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Sun R, Jia J, Wang S, Wang Z, Wang C, Xu Y, Yuan Y. Mediation effect of antithrombin III between chronic renal insufficiency and chronic coronary artery disease in T2DM patients. Endocrine 2024:10.1007/s12020-023-03669-0. [PMID: 38190026 DOI: 10.1007/s12020-023-03669-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Accepted: 12/15/2023] [Indexed: 01/09/2024]
Abstract
PURPOSE The study aimed to investigate the potential effect of Antithrombin III (ATIII) between chronic renal insufficiency and chronic coronary artery disease (chronic CAD) in type 2 diabetes mellitus (T2DM) patients. METHODS T2DM patients hospitalized in ZhongDa Hospital from 2013 to 2018 were enrolled. Relationships between renal function, ATIII, and chronic CAD risk were explored using multivariate regression models. Multiplicative and additive interactions were investigated between ATIII and renal function for CAD risk, and the role of ATIII was determined by bootstrap mediation analysis in patients with chronic renal dysfunction. RESULTS A total of 4197 patients were included in the study, with a chronic CAD prevalence of 23.02%. Low ATIII level was statistically associated with chronic renal insufficiency and elevated CAD risk even after adjustments (P < 0.05). A positive correlation between renal function and ATIII was demonstrated, and each 1 SD increase in renal function, ATIII increased by 2.947% (2.406-3.488%, P < 0.001) and 0.969% (0.297-1.642%, P < 0.001) in crude and adjusted models respectively. Patients with decreased renal function and ATIII were at the highest chronic CAD risk (OR = 1.51, 95%CI:1.15-1.98, P < 0.05), while no multiplicative and additive interaction effects were significant. Bootstrap mediation analysis estimated that ATIII mediated approximately 4.27% of the effect of chronic renal insufficiency on chronic CAD risk. CONCLUSION ATIII may serve as a mediator between chronic renal insufficiency and chronic CAD, providing mechanistic clues for renal-heart association and new insight into clinical therapies.
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Affiliation(s)
- Ruoyu Sun
- Department of Endocrinology, The Affiliated Zhongda Hospital of Southeast University, Nanjing, 210009, China
- School of Medicine, Southeast University, Nanjing, 210009, China
| | - Jianhong Jia
- Department of Endocrinology, Siyang Hospital of Traditional Chinese Medicine, Suqian, 223700, China
| | - Shaohua Wang
- Department of Endocrinology, The Affiliated Zhongda Hospital of Southeast University, Nanjing, 210009, China
| | - Zheng Wang
- Gansu Province Maternal and Child-Care Hospital, Lanzhou, 730050, China
| | - Chenchen Wang
- Department of Endocrinology, The Affiliated Zhongda Hospital of Southeast University, Nanjing, 210009, China
| | - Yanchao Xu
- College of Computer Science and Technology, Zhejiang University, Hangzhou, 310058, China
| | - Yang Yuan
- Department of Endocrinology, The Affiliated Zhongda Hospital of Southeast University, Nanjing, 210009, China.
- School of Medicine, Southeast University, Nanjing, 210009, China.
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2
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La pandemia diabete in Italia. L'ENDOCRINOLOGO 2022. [PMCID: PMC9327878 DOI: 10.1007/s40619-022-01130-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
In Italia vivono circa 4 milioni di persone con il diabete e ogni anno ci sono circa 350 mila nuove diagnosi. Le persone con diabete ricevono prescrizioni di farmaci, esami di laboratorio e strumentali e richiedono ricoveri ospedalieri più spesso delle persone senza il diabete. Il diabete è gravato da aumentata mortalità e accorcia la vita, soprattutto nelle persone di media età. La qualità della cura nelle persone con diabete è subottimale, soprattutto fra chi non è assistito nei centri diabetologici (che, peraltro, rappresentano dei luoghi “salvavita”). Il diabete contribuisce fortemente alla spesa sanitaria e comporta ingenti spese, non tutte specificamente sanitarie. Nonostante tutto questo e nonostante leggi nazionali e regionali, documenti di indirizzo nazionali e regionali, PDTA regionali e locali, promesse e proponimenti di varia provenienza, la pandemia diabete non riceve le attenzioni che merita.
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3
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Matsuura S, Shibazaki K, Uchida R, Imai Y, Mukoyama T, Shibata S, Morita H. Sarcopenia is associated with the Geriatric Nutritional Risk Index in elderly patients with poorly controlled type-2 diabetic mellitus. J Diabetes Investig 2022; 13:1366-1373. [PMID: 35290727 PMCID: PMC9340875 DOI: 10.1111/jdi.13792] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Revised: 03/06/2022] [Accepted: 03/13/2022] [Indexed: 11/28/2022] Open
Abstract
Aims/Introduction Diabetes and sarcopenia have a two‐way relationship with each other with advanced age. Additionally, malnutrition is correlated with a higher risk of sarcopenia in elderly patients. This study evaluated the association between sarcopenia and geriatric nutritional risk index (GNRI) in elderly patients with type 2 diabetes mellitus. Materials and Methods Patients with type 2 diabetes mellitus aged ≥60 years were recruited from June 2018 to August 2020. This study analyzed 234 patients, who completed a physical performance test required for the diagnosis of sarcopenia. To investigate the effect of GNRI on sarcopenia, logistic regression analyses was used. Results Patients with sarcopenia were significantly older with a lower body mass index (BMI) and GNRI compared with normal patients. The GNRI showed a positive correlation with the skeletal muscle index (SMI) and handgrip strength (SMI: R = 0.486, P < 0.001 for male; R = 0.589, P < 0.001 for female, handgrip strength: R = 0.470, P < 0.001 for male, R = 0.364, P < 0.001 for female). In the multivariate logistic regression model, a higher GNRI was associated with a lower risk of sarcopenia in older men and women with diabetes (adjusted odds ratio [OR], 0.892; 95% confidence interval [CI], 0.839–0.948 for male; adjusted OR, 0.928; 95% CI, 0.876–0.982 for female). One year of diabetes treatment improved the GNRI in the sarcopenia group with type 2 diabetes mellitus. Conclusions A low GNRI was associated with an increased risk of sarcopenia in elderly patients with type 2 diabetes mellitus. Treatment with glucose‐lowering drugs improved the GNRI in the sarcopenia group.
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Affiliation(s)
- Shun Matsuura
- Division of Diabetes Endocrinology medicine, Fujieda Municipal General Hospital, 4-1-11, Surugadai, Fujieda, Shizuoka, 426-8677, Japan.,Division of Respiratory Internal medicine, Fujieda Municipal General Hospital, 4-1-11, Surugadai, Fujieda, Shizuoka, 426-8677, Japan
| | - Koji Shibazaki
- Division of Diabetes Endocrinology medicine, Fujieda Municipal General Hospital, 4-1-11, Surugadai, Fujieda, Shizuoka, 426-8677, Japan
| | - Reiko Uchida
- Division of Diabetes Endocrinology medicine, Fujieda Municipal General Hospital, 4-1-11, Surugadai, Fujieda, Shizuoka, 426-8677, Japan
| | - Yukiko Imai
- Division of Diabetes Endocrinology medicine, Fujieda Municipal General Hospital, 4-1-11, Surugadai, Fujieda, Shizuoka, 426-8677, Japan
| | - Takuya Mukoyama
- Division of Diabetes Endocrinology medicine, Fujieda Municipal General Hospital, 4-1-11, Surugadai, Fujieda, Shizuoka, 426-8677, Japan
| | - Shoko Shibata
- Division of Diabetes Endocrinology medicine, Fujieda Municipal General Hospital, 4-1-11, Surugadai, Fujieda, Shizuoka, 426-8677, Japan
| | - Hiroshi Morita
- Division of Diabetes Endocrinology medicine, Fujieda Municipal General Hospital, 4-1-11, Surugadai, Fujieda, Shizuoka, 426-8677, Japan
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Compliance with Prescription Guidelines for Glucose-Lowering Therapies According to Renal Function: Real-Life Study in Inpatients of Internal Medicine, Endocrinology and Cardiology Units. Medicina (B Aires) 2021; 57:medicina57121376. [PMID: 34946320 PMCID: PMC8704212 DOI: 10.3390/medicina57121376] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Revised: 12/13/2021] [Accepted: 12/16/2021] [Indexed: 12/19/2022] Open
Abstract
Background and objectives: Renal failure is a contraindication for some glucose-lowering drugs and requires dosage adjustment for others, particularly biguanides, sulfonylureas, and inhibitors of dipeptidyl peptidase 4. In this study, we assessed adherence to prescription recommendations for glucose-lowering drugs according to renal function in hospitalized diabetic subjects. Materials and Methods: This prospective cohort study was carried out over a 2-year period in a university hospital. Glomerular filtration rate (GFR) was determined by averaging all measurements performed during hospitalization. Glucose-lowering drug dosages were analyzed according to the recommendations of the relevant medical societies. Results: In total, 2071 diabetic patients (53% hospitalized in cardiology units) were examined. GFR was <30 mL/min/1.73 m2 in 13.4% of these patients, 30–44 in 15.1%, 45–60 in 18.3%, and >60 in 53.3%. Inappropriate oral glucose-lowering treatments were administered to 273 (13.2%) patients, including 53 (2.6%) with a contraindication. In cardiology units, 53.1% and 14.3% of patients had GFRs of <60 and <30 mL/min/1.73 m2, respectively, and 179 (15.4%) patients had a contraindication or were prescribed an excessive dose of glucose-lowering drugs. Conclusions: We showed that the burden of inappropriate prescriptions is high in diabetic patients. Given the high number of patients receiving these medications, particularly in cardiology units, a search for potential adverse effects related to these drugs should be performed.
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Bonora E, Cataudella S, Marchesini G, Miccoli R, Vaccaro O, Fadini GP, Martini N, Rossi E. Initial treatment of diabetes in Italy. A nationwide population-based study from of the ARNO Diabetes Observatory. Nutr Metab Cardiovasc Dis 2021; 31:2661-2668. [PMID: 34218990 DOI: 10.1016/j.numecd.2021.06.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Revised: 05/24/2021] [Accepted: 06/03/2021] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND AIMS To investigate diabetes treatment initiation and continuation in the next sixth months in newly diagnosed Italian subjects. METHODS AND RESULTS We analyzed administrative claims of 11,300,750 Italian residents. Subjects with incident diabetes were identified by glucose lowering drug prescriptions, disease-specific co-payment exemptions and hospital discharge codes occurring in 2018 but not in 2017. Incident cases were 65,932 of whom 91.4% received the prescription of a glucose lowering drug. Among the latter, those receiving a prescription of a noninsulin medication but no insulin were 84.8%, those receiving a prescription of insulin only were 9.4%, and those receiving prescriptions of both insulin and noninsulin drugs were 5.8%. Metformin was the most frequently drug initially prescribed in noninsulin treated subjects (~85%) and sulphonylurea receptor (SUR) agonists collectively ranked as second (~13%). Lispro (35%) and glargine (34%) were the most frequently prescribed molecules in subjects who were insulin treated. Differences in prescriptions were found in age categories, with increased use of SUR agonists across decades. In the first six months, as many as 50% of noninsulin treated patients continued with the initial drug, ~15% added a second agent, ~5% switched to another medication, and ~30% discontinued any glucose lowering treatment. CONCLUSIONS These data document that current guidelines are often neglected because prescriptions of SUR agonists as first agent are still quite common and insulin is prescribed more than expected. They point out the urgent need to improve the dissemination and implementations of guidelines in diabetes care.
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MESH Headings
- Adolescent
- Adult
- Aged
- Aged, 80 and over
- Biomarkers/blood
- Blood Glucose/drug effects
- Blood Glucose/metabolism
- Child
- Child, Preschool
- Databases, Factual
- Diabetes Mellitus, Type 1/blood
- Diabetes Mellitus, Type 1/diagnosis
- Diabetes Mellitus, Type 1/drug therapy
- Diabetes Mellitus, Type 1/epidemiology
- Diabetes Mellitus, Type 2/blood
- Diabetes Mellitus, Type 2/diagnosis
- Diabetes Mellitus, Type 2/drug therapy
- Diabetes Mellitus, Type 2/epidemiology
- Drug Prescriptions
- Drug Substitution/trends
- Drug Therapy, Combination/trends
- Drug Utilization/trends
- Female
- Humans
- Hypoglycemic Agents/adverse effects
- Hypoglycemic Agents/therapeutic use
- Infant
- Infant, Newborn
- Insulin/therapeutic use
- Italy/epidemiology
- Male
- Metformin/therapeutic use
- Middle Aged
- Practice Patterns, Physicians'/trends
- Sulfonylurea Compounds/therapeutic use
- Time Factors
- Treatment Outcome
- Young Adult
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Affiliation(s)
| | | | | | | | | | | | | | - Elisa Rossi
- CINECA - Interuniversity Consortium, Bologna, Italy
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6
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Diabetic kidney disease: new clinical and therapeutic issues. Joint position statement of the Italian Diabetes Society and the Italian Society of Nephrology on "The natural history of diabetic kidney disease and treatment of hyperglycemia in patients with type 2 diabetes and impaired renal function". J Nephrol 2021; 33:9-35. [PMID: 31576500 PMCID: PMC7007429 DOI: 10.1007/s40620-019-00650-x] [Citation(s) in RCA: 55] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Aims This joint document of the Italian Diabetes Society and the Italian Society of Nephrology reviews the natural history of diabetic kidney disease (DKD) in the light of the recent epidemiological literature and provides updated recommendations on anti-hyperglycemic treatment with non-insulin agents. Data Synthesis Recent epidemiological studies have disclosed a wide heterogeneity of DKD. In addition to the classical albuminuric phenotype, two new albuminuria-independent phenotypes have emerged, i.e., “nonalbuminuric renal impairment” and “progressive renal decline”, suggesting that DKD progression toward end-stage kidney disease (ESKD) may occur through two distinct pathways, albuminuric and nonalbuminuric. Several biomarkers have been associated with decline of estimated glomerular filtration rate (eGFR) independent of albuminuria and other clinical variables, thus possibly improving ESKD prediction. However, the pathogenesis and anatomical correlates of these phenotypes are still unclear. Also the management of hyperglycemia in patients with type 2 diabetes and impaired renal function has profoundly changed during the last two decades. New anti-hyperglycemic drugs, which do not cause hypoglycemia and weight gain and, in some cases, seem to provide cardiorenal protection, have become available for treatment of these individuals. In addition, the lowest eGFR safety thresholds for some of the old agents, particularly metformin and insulin secretagogues, have been reconsidered. Conclusions The heterogeneity in the clinical presentation and course of DKD has important implications for the diagnosis, prognosis, and possibly treatment of this complication. The therapeutic options for patients with type 2 diabetes and impaired renal function have substantially increased, thus allowing a better management of these individuals.
