric mean ratio (with 90% CIs) of Cmax,ss and AUCτ,ss for lobeglitazone administered concomitantly with amlodipine versus lobeglitazone administered alone was 1.01 (0.93-1.09) and 1.06 (0.92-1.23), respectively. The geometric mean ratio (with 90% CIs) of Cmax,ss and AUCτ,ss for amlodipine administered concomitantly with lobeglitazone versus amlodipine administered alone was 0.98 (0.94-1.02) and 1.00 (0.96-1.05). No serious drug-induced adverse events were reported in the study, and no clinically significant changes in vital signs, physical examination results, clinical laboratory results, or ECGs were noted.

IMPLICATIONS

The coadministration of lobeglitazone and amlodipine did not affect the pharmacokinetics of lobeglitazone or amlodipine in these healthy male Korean subjects. ClinicalTrials.gov identifier: NCT01341392.

Health care system-level factors associated with performance on Medicare STAR adherence metrics in a large, integrated delivery system

Background:

The Centers for Medicare and Medicaid Services provide significant incentives to health plans that score well on Medicare STAR metrics for cardiovascular disease risk factor medication adherence. Information on modifiable health system-level predictors of adherence can help clinicians and health plans develop strategies for improving Medicare STAR scores, and potentially improve cardiovascular disease outcomes.

Objective:

To examine the association of Medicare STAR adherence metrics with system-level factors.

Research Design:

A cross-sectional study.

Subjects:

A total of 129,040 diabetes patients aged 65 years and above in 2010 from 3 Kaiser Permanente regions.

Measures:

Adherence to antihypertensive, antihyperlipidemic, and oral antihyperglycemic medications in 2010, defined by Medicare STAR as the proportion of days covered ≥80%.

Results:

After controlling for individual-level factors, the strongest predictor of achieving STAR-defined medication adherence was a mean prescribed medication days’ supply of >90 days (RR=1.61 for antihypertensives, oral antihyperglycemics, and statins; all P<0.001). Using mail order pharmacy to fill medications >50% of the time was independently associated with better adherence with these medications (RR=1.07, 1.06, 1.07; P<0.001); mail order use had an increased positive association among black and Hispanic patients. Medication copayments ≤$10 for 30 days’ supply (RR=1.02, 1.02, 1.02; P<0.01) and annual individual out-of-pocket maximums ≤$2000 (RR=1.02, 1.01, 1.02; P<0.01) were also significantly associated with higher adherence for all 3 therapeutic groupings.

Conclusions:

Greater medication days’ supply and mail order pharmacy use, and lower copayments and out-of-pocket maximums, are associated with better Medicare STAR adherence. Initiatives to improve adherence should focus on modifiable health system-level barriers to obtaining evidence-based medications.

Medicare Star excludes diabetes patients with poor CVD risk factor control

OBJECTIVES

CMS recently added medication adherence to antihypertensives, antihyperlipidemics, and oral antihyperglycemics to its Medicare Star quality measures. These CMS metrics exclude patients with <2 medication fills (ie, "early nonadherence") and patients concurrently taking insulin. This study examined the proportion of patients with diabetes prescribed cardiovascular disease (CVD) medications excluded from Star adherence metrics and assessed the relationship of both Star-defined adherence and exclusion from Star metrics with CVD risk factor control.

STUDY DESIGN

Cross-sectional, population-based analysis of 129,040 patients with diabetes aged ≥65 years in 2010 from 3 Kaiser Permanente regions.

METHODS

We estimated adjusted risk ratios to assess the relationship between achieving Star adherence and being excluded from Star adherence metrics, with CVD risk factor control (glycated hemoglobin [A1C]<8.0%, low-density lipoprotein cholesterol [LDL-C]<100 mg/dL, and systolic blood pressure [SBP]<130 mm Hg) in patients with diabetes.