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7
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Wanner C, Cooper ME, Johansen OE, Toto R, Rosenstock J, McGuire DK, Kahn SE, Pfarr E, Schnaidt S, von Eynatten M, George JT, Gollop ND, Marx N, Alexander JH, Zinman B, Perkovic V. Effect of linagliptin versus placebo on cardiovascular and kidney outcomes in nephrotic-range proteinuria and type 2 diabetes: the CARMELINA randomized controlled trial. Clin Kidney J 2021; 14:226-236. [PMID: 33564423 PMCID: PMC7857804 DOI: 10.1093/ckj/sfaa225] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2020] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Nephrotic-range proteinuria (NRP) is associated with rapid kidney function loss and increased cardiovascular (CV) disease risk. We assessed the effects of linagliptin (LINA) on CV and kidney outcomes in people with Type 2 diabetes (T2D) with or without NRP. METHODS Cardiovascular and renal microvascular outcome study with LINA randomized participants with T2D and CV disease and/or kidney disease to LINA 5 mg or placebo (PBO). The primary endpoint [time to first occurrence of 3-point major adverse cardiac events (3P-MACE)], and kidney outcomes, were evaluated by NRP status [urinary albumin:creatinine ratio (UACR) ≥2200 mg/g] at baseline (BL) in participants treated with one or more dose of study medication. RESULTS NRP was present in 646/6979 [9.3% (LINA/PBO n = 317/n = 329); median UACR 3486 (Q1: 2746/Q3: 4941) mg/g] participants, who compared with no-NRP were younger (62.3/66.1 years) and had lower estimated glomerular filtration rate (eGFR) (39.9/56.1 mL/min/1.73 m2). Over a median of 2.2 years, 3P-MACE occurred with a 2.0-fold higher rate in NRP versus no-NRP (PBO group), with a neutral LINA effect, regardless of NRP. The composite of time to renal death, end-stage kidney disease (ESKD) or decrease of ≥40 or ≥50% in eGFR, occurred with 12.3- and 13.6-fold higher rate with NRP (PBO group); evidence of heterogeneity of effects with LINA was observed for the former [NRP yes/no: hazard ratio 0.80 (0.63-1.01)/1.25 (1.02-1.54); P-interaction 0.005], but not the latter [0.83 (0.64-1.09)/1.17 (0.91-1.51), P-interaction 0.07]. No heterogeneity was observed for renal death or ESKD [0.88 (0.64-1.21)/0.94 (0.67-1.31), P-interaction 0.79]. Glycated haemoglobin A1c (HbA1c) was significantly reduced regardless of NRP, without increasing hypoglycaemia risk. Regression to normoalbuminuria [1.20 (1.07-1.34)] and reduction of UACR ≥50% [1.15 (1.07-1.25)] from BL, occurred more frequently with LINA, regardless of NRP status (P-interactions >0.05). CONCLUSIONS Individuals with T2D and NRP have a high disease burden. LINA reduces their albuminuria burden and HbA1c, without affecting CV or kidney risk.
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Affiliation(s)
- Christoph Wanner
- Department of Medicine, Division of Nephrology, Würzburg University Clinic, Würzburg, Germany
| | - Mark E Cooper
- Department of Diabetes, Central Clinical School, Monash University, Melbourne, Australia
| | | | - Robert Toto
- University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Julio Rosenstock
- Dallas Diabetes Research Center at Medical City, Dallas, TX, USA
| | - Darren K McGuire
- University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Steven E Kahn
- Department of Medicine, Division of Metabolism, Endocrinology and Nutrition, Puget Sound Health Care System and University of Washington, Seattle, WA, USA
| | - Egon Pfarr
- Boehringer Ingelheim Pharma GmbH & Co. KG, Ingelheim, Germany
| | - Sven Schnaidt
- Boehringer Ingelheim Pharma GmbH & Co. KG, Biberach, Germany
| | | | | | | | - Nikolaus Marx
- Department of Internal Medicine I, University Hospital Aachen, RWTH Aachen University, Aachen, Germany
| | | | - Bernard Zinman
- Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, Canada
- Division of Endocrinology, University of Toronto, Toronto, Canada
| | - Vlado Perkovic
- Faculty of Medicine, The George Institute for Global Health, University of New South Wales, Sydney, Australia
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8
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Bonora E, Cataudella S, Marchesini G, Miccoli R, Vaccaro O, Fadini GP, Martini N, Rossi E. A view on the quality of diabetes care in Italy and the role of Diabetes Clinics from the 2018 ARNO Diabetes Observatory. Nutr Metab Cardiovasc Dis 2020; 30:1945-1953. [PMID: 32998821 DOI: 10.1016/j.numecd.2020.08.018] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Revised: 08/03/2020] [Accepted: 08/11/2020] [Indexed: 01/08/2023]
Abstract
BACKGROUNDS AND AIMS To investigate relevant indicators of quality of care in a large population-based sample of people with diabetes representative of clinical practice in Italy in 2018. METHODS AND RESULTS We analyzed data from 11,300,750 subjects. All administrative healthcare claims collected in 2018 were scrutinized to identify subjects with diabetes and investigate several indicators of quality of care. Subjects with diabetes were identified by anti-hyperglycemic drug prescriptions, disease-specific co-payment exemption and hospital discharge codes. Indicators of quality of care pertained to monitoring (HbA1c, creatinine, lipid profile, microalbuminuria, eye examination, ECG, ultrasonography of carotid and lower limb arteries) and diabetes treatment (anti-hyperglycemic agents in subjects with cardiovascular disease, CVD). Subjects attending and nonattending Diabetes Clinics were compared. We identified 697,208 individuals with diabetes. HbA1c was assessed at least once in the year in 62.7%, creatinine in 62.3%, total cholesterol in 59.6%, microalbuminuria in 34.3%. Frequency of eye examination was 8.2%, ECG 23.5%, carotid ultrasonography 14.3%, lower limb ultrasonography 7.6%. Among anti-hyperglycemic drugs, SGLT-2 inhibitors were prescribed to ~5% and GLP-1 receptor agonists to ~5% although the proportion of subjects with CVD was ~45%. Subjects attending Diabetes Clinics had higher figures for all these monitoring and treatment indicators. CONCLUSIONS The implementation of national and international guidelines regarding disease monitoring and treatment is far from being satisfactory, especially among subjects nonattending Diabetes Clinics. Further efforts and investments are needed for better disseminating guidelines, more efficaciously engaging healthcare professionals and more strongly empowering the healthcare system to improve diabetes care.
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Affiliation(s)
| | | | | | | | | | | | | | - Elisa Rossi
- CINECA - Interuniversity Consortium, Bologna, Italy
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9
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Piragine E, Calderone V. Pharmacological modulation of the hydrogen sulfide (H 2 S) system by dietary H 2 S-donors: A novel promising strategy in the prevention and treatment of type 2 diabetes mellitus. Phytother Res 2020; 35:1817-1846. [PMID: 33118671 DOI: 10.1002/ptr.6923] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Revised: 09/15/2020] [Accepted: 10/06/2020] [Indexed: 12/25/2022]
Abstract
Type 2 diabetes mellitus (T2DM) represents the most common age-related metabolic disorder, and its management is becoming both a health and economic issue worldwide. Moreover, chronic hyperglycemia represents one of the main risk factors for cardiovascular complications. In the last years, the emerging evidence about the role of the endogenous gasotransmitter hydrogen sulfide (H2 S) in the pathogenesis and progression of T2DM led to increasing interest in the pharmacological modulation of endogenous "H2 S-system". Indeed, H2 S directly contributes to the homeostatic maintenance of blood glucose levels; moreover, it improves impaired angiogenesis and endothelial dysfunction under hyperglycemic conditions. Moreover, H2 S promotes significant antioxidant, anti-inflammatory, and antiapoptotic effects, thus preventing hyperglycemia-induced vascular damage, diabetic nephropathy, and cardiomyopathy. Therefore, H2 S-releasing molecules represent a promising strategy in both clinical management of T2DM and prevention of macro- and micro-vascular complications associated to hyperglycemia. Recently, growing attention has been focused on dietary organosulfur compounds. Among them, garlic polysulfides and isothiocyanates deriving from Brassicaceae have been recognized as H2 S-donors of great pharmacological and nutraceutical interest. Therefore, a better understanding of the therapeutic potential of naturally occurring H2 S-donors may pave the way to a more rational use of these nutraceuticals in the modulation of H2 S homeostasis in T2DM.
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Affiliation(s)
| | - Vincenzo Calderone
- Department of Pharmacy, University of Pisa, Pisa, Italy.,Interdepartmental Research Center Nutrafood "Nutraceuticals and Food for Health", University of Pisa, Pisa, Italy.,Interdepartmental Research Centre of Ageing Biology and Pathology, University of Pisa, Pisa, Italy
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10
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Perkovic V, Toto R, Cooper ME, Mann JFE, Rosenstock J, McGuire DK, Kahn SE, Marx N, Alexander JH, Zinman B, Pfarr E, Schnaidt S, Meinicke T, von Eynatten M, George JT, Johansen OE, Wanner C. Effects of Linagliptin on Cardiovascular and Kidney Outcomes in People With Normal and Reduced Kidney Function: Secondary Analysis of the CARMELINA Randomized Trial. Diabetes Care 2020; 43:1803-1812. [PMID: 32444457 PMCID: PMC7372065 DOI: 10.2337/dc20-0279] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2020] [Accepted: 04/06/2020] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Type 2 diabetes is a leading cause of kidney failure, but few outcome trials proactively enrolled individuals with chronic kidney disease (CKD). We performed secondary analyses of cardiovascular (CV) and kidney outcomes across baseline estimated glomerular filtration rate (eGFR) categories (≥60, 45 to <60, 30 to <45, and <30 mL/min/1.73 m2) in Cardiovascular and Renal Microvascular Outcome Study With Linagliptin (CARMELINA), a cardiorenal placebo-controlled outcome trial of the dipeptidyl peptidase 4 inhibitor linagliptin (NCT01897532). RESEARCH DESIGN AND METHODS Participants with CV disease and/or CKD were included. The primary outcome was time to first occurrence of CV death, nonfatal myocardial infarction, or nonfatal stroke (three-point major adverse CV event [3P-MACE]), with a secondary outcome of renal death, end-stage kidney disease, or sustained ≥40% decrease in eGFR from baseline. Other end points included progression of albuminuria, change in HbA1c, and adverse events (AEs) including hypoglycemia. RESULTS A total of 6,979 subjects (mean age 65.9 years; eGFR 54.6 mL/min/1.73 m2; 80.1% albuminuria) were followed for 2.2 years. Across eGFR categories, linagliptin as compared with placebo did not affect the risk for 3P-MACE (hazard ratio 1.02 [95% CI 0.89, 1.17]) or the secondary kidney outcome (1.04 [0.89, 1.22]) (interaction P values >0.05). Regardless of eGFR, albuminuria progression was reduced with linagliptin, as was HbA1c, without increasing risk for hypoglycemia. AEs were balanced among groups overall and across eGFR categories. CONCLUSIONS Across all GFR categories, in participants with type 2 diabetes and CKD and/or CV disease, there was no difference in risk for linagliptin versus placebo on CV and kidney events. Significant reductions in risk for albuminuria progression and HbA1c and no difference in AEs were observed.
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Affiliation(s)
- Vlado Perkovic
- Faculty of Medicine, The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Robert Toto
- University of Texas Southwestern Medical Center, Dallas, TX
| | - Mark E Cooper
- Department of Diabetes, Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Johannes F E Mann
- Kuratorium für Dialyse Kidney Centre, Munich, Germany.,Department of Nephrology, Friedrich-Alexander University of Erlangen-Nürnberg, Erlangen, Germany
| | | | | | - Steven E Kahn
- Division of Metabolism, Endocrinology and Nutrition, Department of Medicine, VA Puget Sound Health Care System and University of Washington, Seattle, WA
| | - Nikolaus Marx
- Department of Internal Medicine I, University Hospital Aachen, RWTH Aachen University, Aachen, Germany
| | | | - Bernard Zinman
- Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, Ontario, Canada.,Division of Endocrinology, University of Toronto, Toronto, Ontario, Canada
| | - Egon Pfarr
- Boehringer Ingelheim Pharma GmbH & Co. KG, Ingelheim, Germany
| | - Sven Schnaidt
- Boehringer Ingelheim Pharma GmbH & Co. KG, Biberach, Germany
| | - Thomas Meinicke
- Boehringer Ingelheim Pharma GmbH & Co. KG, Biberach, Germany
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11
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Busch M, Lehmann T, Wolf G, Günster C, Müller UA, Müller N. Antidiabetic Therapy and Rate of Severe Hypoglycaemia in Patients with Type 2 Diabetes and Chronic Kidney Disease of Different Stages - A Follow-up Analysis of Health Insurance Data from Germany. Exp Clin Endocrinol Diabetes 2020; 129:821-830. [PMID: 32289830 DOI: 10.1055/a-1129-6699] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND The presence of chronic kidney disease (CKD) influences the type of antiglycaemic therapy and the risk for hypoglycaemia. METHODS In 2006, 2011 and 2016 health insurance data of people with diabetes type 2 were screened for CKD and the presence of severe hypoglycaemia (sHypo). The type of antihyperglycaemic therapy was recorded due to Anatomical Therapeutic Chemical (ATC) codes up to 3 months before suffering sHypo. RESULTS The prevalence of CKD increased from 5.3% in 2006 to 7.3% in 2011 and 11.2% in 2016. Insulin-based therapies were used in 39.0, 39.1, and 37.9% of patients with, but only in 17.7, 17.4, and 18.8% of patients without CKD. Although the proportion of the CKD stages 1, 2 and 5 decreased, CKD stages 3 and 4 increased. The proportion of sHypo in CKD declined from 2006 (3.5%) to 2011 (3.0%) and 2016 (2.2%) but was still more than 10 times higher as compared to type 2 diabetic patients without CKD (0.3/0.2/0.2%) conferring a significantly higher probability of sHypo (OR 9.30, 95%CI 9.07-9.54) in CKD. The probability of sHypo was significantly lower in 2016 than in 2006 both in patients with (OR 0.58; CI 0.55-0.61) and without CKD (OR 0.70; CI 0.68-0.73). CONCLUSION The prevalence of CKD increased from 2006 to 2016. Patients with CKD exhibited a 9-fold increased probability of sHypo, especially in patients treated with insulin plus oral anti-diabetic drugs. However, the rate and risk for sHypo decreased over time, probably as a consequence of new antidiabetic treatment options, better awareness of sHypo, and changed therapy goals.
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Affiliation(s)
- Martin Busch
- Department of Internal Medicine III, University Hospital Jena, Jena, Germany
| | - Thomas Lehmann
- Center for Clinical Studies, University Hospital Jena, Jena, Germany
| | - Gunter Wolf
- Department of Internal Medicine III, University Hospital Jena, Jena, Germany
| | | | | | - Nicolle Müller
- Department of Internal Medicine III, University Hospital Jena, Jena, Germany
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12
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Al-Hwiesh AK, Abdul-Rahman IS, Noor AS, Nasr-El-Deen MA, Abdelrahman A, El-Salamoni TS, Al-Muhanna FA, Al-Otaibi K, Al-Audah N. The Phantom of Metformin-Induced Lactic Acidosis in End-Stage Renal Disease Patients: Time to Reconsider with Peritoneal Dialysis Treatment. Perit Dial Int 2020; 37:56-62. [DOI: 10.3747/pdi.2015.00309] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2015] [Accepted: 05/17/2016] [Indexed: 01/22/2023] Open
Abstract
ObjectiveMetformin continues to be the safest and most widely used antidiabetic drug. In spite of its well-known benefits; metformin use in end-stage renal disease (ESRD) patients is still restricted. Little has been reported about the effect of peritoneal dialysis (PD) on metformin clearance and the phantom of lactic acidosis deprives ESRD patients from metformin therapeutic advantages. Peritoneal dialysis is probably a safeguard against lactic acidosis, and it is likely that using this drug would be feasible in this group of patients.Material and methodsThe study was conducted on 83 PD patients with type 2 diabetes mellitus. All patients were on automated PD (APD). Metformin was administered in a dose of 500 - 1,000 mg daily. Patients were monitored for glycemic control. Plasma lactic acid and plasma metformin levels were monitored on a scheduled basis. Peritoneal fluid metformin levels were measured. In addition, the relation between plasma metformin and plasma lactate was studied.ResultsMean fasting blood sugar (FBS) was 10.9 ± 0.5 and 7.8 ± 0.7, and mean hemoglobin A1-C (HgA1C) was 8.2 ± 0.8 and 6.4 ± 1.1 at the beginning and end of the study, respectively (p < 0.001). The mean body mass index (BMI) was 29.1 ± 4.1 and 27.3 ± 4.5 at the beginning and at the end of the study, respectively (p < 0.001). The overall mean plasma lactate level across all blood samples was 1.44 ± 0.6. Plasma levels between 2 and 3 mmol/L were found in 11.8% and levels of 3 - 3.6 mmol/L in 2.4% plasma samples. Hyperlactemia (level > 2 and < 5 mmol/L) was not associated with overt acidemia. None of our patients had lactic acidosis (levels > 5 mmol/L). Age ≥ 60 was a predictor for hyperlactemia. No relationship was found between plasma metformin and lactate levels.ConclusionMetformin may be used with caution in a particular group of ESRD patients who are on APD. Metformin allows better diabetic control with significant reduction of BMI. Information on the relationship between metformin and plasma lactate levels is lacking. Peritoneal dialysis appears to be a safeguard against the development of lactic acidosis in this group of patients.
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Affiliation(s)
| | | | - Abdul-Salam Noor
- Department of Internal Medicine, Queens University, Kingston, Ontario, Canada
| | | | - Abdalla Abdelrahman
- Nephrology Division, King Fahd Hospital of the University, University of Dammam, Saudi Arabia; and Department of Electrical Engineering, Queens University, Kingston, Ontario, Canada
| | | | - Fahd A. Al-Muhanna
- Department of Internal Medicine, Queens University, Kingston, Ontario, Canada
| | - Khalid Al-Otaibi
- Department of Internal Medicine, Queens University, Kingston, Ontario, Canada
| | - Nehad Al-Audah
- Department of Internal Medicine, Queens University, Kingston, Ontario, Canada
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13
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Abstract
Teneligliptin is a dipeptidyl peptidase-4 (DPP-4) inhibitor that was approved for the treatment of type 2 diabetes mellitus (T2DM) in Japan and Korea and is being researched in several countries. Teneligliptin is a potent, selective, and long-lasting DPP-4 inhibitor with a t½ of approximately 24 h and unique pharmacokinetic properties: it is metabolized by cytochrome P450 (CYP) 3A4 and flavin-containing monooxygenase 3 (FMO3), or excreted from the kidney in an unchanged form. Because of its multiple elimination pathways, dose adjustment is not needed in patients with hepatic or renal impairment, and it is considered to have a low potential for drug–drug interactions. Clinical studies and postmarketing surveillance show that teneligliptin, administered as monotherapy and/or in combination with antihyperglycemic agents, is effective and well tolerated in T2DM patients, including in elderly patients and those with renal impairment. Furthermore, teneligliptin has antioxidative properties, which induce the antioxidant cascade, as well as ·OH scavenging properties. In addition, it has shown endothelial protective effects in several non-clinical and clinical studies. From its unique profile and clinical data, teneligliptin represents a potential therapeutic option in a wide variety of patients, including elderly diabetic patients and those with renal impairment. The fixed-dose combination (FDC) tablet of teneligliptin and canagliflozin has been approved in Japan; this is the first FDC tablet of a DPP-4 inhibitor and sodium glucose co-transporter 2 inhibitor in Japan, and the third globally. The FDC tablet may also provide additional prescribing and adherence benefits.
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14
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Pugliese G, Penno G, Natali A, Barutta F, Di Paolo S, Reboldi G, Gesualdo L, De Nicola L. Diabetic kidney disease: New clinical and therapeutic issues. Joint position statement of the Italian Diabetes Society and the Italian Society of Nephrology on "The natural history of diabetic kidney disease and treatment of hyperglycemia in patients with type 2 diabetes and impaired renal function". Nutr Metab Cardiovasc Dis 2019; 29:1127-1150. [PMID: 31586514 DOI: 10.1016/j.numecd.2019.07.017] [Citation(s) in RCA: 51] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Revised: 07/18/2019] [Accepted: 07/18/2019] [Indexed: 02/06/2023]
Abstract
AIMS This joint document of the Italian Diabetes Society and the Italian Society of Nephrology reviews the natural history of diabetic kidney disease (DKD) in the light of the recent epidemiological literature and provides updated recommendations on anti-hyperglycemic treatment with non-insulin agents. DATA SYNTHESIS Recent epidemiological studies have disclosed a wide heterogeneity of DKD. In addition to the classical albuminuric phenotype, two new albuminuria-independent phenotypes have emerged, i.e., "nonalbuminuric renal impairment" and "progressive renal decline", suggesting that DKD progression toward end-stage kidney disease (ESKD) may occur through two distinct pathways, albuminuric and nonalbuminuric. Several biomarkers have been associated with decline of estimated glomerular filtration rate (eGFR) independent of albuminuria and other clinical variables, thus possibly improving ESKD prediction. However, the pathogenesis and anatomical correlates of these phenotypes are still unclear. Also the management of hyperglycemia in patients with type 2 diabetes and impaired renal function has profoundly changed during the last two decades. New anti-hyperglycemic drugs, which do not cause hypoglycemia and weight gain and, in some cases, seem to provide cardiorenal protection, have become available for treatment of these individuals. In addition, the lowest eGFR safety thresholds for some of the old agents, particularly metformin and insulin secretagogues, have been reconsidered. CONCLUSIONS The heterogeneity in the clinical presentation and course of DKD has important implications for the diagnosis, prognosis, and possibly treatment of this complication. The therapeutic options for patients with type 2 diabetes and impaired renal function have substantially increased, thus allowing a better management of these individuals.
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Affiliation(s)
- Giuseppe Pugliese
- Department of Clinical and Molecular Medicine, "La Sapienza" University, Endocrine and Metabolic Unit, Sant'Andrea University Hospital, Rome, Italy.
| | - Giuseppe Penno
- Department of Clinical and Experimental Medicine, University of Pisa, Diabetes Unit, University Hospital, Pisa, Italy
| | - Andrea Natali
- Department of Clinical and Experimental Medicine, University of Pisa, Unit of Internal Medicine, University Hospital, Pisa, Italy
| | - Federica Barutta
- Department of Medical Sciences, University of Turin, Turin, Italy
| | | | | | - Loreto Gesualdo
- Department of Emergency and Organ Transplantation, "Aldo Moro" University, Nephrology, Dialysis and Transplantation Unit, "Policlinico" University Hospital, Bari, Italy
| | - Luca De Nicola
- Nephrology and Dialysis Unit, Department of Advanced Medical and Surgical Sciences, University of Campania "Luigi Vanvitelli", Naples, Italy
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15
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Inzucchi SE, Fonseca V. Dethroning the king?: The future of metformin as first line therapy in type 2 diabetes. J Diabetes Complications 2019; 33:462-464. [PMID: 31003925 DOI: 10.1016/j.jdiacomp.2019.03.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
MESH Headings
- Contraindications, Drug
- Diabetes Mellitus, Type 2/blood
- Diabetes Mellitus, Type 2/complications
- Diabetes Mellitus, Type 2/drug therapy
- Diabetes Mellitus, Type 2/epidemiology
- Diabetic Nephropathies/drug therapy
- Diabetic Nephropathies/epidemiology
- Drug Administration Schedule
- Drug Therapy, Combination/classification
- Drug Therapy, Combination/methods
- Drug Therapy, Combination/trends
- Endocrinology/methods
- Endocrinology/trends
- Evidence-Based Practice/methods
- Evidence-Based Practice/trends
- Glycated Hemoglobin/analysis
- Glycated Hemoglobin/drug effects
- Humans
- Hypoglycemic Agents/administration & dosage
- Hypoglycemic Agents/adverse effects
- Hypoglycemic Agents/classification
- Metformin/administration & dosage
- Metformin/adverse effects
- Precision Medicine/methods
- Precision Medicine/trends
- Renal Insufficiency, Chronic/complications
- Renal Insufficiency, Chronic/drug therapy
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Affiliation(s)
- Silvio E Inzucchi
- Section of Endocrinology, Yale School of Medicine, New Haven, CT, United States of America
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16
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Sesti G, Avogaro A, Belcastro S, Bonora BM, Croci M, Daniele G, Dauriz M, Dotta F, Formichi C, Frontoni S, Invitti C, Orsi E, Picconi F, Resi V, Bonora E, Purrello F. Ten years of experience with DPP-4 inhibitors for the treatment of type 2 diabetes mellitus. Acta Diabetol 2019; 56:605-617. [PMID: 30603867 DOI: 10.1007/s00592-018-1271-3] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2018] [Accepted: 12/10/2018] [Indexed: 12/13/2022]
Abstract
Achieving and maintaining recommended glycemic targets without causing adverse e ffects, including hypoglycemia, is challenging, especially in older patients with type 2 diabetes mellitus (T2DM). The introduction of dipeptidyl peptidase-4 (DPP-4) inhibitors, more than 10 years ago, has provided an alternative to conventional medications for the intensification of glucose-lowering treatment after failure of metformin monotherapy, and therefore, marked an important advance in the management of T2DM. By prolonging the activity of incretin hormones, DPP-4 inhibitors induce insulin release and decrease glucagon secretion in a glucose-dependent manner. This results in a more physiologic glycemic control as compared to that ensured by insulin secretagogues (sulfonylureas and glinides). Overall, DPP-4 inhibitors have a favorable safety profile and can be used without dose adjustments in older adults and in patients with mild renal impairment; they have a neutral effect on body weight and do not cause hypoglycemia by themselves. Safety issues, reported mainly in post-marketing surveillance programs and including cardiovascular outcomes and the risk of acute pancreatitis, are being extensively investigated. The aim of this review is to discuss the impact of DPP-4 inhibitors on the treatment of T2DM, after 10 years of experience, with an emphasis on diabetes care in Italy. We will first describe T2DM treatment in Italy and then provide an overview of the main findings from randomized controlled trials, real-world studies and post-marketing surveillance programs with DPP-4 inhibitors.