RESULTS

Star metrics excluded 27% of patients with diabetes prescribed oral medications. Star-defined nonadherence was negatively associated with CVD risk factor control (risk ratio [RR], 0.95, 0.84, 0.96 for A1C, LDL-C, and SBP control, respectively; P<.001). Exclusion from Star metrics due to early nonadherence was also strongly associated with poor control (RR, 0.83, 0.56, 0.87 for A1C, LDL-C, and SBP control, respectively; P<.001). Exclusion for insulin use was negatively associated with A1C control (RR, 0.78; P<.0001).

CONCLUSIONS

Medicare Star adherence measures underestimate the prevalence of medication nonadherence in diabetes and exclude patients at high risk for poor CVD outcomes. Up to 3 million elderly patients with diabetes may be excluded from these measures nationally. Quality measures designed to encourage effective medication use should focus on all patients treated for CVD risk.

Receipt of Angiotensin-Converting Enzyme Inhibitors or Angiotensin II Receptor Blockers among Medicare Beneficiaries with Diabetes and Hypertension

OBJECTIVES

The proportion of patients with diabetes and hypertension receiving angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers (ACE/ARB), is one of the quality measures for medication management employed by the Centers for Medicare and Medicaid Services to rate Medicare Part D plans. The objectives of this study were to determine the rate and predictors of receiving ACE/ARB in physician office and outpatient visits made by Medicare beneficiaries with diabetes and hypertension.

METHODS

The study population was Medicare beneficiaries with diabetes and hypertension from the National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey Outpatient Department, from 2007 to 2009. Predictors of receiving ACE/ARB were determined using bivariate and multivariate logistic regression analysis.

KEY FINDINGS

Of the 6,311 Medicare outpatient and physician office visits with hypertension and diabetes, 40.70% patient visits were associated with receiving ACE/ARB. Bivariate analysis found that higher proportions of ACE/ARB were received during visits made to primary care physicians compared to visits to non-primary care physicians (48.39% vs. 32.56%; p<0.05). Adjusted multivariate analyses indicated that ACE/ARB were more likely to be received during visits to primary care physicians than visits to non-primary care physicians (odds ratio [OR]: 1.96; 95% confidence interval [CI]: 1.59-2.43), and ACE/ARB were more likely to be received during visits by patients residing in zip codes with median household income within Quartile 2 ($32,794-$40,626), compared to visits by patients residing in zip codes with median household income within Quartile 1 (< $32,793, OR: 1.45; 95% CI: 1.13-1.87).

CONCLUSIONS

Fewer than half of the patient visits were associated with receiving ACE/ARB. Promoting evidence-based medicine and increasing access to primary care may have the potential to increase the rates of receiving ACE/ARB in this population.