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Affiliation(s)
- Giorgio Sesti
- Department of Clinical and Surgical Science, University of Magna Graecia of Catanzaro, Catanzaro, Italy.
| | - Angelo Avogaro
- Department of Medicine, University of Padova, Padova, Italy
| | - Sara Belcastro
- Department of Medical Sciences, University of Turin, Turin, Italy
| | | | - Marina Croci
- Department of Medical Sciences and Rehabilitation, IRCCS Istituto Auxologico Italiano, Milan, Italy
| | - Giuseppe Daniele
- Department of Clinical and Experimental Medicine A.O.U. Pisana, Pisa, Italy
| | - Marco Dauriz
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, University of Verona and Hospital Trust of Verona, Verona, Italy
| | - Francesco Dotta
- Diabetes Unit, Department of Medicine, Surgery and Neuroscience, University of Siena, Siena, Italy
| | - Caterina Formichi
- Diabetes Unit, Department of Medicine, Surgery and Neuroscience, University of Siena, Siena, Italy
| | - Simona Frontoni
- Unit of Endocrinology, Diabetes and Metabolism, Department of Systems Medicine, S. Giovanni Calibita Fatebenefratelli Hospital, University of Rome Tor Vergata, Rome, Italy
| | - Cecilia Invitti
- Department of Medical Sciences and Rehabilitation, IRCCS Istituto Auxologico Italiano, Milan, Italy
| | - Emanuela Orsi
- Diabetes Unit, Fondazione IRCCS'Cà Granda-Ospedale Maggiore Policlinico, Milan, Italy
| | - Fabiana Picconi
- Unit of Endocrinology, Diabetes and Metabolism, Department of Systems Medicine, S. Giovanni Calibita Fatebenefratelli Hospital, University of Rome Tor Vergata, Rome, Italy
| | - Veronica Resi
- Diabetes Unit, Fondazione IRCCS'Cà Granda-Ospedale Maggiore Policlinico, Milan, Italy
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Enzo Bonora
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, University of Verona and Hospital Trust of Verona, Verona, Italy
| | - Francesco Purrello
- Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
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17
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Manski-Nankervis JAE, Thuraisingam S, Sluggett JK, Lau P, Blackberry I, Ilomaki J, Furler J, Bell JS. Prescribing for people with type 2 diabetes and renal impairment in Australian general practice: A national cross sectional study. Prim Care Diabetes 2019; 13:113-121. [PMID: 30262176 DOI: 10.1016/j.pcd.2018.09.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2017] [Revised: 03/23/2018] [Accepted: 09/01/2018] [Indexed: 11/25/2022]
Abstract
AIM To determine whether the prescribing of non-insulin anti-hyperglycaemic medications in Australian general practice is consistent with current guidelines for treatment of type 2 diabetes (T2D) in people with renal impairment. METHODS Cross-sectional study of 9624 people with T2D in the NPS MedicineInsight dataset aged≥18years with average estimated glomerular filtration rate (eGFR) <60ml/min/1.73m2 and prescribed at least one non-insulin anti-hyperglycaemic medication from October 2014 to September 2015. The primary outcome was the proportion of non-insulin anti-hyperglycaemic medications prescribed at doses inconsistent with current guidelines. RESULTS 4650 (48.3%) patients were prescribed at least one non-insulin anti-hyperglycaemic medication at a dose inconsistent with Australian Diabetes Society guidelines. The majority (88.0%) had an average eGFR of 30-59ml/min/1.73m2. Metformin was the most frequently prescribed agent (n=7408; 77.0%), and was prescribed at a dose inconsistent with guidelines for 52% of patients. 123/136 (90.5%) people prescribed a sodium glucose co-transporter 2 inhibitor and 1114/2194 (50.8%) prescribed a dipeptidyl peptidase-4 inhibitor were prescribed a dose inconsistent with guidelines. Decreasing age, being male or being on insulin was associated with greater odds of at least one prescription inconsistent with guidelines. CONCLUSION Nearly half of people with T2D and renal impairment were prescribed a non-insulin anti-hyperglycaemic medication at a dose inconsistent with current Australian guidelines, the majority of whom had an eGFR consistent with stage 3 chronic kidney disease.
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Affiliation(s)
| | | | - Janet K Sluggett
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, Australia
| | - Phyllis Lau
- Department of General Practice, University of Melbourne, Carlton, Australia
| | - Irene Blackberry
- Department of General Practice, University of Melbourne, Carlton, Australia; John Richards Initiative, La Trobe University, Wodonga, Australia
| | - Jenni Ilomaki
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, Australia
| | - John Furler
- Department of General Practice, University of Melbourne, Carlton, Australia
| | - J Simon Bell
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, Australia
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18
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Fukuoka Y, Narita T, Fujita H, Morii T, Sato T, Sassa MH, Yamada Y. Importance of physical evaluation using skeletal muscle mass index and body fat percentage to prevent sarcopenia in elderly Japanese diabetes patients. J Diabetes Investig 2019; 10:322-330. [PMID: 30098231 PMCID: PMC6400206 DOI: 10.1111/jdi.12908] [Citation(s) in RCA: 67] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2018] [Revised: 07/04/2018] [Accepted: 08/06/2018] [Indexed: 12/18/2022] Open
Abstract
AIMS/INTRODUCTION To investigate the prevalence of sarcopenia, its related factors and indicators of physical evaluation in elderly diabetes patients. MATERIALS AND METHODS This was a cross-sectional observation study. A total of 267 diabetes patients (159 men, 108 women) aged >65 years were recruited in the present study. Skeletal muscle mass index, grip strength and usual gait speed were measured to diagnose sarcopenia according to the Asian Working Group for Sarcopenia. Body composition was measured using bioelectrical impedance analysis. Body mass index (BMI) and body fat percentage were evaluated in quartiles to investigate the relationship with sarcopenia. A multiple logistic regression analysis examined sarcopenia-related factors. RESULTS The prevalence of sarcopenia in all participants was 18.7% and increased with age. Sarcopenia decreased as BMI increased (P < 0.01, Cochran-Armitage test). In contrast, the third quartile body fat percentage group showed the lowest prevalence of sarcopenia. A strong positive correlation was observed between body mass and skeletal muscle mass indices (R = 0.702-0.682). Multiple logistic regression analysis showed that sarcopenia was associated with lower BMI, non-use of metformin and lower bone mineral content in men (P < 0.05), and lower bone mineral content, lower serum levels of albumin and older age in women (P < 0.05). CONCLUSIONS The present study suggests that diabetes patients with a high body fat percentage in addition to low BMI might develop sarcopenia. It is suggested that physical management in elderly diabetes patients should be carried out based on the evaluation of BMI and body fat percentage to prevent sarcopenia.
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Affiliation(s)
- Yuki Fukuoka
- Division of Endocrinology, Metabolism and Geriatric MedicineAkita University Graduate School of MedicineAkitaJapan
| | - Takuma Narita
- Division of Endocrinology, Metabolism and Geriatric MedicineAkita University Graduate School of MedicineAkitaJapan
| | - Hiroki Fujita
- Division of Endocrinology, Metabolism and Geriatric MedicineAkita University Graduate School of MedicineAkitaJapan
| | - Tsukasa Morii
- Division of Endocrinology, Metabolism and Geriatric MedicineAkita University Graduate School of MedicineAkitaJapan
| | - Takehiro Sato
- Division of Endocrinology, Metabolism and Geriatric MedicineAkita University Graduate School of MedicineAkitaJapan
| | - Mariko Harada Sassa
- Institute for Advancement of Clinical and Translational ScienceKyoto University HospitalKyotoJapan
| | - Yuichiro Yamada
- Division of Endocrinology, Metabolism and Geriatric MedicineAkita University Graduate School of MedicineAkitaJapan
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19
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Manski-Nankervis JA, Thuraisingam S, Sluggett JK, Kilov G, Furler J, O'Neal D, Jenkins A. Prescribing of diabetes medications to people with type 2 diabetes and chronic kidney disease: a national cross-sectional study. BMC FAMILY PRACTICE 2019; 20:29. [PMID: 30777033 PMCID: PMC6378720 DOI: 10.1186/s12875-019-0915-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Accepted: 01/29/2019] [Indexed: 12/27/2022]
Abstract
Background Previous studies in general practice and hospital settings have identified that prescribing of non-insulin diabetes medications may be sub-optimal in people with type 2 diabetes (T2D) and renal impairment. Since these publications, a number of new medications have become available for the management of T2D. Study aims were to, in a cohort of Australians with T2D and renal impairment attending general practice, (1) investigate whether the prescribing of non-insulin diabetes medications is consistent with dosing adjustments recommended within current Australian Diabetes Society (ADS) guidelines; and (2) identify patient socio-demographic and clinical factors associated with at least one prescription of a non-insulin diabetes medication inconsistent with current ADS guidelines for medication doses. Methods Cross-sectional study using data from the MedicineInsight general practice database managed by NPS MedicineWise. Patients with T2D who were aged 18 years and over, with an average eGFR< 60 ml/min/1.73m2 and at least one prescription of a non-insulin diabetes medication between 1st January 2015 and 30th June 2017 were included. Descriptive statistics were used to summarise patient characteristics and medication use. Marginal logistic regression models were used to estimate associations between sociodemographic and clinical factors and prescribing of ≥1non-insulin diabetes medicine not consistent with ADS guidelines. Results The majority of the 3505 patients included (90.4%) had an average eGFR of 30-59 ml/min/1.73m2. In terms of absolute numbers, metformin was the medication most frequently prescribed at a dose not consistent with current ADS guidelines for dosing in renal impairment (n = 1601 patients), followed by DPP4 inhibitors (n = 611) and sulphonylureas (n = 278). The drug classes with the highest proportion of prescriptions with dosage not consistent with ADS guidelines were SGLT2 inhibitors (83%), followed by biguanides (58%) and DPP4 inhibitors (46%). Higher HbA1c, longer known diabetes duration and diagnosis of retinopathy were associated with receiving ≥1prescription with a dosage not consistent with guidelines. Conclusions Prescribing of non-insulin diabetes medications at doses inconsistent with current ADS guideline recommendations for dosing adjustments for people with renal impairment was common. Further research is needed to understand how general practitioners access, interpret and apply the ADS guidelines and the impact this may have on patient outcomes. Electronic supplementary material The online version of this article (10.1186/s12875-019-0915-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
| | | | - Janet K Sluggett
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, Australia
| | - Gary Kilov
- Department of General Practice, University of Melbourne, Carlton, Australia
| | - John Furler
- Department of General Practice, University of Melbourne, Carlton, Australia
| | - David O'Neal
- Department of Medicine, St Vincent's Hospital and University of Melbourne, Fitzroy, Australia.,Department of Endocrinology and Diabetes, St Vincent's Hospital, Fitzroy, Australia
| | - Alicia Jenkins
- Department of Medicine, St Vincent's Hospital and University of Melbourne, Fitzroy, Australia.,Department of Endocrinology and Diabetes, St Vincent's Hospital, Fitzroy, Australia.,NHMRC Clinical Trials Centre, University of Sydney, Camperdown, Australia
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20
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Fadini GP, Solini A, Manca ML, Zatti G, Karamouzis I, Di Benedetto A, Frittitta L, Avogaro A. Phenotyping normal kidney function in elderly patients with type 2 diabetes: a cross-sectional multicentre study. Acta Diabetol 2018; 55:1121-1129. [PMID: 30090961 DOI: 10.1007/s00592-018-1194-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2018] [Accepted: 07/17/2018] [Indexed: 12/26/2022]
Abstract
AIMS Type 2 diabetes (T2D) accelerates the decline in glomerular function; however, some individuals do not develop chronic kidney disease despite advanced age and long-lasting T2D. We aimed to phenotype patients with T2D aged 80 years or older who presented with a fully preserved kidney function. METHODS From an Italian population of 281,217 T2D outpatients, we collected data on demographics, anthropometrics, diabetes duration, HbA1c, fasting plasma glucose, lipids, liver enzymes, estimated glomerular filtration rate (eGFR), albumin excretion rate (AER), chronic complications, and medication use. We primarily compared patients with a fully preserved kidney function (eGFR > 90 ml/min/1.73 m2 and AER < 30 mg/24 h, or G1A1) with those with mild kidney impairment (eGFR 60-90 ml/min/1.73 m2 and AER < 30 mg/24 h, or G2A1). RESULTS N = 113,860 had available data for eGFR and AER, 21,648 of whom were aged ≥ 80. G1A1 (n = 278) and G2A1 (n = 6647) patients represented 1.3 and 30.7% of aged T2D patients, respectively, with an average diabetes duration of 16 years. Differences between the G1A1 and G2A1 groups were entered in a multiple logistic regression analysis with and without imputation of missing data. After adjustment and in both imputed and non-imputed datasets, younger age, lower BMI and lower triglycerides were associated with fully preserved versus mildly impaired kidney function. The comparison between G1A1 and G1A2/3 yielded different results. CONCLUSIONS In a rare population of patients with a fully preserved kidney function despite old age and long-lasting diabetes, lower BMI and triglycerides suggest that protection from lipotoxicity may preserve kidney function over time.
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Affiliation(s)
- G P Fadini
- Department of Medicine, University of Padova, Via Giustiniani 2, 35128, Padua, Italy.
| | - A Solini
- Department of Surgical, Medical, Molecular and Critical Area Pathology, University of Pisa, Pisa, Italy
| | - M L Manca
- Department of Mathematics, University of Pisa, Pisa, Italy
| | - G Zatti
- Department of Medicine, University of Padova, Via Giustiniani 2, 35128, Padua, Italy
| | - I Karamouzis
- Ospedale Maggiore di Novara, 28100, Novara, Italy
| | - A Di Benedetto
- Department of Clinical and Experimental Medicine, University of Messina, 98122, Messina, Italy
| | - L Frittitta
- Department of Internal and Special Medicine, University of Catania, 95122, Catania, Italy
| | - A Avogaro
- Department of Medicine, University of Padova, Via Giustiniani 2, 35128, Padua, Italy
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21
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Hisni D, Rukmaini R, Saryono S, Chinnawong T, Thaniwattananon P. Cardiovascular self-management support program for preventing cardiovascular complication behaviors and clinical outcomes in the elderly with poorly controlled type 2 diabetes mellitus in Indonesia: A pilot study. Jpn J Nurs Sci 2018; 16:25-36. [DOI: 10.1111/jjns.12208] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2017] [Revised: 12/02/2017] [Accepted: 01/11/2018] [Indexed: 12/16/2022]
Affiliation(s)
- Dayan Hisni
- Medical and Surgical Nursing Department, Faculty of Health Sciences; National University; Jakarta Indonesia
| | - Rukmaini Rukmaini
- Midwifery Department, Faculty of Health Sciences; National University; Jakarta Indonesia
| | - Saryono Saryono
- Department of Nursing, Faculty of Health Sciences; Jenderal Soedirman University; Purwokerto Indonesia
| | - Tippamas Chinnawong
- Medical Nursing Department; Faculty of Nursing, Prince of Songkla University; Hat Yai Thailand
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[Essence and Perspective of the JGS/JDS Clinical Practice Guideline for the Treatment of Diabetes in the Elderly]. Nihon Ronen Igakkai Zasshi 2018; 55:1-12. [PMID: 29503351 DOI: 10.3143/geriatrics.55.1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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Gómez-Huelgas R, Gómez Peralta F, Rodríguez Mañas L, Formiga F, Puig Domingo M, Mediavilla Bravo JJ, Miranda C, Ena J. [Treatment of type 2 diabetes mellitus in elderly patients]. Rev Esp Geriatr Gerontol 2018; 53:89-99. [PMID: 29439834 DOI: 10.1016/j.regg.2017.12.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2017] [Accepted: 12/18/2017] [Indexed: 06/08/2023]
Abstract
The prevalence of type 2 diabetes mellitus (DM2) increases markedly with age. Antidiabetic treatment and the objectives of glycaemic control in elderly patients with DM2 should be individualised according to their biopsychosocial characteristics. In elderly patients for whom the benefits of intensive antidiabetic treatment are limited, the basic objectives should be to improve the quality of life, preserve functionality and avoid adverse effects, especially hypoglycaemia. Treatment of DM2 in the elderly was the subject of a consensus document published in 2012 and endorsed by several Spanish scientific societies. Since then, new therapeutic groups and evidence have emerged that warrant an update to this consensus document. The present document focuses on the therapeutic aspects of DM2 in elderly patients, understood as being older than 75 years or frail.
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Affiliation(s)
- R Gómez-Huelgas
- Servicio de Medicina Interna, Hospital Regional Universitario de Málaga, Málaga, España; Instituto de Investigación Biomédica de Málaga (IBIMA); CIBER de Obesidad y Nutrición (CIBEROBN), Instituto de Salud Carlos III; Sociedad Española de Medicina Interna (SEMI).
| | - F Gómez Peralta
- Unidad de Endocrinología y Nutrición, Hospital General de Segovia, Segovia, España; Sociedad Española de Diabetes (SED)
| | - L Rodríguez Mañas
- Servicio de Geriatría, Hospital Universitario de Getafe, Madrid, España; CIBER de Fragilidad y Envejecimiento Saludable (CIBERFES), Instituto de Salud Carlos III; Sociedad Española de Medicina Geriátrica (SEMEG)
| | - F Formiga
- Unidad de Geriatría, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, España; Sociedad Española de Geriatría y Gerontología (SEGG)
| | - M Puig Domingo
- Servicio de Endocrinología y Nutrición, Hospital Germans Trias i Pujol, Badalona, Barcelona, España; Institut d'Investigació en Ciències de la Salut Germans Trias i Pujol, Badalona, Barcelona, España; CIBER de Diabetes y Enfermedades Metabólicas Asociadas (CIBERDEM), Instituto de Salud Carlos III; Sociedad Española de Endocrinología y Nutrición (SEEN)
| | - J J Mediavilla Bravo
- Centro de Salud Burgos Rural, Burgos, España; Sociedad Española de Medicina General (SEMERGEN)
| | - C Miranda
- Centro de Salud Buenavista, Toledo, España; Sociedad Española de Médicos Generales y de Familia (SEMG)
| | - J Ena
- Servicio de Medicina Interna, Hospital Marina Baixa, La Vila Joiosa, Alicante, España; Sociedad Española de Medicina Interna (SEMI)
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Tubbs E, Axelsson AS, Vial G, Wollheim CB, Rieusset J, Rosengren AH. Sulforaphane improves disrupted ER-mitochondria interactions and suppresses exaggerated hepatic glucose production. Mol Cell Endocrinol 2018; 461:205-214. [PMID: 28923347 DOI: 10.1016/j.mce.2017.09.016] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2017] [Revised: 08/10/2017] [Accepted: 09/13/2017] [Indexed: 02/07/2023]
Abstract
AIMS Exaggerated hepatic glucose production is one of the hallmarks of type 2 diabetes. Sulforaphane (SFN) has been suggested as a new potential anti-diabetic compound. However, the effects of SFN in hepatocytes are yet unclear. Accumulating evidence points to the close structural contacts between the ER and mitochondria, known as mitochondria-associated ER membranes (MAMs), as important hubs for hepatic metabolism. We wanted to investigate whether SFN could affect hepatic glucose production and MAMs. MATERIALS AND METHODS We used proximity ligation assays, analysis of ER stress markers and glucose production assays in hepatoma cell lines, primary mouse hepatocytes and diabetic animal models. RESULTS SFN counteracted the increase of glucose production in palmitate-treated mouse hepatocytes. SFN also counteracted palmitate-induced MAM disruptions. Moreover, SFN decreased the ER stress markers CHOP and Grp78. In ob/ob mice, SFN improved glucose tolerance and reduced exaggerated glucose production. In livers of these mice, SFN increased MAM protein content, restored impaired VDAC1-IP3R1 interactions and reduced ER stress markers. In mice on HFHSD, SFN improved glucose tolerance, MAM protein content and ER-mitochondria interactions to a similar extent to that of metformin. CONCLUSIONS The present findings show that MAMs are severely reduced in animal models of glucose intolerance, which reinforces the role of MAMs as a hub for insulin signaling in the liver. We also show that SFN restores MAMs and improves glucose tolerance by a similar magnitude to that of metformin. These data highlight SFN as a new potential anti-diabetic compound.
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Affiliation(s)
- Emily Tubbs
- Lund University Diabetes Centre, Jan Waldenströms Gata 35, SE-20502 Malmö, Sweden
| | - Annika S Axelsson
- Lund University Diabetes Centre, Jan Waldenströms Gata 35, SE-20502 Malmö, Sweden
| | - Guillaume Vial
- INSERM UMR-1060 CarMeN Laboratory, Lyon 1 University, INRA U1235, INSA of Lyon, Charles Merieux Lyon-Sud Medical Universities, Lyon, France
| | - Claes B Wollheim
- Lund University Diabetes Centre, Jan Waldenströms Gata 35, SE-20502 Malmö, Sweden; Department of Cell Physiology and Metabolism, University Medical Center, 1211 Geneva, Switzerland
| | - Jennifer Rieusset
- INSERM UMR-1060 CarMeN Laboratory, Lyon 1 University, INRA U1235, INSA of Lyon, Charles Merieux Lyon-Sud Medical Universities, Lyon, France
| | - Anders H Rosengren
- Lund University Diabetes Centre, Jan Waldenströms Gata 35, SE-20502 Malmö, Sweden; Department of Neuroscience and Physiology, University of Gothenburg, Medicinaregatan 11, SE-41390 Göteborg, Sweden.
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Russo GT, De Cosmo S, Viazzi F, Mirijello A, Ceriello A, Guida P, Giorda C, Cucinotta D, Pontremoli R, Fioretto P. Diabetic kidney disease in the elderly: prevalence and clinical correlates. BMC Geriatr 2018; 18:38. [PMID: 29394888 PMCID: PMC5797340 DOI: 10.1186/s12877-018-0732-4] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2017] [Accepted: 01/25/2018] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Diabetic kidney disease (DKD) is a major burden in elderly patients with type 2 diabetes (T2DM). Low estimated glomerular filtration rate (eGFR+, < 60 mL/min/1.73 m2) and albuminuria (Alb+) are essential for the diagnosis of DKD, but their association with clinical variables and quality of care may be influenced by ageing. METHODS Here we investigated the association of clinical variables and quality of care measures with eGFR+ and Alb+ in 157,595 T2DM individuals participating to the Italian Association of Clinical Diabetologists (AMD) Annals Initiative, stratified by age. RESULTS The prevalence of eGFR+ and Alb+ increased with ageing, although this increment was more pronounced for low eGFR. Irrespective of age, both the eGFR+ and Alb + groups had the worst risk factors profile when compared to subjects without renal disease, showing a higher prevalence of out-of target values of HbA1c, BMI, triglycerides, HDL-C, blood pressure and more complex cardiovascular (CVD) and anti-diabetic therapies, including a larger use of insulin In all age groups, these associations differed according to the specific renal outcome examined: male sex and smoking were positively associated with Alb+ and negatively with eGFR+; age and anti-hypertensive therapies were more strongly associated with eGFR+, glucose control with Alb+, whereas BMI, and lipid-related variables with both abnormalities. All these associations were attenuated in the older (> 75 years) as compared to the younger groups (< 65 years; 65-75 years), and they were confirmed by multivariate analysis. Notably, Q-score values < 15, indicating a low quality of care, were strongly associated with Alb+ (OR 8.54; P < 0.001), but not with eGFR+. CONCLUSIONS In T2DM patients, the prevalence of both eGFR and Albuminuria increase with age. DKD is associated with poor cardiovascular risk profile and a lower quality of care, although these associations are influenced by the type of renal abnormality and by ageing. These data indicate that clinical surveillance of DKD should not be unerestimated in old T2DM patients.
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Affiliation(s)
- Giuseppina T Russo
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy. .,Department of Clinical and experimental Medicine, Policlinico Universitario "G. Martino", via C. Valeria, 98121, Messina, Italy.
| | - Salvatore De Cosmo
- Department of Medical Sciences, Scientific Institute "Casa Sollievo della Sofferenza,", San Giovanni Rotondo, (FG), Italy
| | - Francesca Viazzi
- Department of Internal Medicine, University of Genoa and Policlinico San Martino, Genoa, Italy
| | - Antonio Mirijello
- Department of Medical Sciences, Scientific Institute "Casa Sollievo della Sofferenza,", San Giovanni Rotondo, (FG), Italy
| | - Antonio Ceriello
- Institut d'Investigacions Biomediques August Pii Sunyer (IDIBAPS) and Centro de Investigacion Biomedicaen Red de Diabetes y Enfermedades Metabolicas Asociadas (CIBERDEM), Barcelona, Spain.,Department of Cardiovascular and Metabolic Diseases, IRCCS Gruppo Multimedica, Sesto San Giovanni, Italy
| | | | - Carlo Giorda
- Diabetes and Metabolism Unit, ASL, Turin 5, Chieri (TO), Turin, Italy
| | - Domenico Cucinotta
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Roberto Pontremoli
- Department of Internal Medicine, University of Genoa and Policlinico San Martino, Genoa, Italy
| | - Paola Fioretto
- Department of Medicine, University of Padua, Padua, Italy
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Gómez-Huelgas R, Gómez Peralta F, Rodríguez Mañas L, Formiga F, Puig Domingo M, Mediavilla Bravo JJ, Miranda C, Ena J. Treatment of type 2 diabetes mellitus in elderly patients. Rev Clin Esp 2018; 218:74-88. [PMID: 29366502 DOI: 10.1016/j.rce.2017.12.003] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2017] [Accepted: 12/03/2017] [Indexed: 02/06/2023]
Abstract
The prevalence of type 2 diabetes mellitus (DM2) increases markedly with age. Antidiabetic treatment and the objectives of glycaemic control in elderly patients with DM2 should be individualised according to their biopsychosocial characteristics. In elderly patients for whom the benefits of intensive antidiabetic treatment are limited, the basic objectives should be to improve the quality of life, preserve functionality and avoid adverse effects, especially hypoglycaemia. Treatment of DM2 in the elderly was the subject of a consensus document published in 2012 and endorsed by several Spanish scientific societies. Since then, new therapeutic groups and evidence have emerged that warrant an update to this consensus document. The present document focuses on the therapeutic aspects of DM2 in elderly patients, understood as being older than 75 years or frail.