Clinical pharmacokinetics and pharmacodynamics of vildagliptin

Vildagliptin is an orally active, potent and selective dipeptidyl peptidase-4 (DPP-4) inhibitor, shown to be effective and well tolerated in patients with type 2 diabetes mellitus (T2DM) as either monotherapy or in combination with other anti-diabetic agents. Vildagliptin possesses several desirable pharmacokinetic properties that contribute to its lower variability and low potential for drug interaction. Following oral administration, vildagliptin is rapidly and well absorbed with an absolute bioavailability of 85%. An approximately dose-proportional increase in exposure to vildagliptin over the dose range of 25-200 mg has been reported. Food does not have a clinically relevant impact on the pharmacokinetics of vildagliptin, and it can be taken without regard to food. Vildagliptin is minimally bound to plasma proteins (9.3%) and, on the basis of a volume of distribution of 71 L, it is considered to distribute extensively into extravascular spaces. Renal clearance of vildagliptin (13 L/h) accounts for 33% of the total body clearance after intravenous administration (41 L/h). The primary elimination pathway is hydrolysis by multiple tissues/organs. The DPP-4 enzyme contributes to the formation of the major hydrolysis metabolite, LAY151; therefore, vildagliptin is also a substrate of DPP-4. Vildagliptin has a low potential for drug interactions, as cytochrome P450 (CYP) enzymes are minimally (<1.6%) involved in the overall metabolism. Clinical pharmacokinetic studies have reported the lack of drug interaction with several drugs (metformin, pioglitazone, glyburide, simvastatin, amlodipine, valsartan, ramipril, digoxin and warfarin) that are likely to be frequently co-administered to patients with T2DM. In particular, vildagliptin does not affect the pharmacokinetics of pioglitazone, glyburide, warfarin and simvastatin; therefore, it is not expected to affect the pharmacokinetics of a drug that is a substrate for CYP2C8, CYP2C9 or CYP3A4. In the elderly, vildagliptin exposure increases by approximately 30%, which is considered to be mostly attributable to compromised renal function in the elderly population and is not considered to be clinically relevant. Vildagliptin has been demonstrated to be efficacious, safe and well tolerated in elderly patients with T2DM without dose adjustment. In subjects with varying degrees of renal impairment, vildagliptin exposure increases by approximately 2-fold; however, the increase in the exposure does not correlate with the severity of renal impairment. The lack of a clear correlation between the increased exposure and the severity of renal impairment is considered to be attributable to the fact that the kidneys contribute to both the excretion and the hydrolysis metabolism of vildagliptin. Hepatic impairment, gender, body mass index (BMI) and ethnicity do not have an influence on the pharmacokinetics of vildagliptin. These findings suggest that vildagliptin can be used in a diverse patient population without dose adjustment. Oral administration of vildagliptin to patients with T2DM completely inhibits DPP-4 activity at a variety of doses. The onset of DPP-4 inhibition is rapid, and the duration of DPP-4 inhibition is dose dependent. Vildagliptin is a potent inhibitor of the DPP-4 enzyme, with a concentration required to achieve 50% DPP-4 inhibition (IC(50)) of 4.5 nmol/L in patients with T2DM. Similar potency of DPP-4 inhibition by vildagliptin has been reported in different ethnic groups, indicating that ethnicity does not affect the pharmacodynamics of vildagliptin. Vildagliptin significantly increases the active glucagon-like peptide 1 (GLP-1) levels by approximately 2- to 3-fold and glucose-dependent insulinotropic polypeptide (GIP) levels by approximately 5-fold, and significantly suppresses the postprandial glucagon levels in response to a meal or following an oral glucose tolerance test (OGTT) in patients with T2DM. Vildagliptin significantly reduces both fasting and postprandial glucose levels over the dose range of 50-100 mg daily (administered either once daily or twice daily), and there are no substantial additional benefits of doses greater than 50 mg twice daily. The primary clinical dosing regimen is 50 mg twice daily as monotherapy or in combination with metformin. Vildagliptin increases the insulin levels following an OGTT and an intravenous glucose tolerance test (IVGTT), and the stimulation of insulin secretion is glucose dependent. Vildagliptin has been shown to improve beta-cell function on the basis of pharmacodynamic modelling taking the reduced glucose levels into account. The improvement of beta-cell function by vildagliptin has been confirmed after chronic treatment with vildagliptin for up to 2 years. Reduction of the endogenous glucose production appears to contribute to the glucose-lowering effects. Unlike the GLP-1 receptor agonists, vildagliptin does not affect gastric emptying, and this is consistent with the favourable gastrointestinal safety profile. Vildagliptin improves the sensitivity of the alpha cell to glucose in patients with T2DM by enhancing the alpha-cell responsiveness to both suppressive effects of hyperglycaemia and stimulatory effects of hypoglycaemia. Consistently, a lower incidence of hypoglycaemic events with vildagliptin is reported when it is used as either monotherapy or in combination with other anti-diabetic agents, such as metformin or insulin, as compared with a sulphonylurea. Numerous long-term clinical trials of up to 2 years have demonstrated that vildagliptin 50 mg once daily or twice daily is effective, safe and well tolerated in patients with T2DM as either monotherapy or in combination with a variety of other anti-diabetic agents.

Competence of Polish primary-care doctors in the pharmacological treatment of hypertension

RATIONALE, AIMS AND OBJECTIVES

Compliance with treatment guidelines for hypertension is variable. This study assessed the competence of Polish general practitioners in compliance with hypertension treatment guidelines, and doctor and patient characteristics associated with compliance.