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Affiliation(s)
- R Gómez-Huelgas
- Servicio de Medicina Interna, Hospital Regional Universitario de Málaga, Málaga, España; Instituto de Investigación Biomédica de Málaga (IBIMA); CIBER de Obesidad y Nutrición (CIBEROBN), Instituto de Salud Carlos III; Sociedad Española de Medicina Interna (SEMI).
| | - F Gómez Peralta
- Unidad de Endocrinología y Nutrición, Hospital General de Segovia, Segovia, España; Sociedad Española de Diabetes (SED)
| | - L Rodríguez Mañas
- Servicio de Geriatría, Hospital Universitario de Getafe, Madrid, España; CIBER de Fragilidad y Envejecimiento Saludable (CIBERFES), Instituto de Salud Carlos III; Sociedad Española de Medicina Geriátrica (SEMEG)
| | - F Formiga
- Unidad de Geriatría, Hospital Universitari de Bellvitge, ĹHospitalet de Llobregat, Barcelona, España; Sociedad Española de Geriatría y Gerontología (SEGG)
| | - M Puig Domingo
- Servicio de Endocrinología y Nutrición, Hospital Germans Trias i Pujol, Badalona, Barcelona, España; Institut d'Investigació en Ciències de la Salut Germans Trias i Pujol, Badalona, Barcelona, España; CIBER de Diabetes y Enfermedades Metabólicas Asociadas (CIBERDEM), Instituto de Salud Carlos III; Sociedad Española de Endocrinología y Nutrición (SEEN)
| | - J J Mediavilla Bravo
- Centro de Salud Burgos Rural, Burgos, España; Sociedad Española de Medicina General (SEMERGEN)
| | - C Miranda
- Centro de Salud Buenavista, Toledo, España; Sociedad Española de Médicos Generales y de Familia (SEMG)
| | - J Ena
- Servicio de Medicina Interna, Hospital Marina Baixa, La Vila Joiosa, Alicante, España; Sociedad Española de Medicina Interna (SEMI)
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Ujihara N, Sakura H, Hashimoto N, Sasamoto K, Ohashi H, Hasumi S, Kasahara T, Tomonaga O, Nunome H, Honda M, Iwamoto Y. Efficacy and safety of sitagliptin in elderly patients with type 2 diabetes mellitus and comparison of hypoglycemic action of concomitant medications: a subanalysis of the JAMP study. Diabetol Int 2017; 9:56-65. [PMID: 30603350 DOI: 10.1007/s13340-017-0330-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2017] [Accepted: 07/09/2017] [Indexed: 11/30/2022]
Abstract
Purpose To determine the efficacy and safety of sitagliptin when used with some therapeutic drugs to treat elderly patients. Methods Sitagliptin (50 mg/day) was added to the pre-existing therapy for type 2 diabetes. Changes in the glycated hemoglobin (HbA1c) level after 3 months of treatment were compared with the baseline, and exploratory analysis was performed. These analyses were conducted as subanalyses of the JAMP study, which was an open-label observational study. Results For patients who were ≥65 years of age, the change in HbA1c level from baseline ranged from -0.50 to -0.87% at 3 months after starting treatment. There was no significant difference in the change in HbA1c level between the patients treated with different concomitant drugs. No significant difference in HbA1c variations at 3 and 12 months from baseline was noted among the three age groups (≥75, 65-74, and <65 years). Multiple regression analysis was performed, and it revealed that patients with higher HbA1c levels at baseline were likely to show decreased HbA1c levels, while those with higher triglyceride (TG) levels were unlikely to show decreased HbA1c levels. Conclusion Sitagliptin has the potential to both improve glycemic control and prevent hypoglycemia, and can be considered a potent alternative drug.
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Affiliation(s)
- Noriko Ujihara
- 1Department of Medicine, Diabetes Center, Institute of Geriatrics, Tokyo Women's Medical University, Shibuya Cross Tower 21F, 2-15-1, Shibuya, Shibuya-ku, Tokyo, 150-0002 Japan
| | - Hiroshi Sakura
- 2Department of Medicine, Tokyo Women's Medical University, Medical Center East, 2-1-10 Nishiogu, Arakawa-ku, Tokyo, 116-8567 Japan
| | - Naotake Hashimoto
- 3Department of Diabetes, Endocrine and Metabolic Diseases, Tokyo Women's Medical University Yachiyo Medical Center, 477-96, Owada-shinden, Yachiyo-shi, Chiba 276-0046 Japan
| | - Kazuo Sasamoto
- Internal Medicine, Suzuki Clinic, 1F, 2-10-14, Koyasu-machi, Hachioji-shi, Tokyo, 192-0904 Japan
| | - Hiroshi Ohashi
- Internal Medicine, Oyama East Clinic, 1-32-1, Ekihigashi-dori, Oyama-shi, Tochigi 323-0022 Japan
| | - Sumiko Hasumi
- Internal Medicine, Nishiyamado-Keiwa Hospital, 3247-1, Kounosu, Naka-shi, Ibaraki 311-0133 Japan
| | - Tadasu Kasahara
- Josai Hospital, 2-42-11, Kamiogi, Suginami-ku, Tokyo, 167-0043 Japan
| | - Osamu Tomonaga
- Diabetes and Lifestyle Center, Tomonaga Clinic, Shinyon curumu Building 9F, 4-2-23, Shinjuku, Shinjuku-ku, Tokyo, 160-0022 Japan
| | - Hideo Nunome
- 9Diabetes Center, Edogawa Hospital, Medical Plaza Shinozaki, SK Building, 7-15-12, Shinozaki-machi, Edogawa-ku, Tokyo, 133-0057 Japan
| | - Masashi Honda
- Nishikawa Clinic, 2-16-3, Towa, Adachi-ku, Tokyo, 120-0003 Japan
| | - Yasuhiko Iwamoto
- 11Tokyo Women's Medical University/The Institute for Adult Diseases, Asahi Life Foundation, Asahiseimeisunaga Building 2, 3, 4F, 2-2-6, Nihonbashi Bakuro-cho, Chuo-ku, Tokyo, 103-0002 Japan
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Axelsson AS, Tubbs E, Mecham B, Chacko S, Nenonen HA, Tang Y, Fahey JW, Derry JMJ, Wollheim CB, Wierup N, Haymond MW, Friend SH, Mulder H, Rosengren AH. Sulforaphane reduces hepatic glucose production and improves glucose control in patients with type 2 diabetes. Sci Transl Med 2017; 9:9/394/eaah4477. [DOI: 10.1126/scitranslmed.aah4477] [Citation(s) in RCA: 179] [Impact Index Per Article: 25.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2016] [Revised: 02/23/2017] [Accepted: 05/05/2017] [Indexed: 12/13/2022]
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Wysham CH, Lefebvre P, Pilon D, Ingham M, Lafeuille MH, Emond B, Kamstra R, Chow W, Pfeifer M, Duh MS. Quality measure and weight loss assessment in patients with type 2 diabetes mellitus treated with canagliflozin or dipeptidyl peptidase-4 inhibitors. BMC Endocr Disord 2017; 17:32. [PMID: 28595617 PMCID: PMC5465542 DOI: 10.1186/s12902-017-0180-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2016] [Accepted: 05/24/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Achieving control of glycated hemoglobin (HbA1c), blood pressure (BP), and body weight (BW) remains a challenge for most patients with type 2 diabetes mellitus (T2DM). In clinical trials, canagliflozin (CANA), an inhibitor of sodium-glucose co-transporter 2, has shown significant improvement compared to some dipeptidyl peptidase-4 (DPP-4) inhibitors in the achievement of such quality measures. This study used recent electronic medical records (EMR) data to assess quality measure achievement of HbA1C, BP, and BW loss in patients treated with CANA versus DPP-4 inhibitors. METHODS Adult patients with ≥1 T2DM diagnosis and ≥12 months of clinical activity (baseline) before first CANA or DPP-4 prescription (index) were identified in the QuintilesIMS Health Real-World Data EMRs-US database (03/29/2012-10/30/2015). Patients were observed from the index to last encounter. Inverse probability of treatment weighting (IPTW) was used to adjust for observed baseline confounders between groups. Kaplan-Meier (KM) rates and Cox proportional hazard models were used to compare achievement of HbA1c < 7% (among patients <65 years old), HbA1c < 8%, systolic BP < 140 mmHg, diastolic BP < 90 mmHg, and BW loss ≥ 5% among patients not meeting these respective targets at baseline. RESULTS A total of 10,702 CANA and 17,679 DPP-4 patients were selected. IPTW resulted in balanced baseline demographic, comorbidity, and disease characteristics (CANA: N = 13,793, mean age: 59.0 years; DPP-4: N = 14,588, mean age: 58.9 years). Up until 24 months post-index, CANA patients were more likely to reach an HbA1c < 7% (hazard ratio [HR] = 1.10, P = 0.007, KM rates: 42.8% vs. 40.3%), an HbA1c < 8% (HR = 1.16, P < 0.001, KM rates: 63.7% vs. 60.0%), and a BW loss ≥ 5% (HR = 1.46, P < 0.001, KM rates: 55.2% vs. 46.2%), compared to DPP-4 patients. Up until 12 months post-index, CANA patients were more likely to reach a systolic BP < 140 mmHg (HR = 1.07, P = 0.04, KM rates: 87.8% vs. 83.9%). but not a diastolic BP < 90 mmHg (HR = 0.95, P = 0.361), compared to DPP-4 patients. CONCLUSIONS This retrospective study of EMR data covering up to 30 months after CANA approval (March 2013) suggests that patients initiated on CANA were more likely to reach HbA1c, systolic BP, and weight loss objectives specified by general diabetes care guidelines than patients initiated on DPP-4 inhibitors.
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Affiliation(s)
| | - Patrick Lefebvre
- Groupe d’analyse, Ltée, 1000 De La Gauchetière West, Bureau 1200, Montréal, Québec H3B 4W5 Canada
| | - Dominic Pilon
- Groupe d’analyse, Ltée, 1000 De La Gauchetière West, Bureau 1200, Montréal, Québec H3B 4W5 Canada
| | - Mike Ingham
- Janssen Scientific Affairs, LLC, Raritan, New Jersey USA
| | - Marie-Hélène Lafeuille
- Groupe d’analyse, Ltée, 1000 De La Gauchetière West, Bureau 1200, Montréal, Québec H3B 4W5 Canada
| | - Bruno Emond
- Groupe d’analyse, Ltée, 1000 De La Gauchetière West, Bureau 1200, Montréal, Québec H3B 4W5 Canada
| | - Rhiannon Kamstra
- Groupe d’analyse, Ltée, 1000 De La Gauchetière West, Bureau 1200, Montréal, Québec H3B 4W5 Canada
| | - Wing Chow
- Johnson & Johnson, New Brunswick, NJ USA
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Bradley JN, Edwards KL, Gunter JT, Weideman RA, Kelly KC. Provider Decisions and Patient Outcomes After Premature Metformin Discontinuation. Diabetes Spectr 2017; 30:17-22. [PMID: 28270711 PMCID: PMC5309901 DOI: 10.2337/ds15-0049] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The purpose of this study was to evaluate the effects of alternative antihyperglycemic therapy after discontinuation of metformin due to documented declining renal function. This retrospective, single-site study evaluated patients who had metformin discontinued between 1 January 1999 and 30 September 2013. Medical records were evaluated for documented adverse events, subsequent glycemic control, and costs associated with the alternative therapy. Patients served as their own controls. A total of 179 patients met study entry criteria, and their peak A1C was significantly higher within the year after metformin discontinuation (P <0.001). After the provider added new medications to control patients' blood glucose, their A1C by the end of the first year after discontinuing metformin was similar to their A1C while taking metformin. Significant weight gain accompanied the use of the medications added to replace metformin, with an average increase of 3.81 kg (P <0.001). Additionally, after discontinuing metformin, more patients experienced hypoglycemia with the addition of other medications to control their blood glucose (P <0.001). As expected, the cost of therapy was significantly higher (P <0.0001) after metformin was discontinued because metformin was generically available, whereas the replacement medications frequently were not. Providers should consider the expanded recommendations for the use of metformin in patients with mild to moderate stable renal dysfunction to help such patients avoid weight gain, hypoglycemia, loss of blood glucose control, and increased costs.
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Affiliation(s)
| | - Krystal L. Edwards
- Texas Tech University Health Sciences Center School of Pharmacy, Dallas, TX
| | | | | | - Kevin C. Kelly
- North Texas Veterans Affairs Health Care System, Dallas, TX
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Merger SR, Kerner W, Stadler M, Zeyfang A, Jehle P, Müller-Korbsch M, Holl RW. Prevalence and comorbidities of double diabetes. Diabetes Res Clin Pract 2016; 119:48-56. [PMID: 27449710 DOI: 10.1016/j.diabres.2016.06.003] [Citation(s) in RCA: 67] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2015] [Revised: 03/18/2016] [Accepted: 06/06/2016] [Indexed: 11/19/2022]
Abstract
BACKGROUND A growing number of people with type 1 diabetes (T1DM) are identified with features of metabolic syndrome (MS) known as "double diabetes", but epidemiologic data on the prevalence of MS in T1DM and its comorbidities are still lacking. Aim of this cross sectional study is to better estimate the prevalence of MS in T1DM, and to assess its association with comorbidities. METHODS Data of 31,119 persons with autoimmune diabetes mellitus were analysed for signs of MS and presence of late complications. Double diabetes was defined as T1DM coexisting with MS (obesity, hypertension, dyslipidemia). Multiple linear or logistic regression analyses were performed to identify associations between double diabetes and late complications. RESULTS 25.5% (n=7926) of persons with T1DM presented additionally the MS. Persons with double diabetes showed significantly more macrovascular comorbidities (coronary heart disease 8.0% versus 3.0% w/o MS, stroke 3.6% versus 1.6%, diabetic foot syndrome 5.5% versus 2.1%). Also microvascular diseases were increased in people with double diabetes (retinopathy 32.4% versus 21.7%, nephropathy 28.3% versus 17.8%). Both macrovascular and microvascular comorbidities were increased independent of glucose control, even if patients with good metabolic control (HbA1c <7.0%, 53mmol/mol) showed significantly less macrovascular (coronary heart disease 2.3% versus 1.8%, p<0.0001) and microvascular problems (retinopathy 8.7% versus 6.6%, p<0.0001). CONCLUSIONS Double diabetes seems to be an independent and important risk factor for persons with T1DM in developing macrovascular and microvascular comorbidities. Therefore, patients should be identified and development of MS should be avoided. Longterm studies are needed to observe the effect of insulin resistance on patients with autoimmune diabetes.
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Affiliation(s)
- S R Merger
- Division of Endocrinology, Department of Internal Medicine, Ulm University, Germany.
| | - W Kerner
- Klinikum Karlsburg, Department of Diabetes, Germany
| | - M Stadler
- King's College London, Diabetes Research Group, Denmark Hill Campus, 10, Cutcombe Road, SE5 9RS London, UK; Hietzing Hospital Vienna, 3rd Medical Department, Wolkersbergenstr. 1, 1130 Vienna, Austria
| | - A Zeyfang
- Bethesda Hospital Stuttgart, Hohenheimer Strasse 21, 70184 Stuttgart, Germany
| | - P Jehle
- Evangelisches Krankenhaus, Wittenberg, Department of Internal Medicine, Germany
| | - M Müller-Korbsch
- Wilhelminenspital Wien, Department of Internal Medicine, Austria
| | - R W Holl
- University of Ulm, Institute of Epidemiology and Medical Biometry, ZIBMT, Ulm, Germany; German Center for Diabetes Research (DZD), Germany
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Solini A, Grossman E. What Should Be the Target Blood Pressure in Elderly Patients With Diabetes? Diabetes Care 2016; 39 Suppl 2:S234-43. [PMID: 27440838 DOI: 10.2337/dcs15-3027] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Hypertension is very common in elderly subjects with type 2 diabetes. The coexistence of hypertension and diabetes can be devastating to the cardiovascular system, and in these patients, tight blood pressure (BP) control is particularly beneficial. Little information is available regarding the target BP levels in elderly hypertensive patients with type 2 diabetes, and therefore extrapolation from data in the general population should be done. However, it is difficult to extrapolate from the general population to these frail individuals, who usually have isolated systolic hypertension, comorbidities, organ damage, cardiovascular disease, and renal failure and have a high rate of orthostatic and postprandial hypotension. On the basis of the available evidence, we provide arguments supporting the individualized approach in these patients. Target BP should be based on concomitant diseases, orthostatic BP changes, and the general condition of the patients. It is recommended to lower BP in the elderly patient with diabetes to <140-150/90 mmHg, providing the patient is in good condition. In patients with isolated systolic hypertension, the same target is reasonable providing the diastolic BP is >60 mmHg. In patients with coronary artery disease and in patients with orthostatic hypotension, excessive BP lowering should be avoided. In elderly hypertensive patients with diabetes, BP levels should be monitored closely in the sitting and the standing position, and the treatment should be tailored to prevent excessive fall in BP.
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Affiliation(s)
- Anna Solini
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Ehud Grossman
- Hypertension Unit, Department of Internal Medicine D, Chaim Sheba Medical Center at Tel Hashomer, Tel Aviv, Israel Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Busch M, Nadal J, Schmid M, Paul K, Titze S, Hübner S, Köttgen A, Schultheiss UT, Baid-Agrawal S, Lorenzen J, Schlieper G, Sommerer C, Krane V, Hilge R, Kielstein JT, Kronenberg F, Wanner C, Eckardt KU, Wolf G. Glycaemic control and antidiabetic therapy in patients with diabetes mellitus and chronic kidney disease - cross-sectional data from the German Chronic Kidney Disease (GCKD) cohort. BMC Nephrol 2016; 17:59. [PMID: 27286816 PMCID: PMC4902996 DOI: 10.1186/s12882-016-0273-z] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2015] [Accepted: 06/02/2016] [Indexed: 01/08/2023] Open
Abstract
Background Diabetes mellitus (DM) is the leading cause of end-stage renal disease. Little is known about practice patterns of anti-diabetic therapy in the presence of chronic kidney disease (CKD) and correlates with glycaemic control. We therefore aimed to analyze current antidiabetic treatment and correlates of metabolic control in a large contemporary prospective cohort of patients with diabetes and CKD. Methods The German Chronic Kidney Disease (GCKD) study enrolled 5217 patients aged 18–74 years with an estimated glomerular filtration rate (eGFR) between 30–60 mL/min/1.73 m2 or proteinuria >0.5 g/d. The use of diet prescription, oral anti-diabetic medication, and insulin was assessed at baseline. HbA1c, measured centrally, was the main outcome measure. Results At baseline, DM was present in 1842 patients (35 %) and the median HbA1C was 7.0 % (25th–75th percentile: 6.8–7.9 %), equalling 53 mmol/mol (51, 63); 24.2 % of patients received dietary treatment only, 25.5 % oral antidiabetic drugs but not insulin, 8.4 % oral antidiabetic drugs with insulin, and 41.8 % insulin alone. Metformin was used by 18.8 %. Factors associated with an HbA1C level >7.0 % (53 mmol/mol) were higher BMI (OR = 1.04 per increase of 1 kg/m2, 95 % CI 1.02–1.06), hemoglobin (OR = 1.11 per increase of 1 g/dL, 95 % CI 1.04–1.18), treatment with insulin alone (OR = 5.63, 95 % CI 4.26–7.45) or in combination with oral antidiabetic agents (OR = 4.23, 95 % CI 2.77–6.46) but not monotherapy with metformin, DPP-4 inhibitors, or glinides. Conclusions Within the GCKD cohort of patients with CKD stage 3 or overt proteinuria, antidiabetic treatment patterns were highly variable with a remarkably high proportion of more than 50 % receiving insulin-based therapies. Metabolic control was overall satisfactory, but insulin use was associated with higher HbA1C levels. Electronic supplementary material The online version of this article (doi:10.1186/s12882-016-0273-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Martin Busch
- Department of Internal Medicine III, University Hospital Jena - Friedrich Schiller University, Erlanger Allee 101, D - 07747, Jena, Germany.
| | - Jennifer Nadal
- Institute of Medical Biometry, Informatics and Epidemiology, University of Bonn, Bonn, Germany
| | - Matthias Schmid
- Institute of Medical Biometry, Informatics and Epidemiology, University of Bonn, Bonn, Germany
| | - Katharina Paul
- Department of Internal Medicine III, University Hospital Jena - Friedrich Schiller University, Erlanger Allee 101, D - 07747, Jena, Germany
| | - Stephanie Titze
- Department of Nephrology and Hypertension, University of Erlangen-Nürnberg, Erlangen, Germany
| | - Silvia Hübner
- Department of Nephrology and Hypertension, University of Erlangen-Nürnberg, Erlangen, Germany
| | - Anna Köttgen
- Department of Internal Medicine IV, Medical Center University of Freiburg, Freiburg, Germany
| | - Ulla T Schultheiss
- Department of Internal Medicine IV, Medical Center University of Freiburg, Freiburg, Germany
| | - Seema Baid-Agrawal
- Department of Medicine, Division of Nephrology and Medical Intensive Care, University Hospital Charité, Berlin, Germany
| | - Johan Lorenzen
- Hannover Medical School, Clinic for Nephrology, Hannover, Germany
| | - Georg Schlieper
- Department of Medicine II - Nephrology and Clinical Immunology, University Hospital Aachen, Aachen, Germany
| | - Claudia Sommerer
- Department of Medicine, Division of Nephrology, University Hospital Heidelberg, Heidelberg, Germany
| | - Vera Krane
- Department of Medicine I, Division of Nephrology, University Hospital Würzburg, Würzburg, Germany
| | - Robert Hilge
- Department of Medicine IV, Division of Nephrology, University Hospital of Ludwig-Maximilians University Munich, Munich, Germany
| | - Jan T Kielstein
- Hannover Medical School, Clinic for Nephrology, Hannover, Germany
| | - Florian Kronenberg
- Division of Genetic Epidemiology, Medical University of Innsbruck, Innsbruck, Austria
| | - Christoph Wanner
- Department of Medicine I, Division of Nephrology, University Hospital Würzburg, Würzburg, Germany
| | - Kai-Uwe Eckardt
- Department of Nephrology and Hypertension, University of Erlangen-Nürnberg, Erlangen, Germany
| | - Gunter Wolf
- Department of Internal Medicine III, University Hospital Jena - Friedrich Schiller University, Erlanger Allee 101, D - 07747, Jena, Germany
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Muller C, Dimitrov Y, Imhoff O, Richter S, Ott J, Krummel T, Bazin-Kara D, Chantrel F, Hannedouche T. Oral antidiabetics use among diabetic type 2 patients with chronic kidney disease. Do nephrologists take account of recommendations? J Diabetes Complications 2016; 30:675-80. [PMID: 26900098 DOI: 10.1016/j.jdiacomp.2016.01.016] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2015] [Revised: 01/12/2016] [Accepted: 01/20/2016] [Indexed: 02/08/2023]
Abstract
BACKGROUND There is an increasing prevalence of diabetes type 2 and chronic kidney disease, challenging appropriate prescribing of oral anti-diabetic drugs (OADs). METHODS We have described the practice patterns of 13 nephrologists in 4 centers, in a cohort of 301 consecutive adult type 2 diabetic patients. Among oral anti-diabetic prescriptions, we have detailed drugs dosage for each subject, with 3 different formulae for estimating glomerular filtration rate (GFR) and its adequation according to the latest ERBP recommendations (2015). As individuals were mostly obese in this work, we also compare adequacy rates using both standard indexed CKD-EPI formula and CKD-EPI formula de-indexed from body surface area. RESULTS Using the CKD-EPI formula as the reference method for estimating GFR, 53.5% of patients were outside the recommendations, mostly for metformin (30% of the whole cohort) and for sitagliptin (17.9% of the whole cohort). With Cockcroft and Gault formula, 38.2% of persons were outside recommendations and 45.9% (p<0.001) with CKD-EPI de-indexed. Among individuals consulting a nephrologist for the first time (n=90), 61.1% were outside recommendations (p=0.1). Among those persons under diabetologist supervision (n=103), 63.1% were outside recommendations (p=0.09), and were taking significantly more often metformin and insulin. CONCLUSION We have found a substantial number of inadequate OAD prescriptions in type 2 diabetic patients with chronic kidney disease. The proportion of individuals outside guidelines was strongly affected by the method used for estimating GFR and by the type of practice, i.e., specialists versus general practitioners.
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Affiliation(s)
- Clotilde Muller
- Strasbourg Civil Hospital, Nephrology department, 1 place de l'hôpital, 67000, Strasbourg, France; School of Medicine, University of Strasbourg, Rue Kirschleger, 67000, Strasbourg, France; UMR 1109, Laboratoire Immunologie et Rhumatologie, Strasbourg, France.
| | - Yves Dimitrov
- Haguenau Hospital, Nephrology department, 64 Avenue du Pr Leriche, 67500, Haguenau, France
| | - Olivier Imhoff
- Clinique Ste Anne, Nephrology department, Rue Philippe Thyss, 67085, Strasbourg, France
| | - Sarah Richter
- Clinique Ste Anne, Nephrology department, Rue Philippe Thyss, 67085, Strasbourg, France
| | - Julien Ott
- Haguenau Hospital, Nephrology department, 64 Avenue du Pr Leriche, 67500, Haguenau, France
| | - Thierry Krummel
- Strasbourg Civil Hospital, Nephrology department, 1 place de l'hôpital, 67000, Strasbourg, France
| | - Dorothée Bazin-Kara
- Strasbourg Civil Hospital, Nephrology department, 1 place de l'hôpital, 67000, Strasbourg, France
| | - Francois Chantrel
- Mulhouse Hospital, Nephrology department, 20 Avenue du Dr René Laennec, 68100, Mulhouse, France
| | - Thierry Hannedouche
- Strasbourg Civil Hospital, Nephrology department, 1 place de l'hôpital, 67000, Strasbourg, France; School of Medicine, University of Strasbourg, Rue Kirschleger, 67000, Strasbourg, France
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Abstract
Diabetes is a global epidemic, associated with a high burden of complications and 4.6 million deaths annually worldwide. As a result of decreasing levels of physical activity and increasing rates of obesity, diabetes is shifting from a disease affecting the elderly to one that affects younger patients or even children. Thus, aggressive treatment and optimal control of risk factors is the key to improve outcomes in those patients. Accumulating evidence of the cardiovascular and lipid effects of glucose-lowering medications suggest that treatment efficacy in diabetes can be further improved. This review provides an overview of the lipid effects and cardiovascular disease risk of current anti-diabetic medications and highlights opportunities and challenges in clinical practice.