METHODS

The study was conducted on a random sample of Polish primary-care doctors working in clinics contracted by the national health insurance funds. Doctors completed a questionnaire consisting of eight case vignettes describing patients with elevated blood pressure. The cases differed on three variables relating to the level of blood pressure, the presence or absence of diabetes mellitus, and the presence or absence of other risk factors. Doctors were asked to give their treatment decision for each case. Demographic data and details of the doctor's practice were also collected. Treatment decisions were tabulated, and associations between doctor and patient characteristics and treatments were assessed.

RESULTS

One hundred twenty-five doctors (65% response rate) completed the questionnaire. Compliance with treatment guidelines was judged to be 51%. Poor compliance with guidelines was noted for patients with diabetes mellitus. The level of blood pressure was the strongest predictor of drug treatment. Angiotensin-converting enzyme inhibitors were the most frequently prescribed medications. Appropriate decisions were associated with practice in large cities.

CONCLUSIONS

Compliance with hypertension treatment guidelines was judged to be poor in this study of a sample of Polish primary-care doctors using case vignettes to test competence. Additional emphasis on hypertension guidelines in training doctors is needed, especially for diabetic patients and for doctors outside urban centres.

Trends in blood pressure control and treatment among type 2 diabetes with comorbid hypertension in the United States: 1988-2004

OBJECTIVES

The objectives of this study were to examine the trends in the prevalence of type 2 diabetic patients with comorbid hypertension and blood pressure (BP) control rates in the United States and determine factors associated with these outcomes.

METHODS

We used data from National Health and Nutrition Examination Surveys (NHANES) III (1988-1994) and NHANES 1999-2004, a cross-sectional sample of the noninstitutionalized US populations. Type 2 diabetic patients were identified as patients at least 30 years of age with physician-diagnosed diabetes who were taking insulin or oral antidiabetic drugs to manage the condition. A diagnosis of hypertension was based on physician diagnosis, treatment with antihypertensive medications, or BP at least 140/90 mmHg. BP control was defined as diabetic patients who maintained BP <130/80 mmHg. Logistic regression was used to estimate risks of high BP, and odds of high BP treatment and control rates, after adjusting for demographic and clinical risk factors.

RESULTS

The age-adjusted prevalence of diabetic patients and those with hypertension increased significantly from 5.8 to 7.1% and 3.9 to 4.7%, respectively, from NHANES III to NHANES 1999-2004. Among diabetic patients with hypertension, patients who were treated with medication or lifestyle or behavioral modification therapy have increased significantly from 76.5 to 87.8% during the observation period. The proportion of patients who controlled BP increased from 15.9 to 29.6%, but 70% of patients still did not meet the target BP goal.

CONCLUSION

Aggressive public health efforts are needed to improve BP control in type 2 diabetic patients with hypertension.

The association of Medicare drug coverage with use of evidence-based medications in the Veterans Health Administration

BACKGROUND

Veterans with Medicare managed-care plans have access to pharmacy benefits outside the Veterans Health Administration (VA), but how this coverage affects use of medications for specific disease conditions within the VA is unclear.

OBJECTIVE

To examine patterns of pharmacotherapy among patients with diabetes mellitus, ischemic heart disease, and chronic heart failure enrolled in fee-for-service (FFS) or managed-care (HMO) plans and to test whether pharmacy benefit coverage within Medicare is associated with the receipt of evidence-based medications in the VA.

METHODS

A retrospective analysis of veterans dually enrolled in the VA and Medicare healthcare systems was conducted. We used VA and Medicare administrative data from 2002 in multivariable logistic regression analysis to determine the unique association of enrollment in Medicare FFS or managedcare plans on the use of medications, after adjusting for sociodemographic, geographic, and patient clinical factors.

RESULTS

A total of 369,697 enrollees met inclusion criteria for diabetes, ischemic heart disease, or chronic heart failure. Among patients with diabetes, adjusted odds ratios (ORs) of receiving angiotensin-converting enzyme (ACE) inhibitors and oral hypoglycemics in the FFS group were, respectively, 0.86 and 0.80 (p < 0.001). Among patients with ischemic heart disease, FFS patients were generally less likely to receive beta-blockers, antianginals, and statins. Among patients with chronic heart failure, adjusted ORs of receiving ACE inhibitors, angiotensin-receptor blockers, and statins in the FFS group were, respectively, 0.90, 0.78, and 0.79 (all p < 0.05). There were few systematic differences within HMO coverage levels.

CONCLUSIONS

FFS-enrolled veterans were generally less likely to be receiving condition-related medications from the VA, compared with HMO-enrolled veterans with lower levels of prescription drug coverage. Pharmacy prescription coverage within Medicare affects the use of evidence-based medications for specific disease conditions in the VA.

Racial/Ethnic Disparities in Medication Use Among Veterans with Hypertension and Dementia: A National Cohort Study

Background:

Hypertension and comorbid dementia are common illnesses affecting older adults disproportionally. Medication adherence is vital in achieving therapeutic outcomes. Use of antihypertensive and dementia medications may vary by race/ethnicity and has not been well explored.

Objective:

To evaluate the utilization of antihypertensive and dementia drugs and adherence in a national cohort of veterans aged 65 years or older with a diagnosis of both hypertension and dementia across different racial/ethnic groups.

Methods:

This was a retrospective cohort study that used 2 national databases of the Veterans Health Administration to estimate medication utilization and adherence rates among whites, African Americans, and Hispanics from 2000 to 2005. A medication possession ratio of 0.8 or greater defined adherence. The association between race/ethnicity and adherence was analyzed using multivariate logistic regression analysis.

Results:

A total of 56,561 patients (70.5% white, 15.6% African American, 6.6% Hispanic) aged 65 years or older had diagnoses of dementia and hypertension. African Americans were less likely than whites to receive angiotensin-converting enzyme (ACE) inhibitors, angiotensin receptor blockers (ARBs), β-blockers, acetylcholinesterase inhibitors, and memantine (p < 0.05). Hispanics were more likely than whites to be prescribed an ACE inhibitor and less likely to be prescribed an ARB, β-blocker, nondihydropyridine calcium-channel blocker (CCB), loop diuretic, β-agonist, or potassium-sparing diuretic (PSD) (p < 0.05). Medication adherence was significantly lower in African Americans than whites in all classes except for ARBs, loop diuretics, and PSDs (p < 0.05). Being Hispanic was associated with significantly lower adherence rates than whites for dihydropyridine CCBs and acetylcholinesterase inhibitors (p <0.05).

Conclusions:

Racial/ethnic differences exist in antihypertensive and dementia medication use in a cohort of older adults with hypertension and dementia. Adherence rates for a number of antihypertensive and dementia drugs are lower for minorities compared with whites. Healthcare providers should make special efforts to improve medication adherence among minorities.

Secondary prevention of cardiovascular disease in type 2 diabetes and prediabetes: a cardiologist's perspective

Patients with type 2 diabetes mellitus (T2DM) and prediabetes have a substantially greater risk of developing cardiovascular (CV) disease than the general population. This increased risk of CV disease is due to a complex cluster of risk factors including insulin resistance, hyperglycaemia, diabetic dyslipidaemia, hypertension and systemic inflammation. As a result of this cluster of risk factors, life expectancy is reduced by up to 10 years upon diagnosis of T2DM, principally because of fatal CV events. Patients with T2DM are not only more likely to sustain a CV event, but also have a higher risk of a fatal outcome from this event. Therefore, whilst primary prevention is critical in determining the prognosis of patients newly diagnosed with T2DM, many will go on to suffer CV events and represent a high-risk group requiring intensive secondary prevention techniques. Recent data demonstrate that contemporary prevention therapies do not afford equal benefits to T2DM sufferers after acute myocardial infarction compared with their non-diabetic counterparts. This finding highlights the need for more effective secondary preventative strategies to prevent recurrent CV events in patients with T2DM and prediabetes. The cardiologist's role in the multidisciplinary management of T2DM is to improve patient outcomes by optimising use of evidence-based strategies for the prevention of recurrent CV events.