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Weinrauch LA, D'Elia JA, Finn P, Lewis EF, Desai AS, Claggett BL, Cooper ME, McGill JB. Strategies for glucose control in a study population with diabetes, renal disease and anemia (Treat study). Diabetes Res Clin Pract 2016; 113:143-51. [PMID: 26830074 DOI: 10.1016/j.diabres.2015.12.021] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2015] [Revised: 12/04/2015] [Accepted: 12/26/2015] [Indexed: 01/04/2023]
Abstract
UNLABELLED Glucose lowering medication use among patients with type 2 diabetes and advanced renal disease (eGFR<60) in a large multinational outcome trial (TREAT) is assessed. We demonstrate statistically significant differences regionally in use of metformin at lower eGFR and increasing reliance upon insulin with/without other medications at low eGFR. INTRODUCTION As renal disease advances, most of the oral anti-diabetic agents requiring renal clearance must be reduced or discontinued. The potential for prolonged hypoglycemia, fluid/volume overload and congestive heart failure may complicate medication choices. In order to evaluate patterns of glycemia management we describe glucose lowering medication use among patients with advanced renal disease and type 2 diabetes in a large multinational outcome trial designed to focus on patients with eGFR<60 in order to commence a dialog on best practices. We felt that analysis of this data would be able to describe regional variations in treatment within a multinational trial in order to understand potential outcome differences attributed to complications. RESULTS The patients entering this study had moderate glycemic control. Insulin therapy either alone (32%) or in combination with other agents (17%) reflected a shift towards insulin use in those subjects with decreased renal function when compared with standard populations with normal kidney function. The use of multiple oral agents, or oral agents plus insulin was quite common. While gender did not appear to play a role in medication choices, there were significant regional variations. For example, oral agents were used more in North America compared with other regions (Latin America, Australia/Western Europe, Russia/Eastern Europe). Patients enrolled at more advanced ages were less likely to be on a regimen of rapid-acting insulin alone consistent with recommendations that suggest a preference for longer-acting preparations in the geriatric population (1). Higher degrees of obesity were associated more complex treatment regimens. Despite this population being at high risk for cardiovascular events, the use of beta blockers (50%), statins (64%) and aspirin (48%) were relatively low, especially in the group that did not require medications to achieve adequate glycemic control. CONCLUSIONS Current attempts to compare strategies for diabetes therapy must control for baseline demographic group differences influencing treatment choice. Future recommendations for glycemic control in patients with Grade 3 or higher chronic kidney disease require additional studies, with matched populations. We suggest that evaluation of studies similar to TREAT will assist in determining the optimal therapeutic regimens for populations with moderate to severe renal dysfunction, a condition in which repeated hospitalizations for fluid overload/heart failure add to the high cost of diabetes care.
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Affiliation(s)
- Larry A Weinrauch
- Cardiovascular Division, Department of Medicine Brigham and Women's Hospital, Boston, MA, United States; Kidney and Hypertension Section, Joslin Diabetes Center, Boston, MA, United States.
| | - John A D'Elia
- Kidney and Hypertension Section, Joslin Diabetes Center, Boston, MA, United States
| | - Peter Finn
- Cardiovascular Division, Department of Medicine Brigham and Women's Hospital, Boston, MA, United States
| | - Eldrin F Lewis
- Cardiovascular Division, Department of Medicine Brigham and Women's Hospital, Boston, MA, United States
| | - Akshay S Desai
- Cardiovascular Division, Department of Medicine Brigham and Women's Hospital, Boston, MA, United States
| | - Brian L Claggett
- Cardiovascular Division, Department of Medicine Brigham and Women's Hospital, Boston, MA, United States
| | - Mark E Cooper
- Danielle Alberti Memorial Centre for Diabetes Complications, Baker Heart Research Institute, Melbourne, Australia
| | - Janet B McGill
- Division of Endocrinology, Metabolism and Lipid Research, Washington University School of Medicine, St. Louis, MO, United States
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Alves-Cabratosa L, García-Gil M, Comas-Cufí M, Martí R, Ponjoan A, Parramon D, Blanch J, Ramos R. Diabetes and new-onset atrial fibrillation in a hypertensive population. Ann Med 2016; 48:119-27. [PMID: 26939743 DOI: 10.3109/07853890.2016.1144930] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
AIM The association of diabetes with new-onset atrial fibrillation (AF) remains controversial. Hypertension may partly explain the risk association ascribed to diabetes. We studied the role and characteristics of diabetes in hypertensive patients with no ischemic vascular disease. METHODS Records of 262,892 persons from the Information System for the Development of Research in Primary Care in Catalonia (Spain) were examined from July 2006 to December 2011. Included participants were ≥55-years-old and hypertensive with no ischemic heart disease, stroke, or peripheral artery disease. We used Cox proportional hazards regression to model incidences in the diabetic and non-diabetic subgroups of our population, and among diabetic patients, diabetes duration and pharmacological treatment, hemoglobin A1C, and body mass index. RESULTS New-onset AF incidence in diabetic patients was 13.3 per 1000 person-years (mean follow-up: 4.3 years). In non-diabetic patients, it was 10.4 per 1000 person-years (mean follow-up: 4.1 years). Diabetes hazard ratio (HR) for new-onset AF was 1.11 (95% confidence interval (CI): 1.06-1.16). Diabetic patients also diagnosed with obesity had an HR of 1.41 (95% CI: 1.22-1.64). CONCLUSION Diabetes was modestly associated with new-onset AF in hypertensive patients with no ischemic vascular disease. Among diabetic patients, only obesity reached significance in its association with this arrhythmia.
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Affiliation(s)
- Lia Alves-Cabratosa
- a Vascular Health Research Group (ISV)-Girona, Jordi Gol Institute for Primary Care Research (IDIAP Jordi Gol) , Catalonia , Spain
| | - Maria García-Gil
- a Vascular Health Research Group (ISV)-Girona, Jordi Gol Institute for Primary Care Research (IDIAP Jordi Gol) , Catalonia , Spain ;,b Translab Research Group, Department of Medical Sciences , School of Medicine, University of Girona , Girona , Spain
| | - Marc Comas-Cufí
- a Vascular Health Research Group (ISV)-Girona, Jordi Gol Institute for Primary Care Research (IDIAP Jordi Gol) , Catalonia , Spain
| | - Ruth Martí
- a Vascular Health Research Group (ISV)-Girona, Jordi Gol Institute for Primary Care Research (IDIAP Jordi Gol) , Catalonia , Spain ;,c Girona Biomedical Research Institute (IdibGi), Dr. Trueta University Hospital , Catalonia , Spain
| | - Anna Ponjoan
- a Vascular Health Research Group (ISV)-Girona, Jordi Gol Institute for Primary Care Research (IDIAP Jordi Gol) , Catalonia , Spain ;,c Girona Biomedical Research Institute (IdibGi), Dr. Trueta University Hospital , Catalonia , Spain
| | - Dídac Parramon
- a Vascular Health Research Group (ISV)-Girona, Jordi Gol Institute for Primary Care Research (IDIAP Jordi Gol) , Catalonia , Spain ;,d Primary Care Services, Girona, Catalan Institute of Health (ICS) , Catalonia , Spain
| | - Jordi Blanch
- a Vascular Health Research Group (ISV)-Girona, Jordi Gol Institute for Primary Care Research (IDIAP Jordi Gol) , Catalonia , Spain
| | - Rafel Ramos
- a Vascular Health Research Group (ISV)-Girona, Jordi Gol Institute for Primary Care Research (IDIAP Jordi Gol) , Catalonia , Spain ;,b Translab Research Group, Department of Medical Sciences , School of Medicine, University of Girona , Girona , Spain ;,d Primary Care Services, Girona, Catalan Institute of Health (ICS) , Catalonia , Spain
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Roussel R, Lorraine J, Rodriguez A, Salaun-Martin C. Overview of Data Concerning the Safe Use of Antihyperglycemic Medications in Type 2 Diabetes Mellitus and Chronic Kidney Disease. Adv Ther 2015; 32:1029-64. [PMID: 26581749 DOI: 10.1007/s12325-015-0261-x] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2015] [Indexed: 12/26/2022]
Abstract
INTRODUCTION It can be a challenge to manage glycemic control in patients with type 2 diabetes mellitus (T2DM) and chronic kidney disease (CKD), due to both patient and medication issues. Although most antihyperglycemic medications can be used in mild kidney disease, many medications are either not advised or require dose adjustments in more advanced CKD. This review summarizes product label information, pharmacokinetic and clinical studies, and clinical guidelines relevant to use of antihyperglycemic medications in CKD. METHODS Product labels and guidelines from North America and Europe, as well as pharmacokinetic and clinical studies of diabetes medication use in CKD were identified through Medline and PubMed searches, up to February 2015. Available data are summarized and correlations between treatment recommendations and available research are discussed, as are glycemic targets for patients with CKD. RESULTS Newer medications have significantly more data available than older medications regarding use in CKD, although larger clinical studies are still lacking for some drugs. As CKD advances, dose adjustment is needed for many medications [numerous dipeptidyl peptidase-4 inhibitors, some insulins, sodium glucose co-transporter 2 (SGLT2) inhibitors], although not for others (thiazolidinediones, meglitinides). Some medications are not recommended for use in more advanced CKD (metformin, SGLT2 inhibitors, some glucagon-like protein-1 receptor agonists) for safety or efficacy reasons. There is not always good alignment between label recommendations, pharmacokinetic or clinical studies, and guideline recommendations for use of these drugs in CKD. In particular, controversy remains about the use of metformin in moderate CKD and appropriate use of liraglutide and sulfonylureas in advanced CKD. CONCLUSION Considerable variability exists with respect to recommendations and clinical data for the many antihyperglycemic drugs used in patients with T2DM and CKD. FUNDING Eli Lilly and Company.
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Affiliation(s)
- Ronan Roussel
- Division of Endocrinology Diabetes and Nutrition, DHU FIRE, Groupe Hospitalier Bichat-Claude Bernard, AP-HP, Paris, France.
- INSERM U 1138, Cordeliers Research Center, Paris, France.
- University Paris Diderot-Paris 7, Paris, France.
| | | | | | - Carole Salaun-Martin
- Eli Lilly, Neuilly Cedex, France
- Division of Endocrinology Diabetes and Nutrition, Hopital Max Fourestier, Nanterre, France
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Pea F. Antimicrobial treatment of bacterial infections in frail elderly patients: the difficult balance between efficacy, safety and tolerability. Curr Opin Pharmacol 2015; 24:18-22. [DOI: 10.1016/j.coph.2015.06.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2015] [Revised: 06/05/2015] [Accepted: 06/17/2015] [Indexed: 12/12/2022]
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Mathur S, Zammitt NN, Frier BM. Optimal glycaemic control in elderly people with type 2 diabetes: what does the evidence say? Drug Saf 2015; 38:17-32. [PMID: 25481812 DOI: 10.1007/s40264-014-0247-7] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
The global prevalence of type 2 diabetes mellitus (T2DM) is rising in an ageing population through a combination of lifestyle changes and greater longevity. However, by excluding participants aged over 70 years, most major interventional trials on which current diabetes therapeutic guidelines are based have failed to provide specific evidence to support the prescribed management of diabetes in elderly people. While diabetes per se has a significant impact on the elderly person, the side effects of medications, particularly hypoglycaemia, prevent optimisation of diabetes treatment. Hypoglycaemia is associated with significant morbidity, to which elderly people are often more vulnerable because of factors such as the effects of ageing, progressive renal impairment, frailty, polypharmacy and cognitive decline. T2DM is associated with accelerated cognitive decline in some individuals, and recurrent severe hypoglycaemia has been implicated as a potential contributory factor. Although the evidence for selection of appropriate glycaemic targets in elderly patients is sparse, it is now acknowledged that prevention of hypoglycaemia must influence individualisation of treatment goals in this vulnerable group. This should also be reflected by the choice of anti-diabetes agents that are initiated when diet and lifestyle advice is ineffective. Recently developed international guidelines, which have specifically addressed the management of diabetes in elderly people, highlight the importance of a pragmatic management approach rather than attempting to achieve a generic glycated haemoglobin goal and are summarised in this article.
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Affiliation(s)
- Supriya Mathur
- Department of Diabetes, Royal Infirmary of Edinburgh, Edinburgh, Scotland, UK
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Eppenga WL, Wester WN, Derijks HJ, Hoedemakers RMJ, Wensing M, De Smet PAGM, Van Marum RJ. Fluctuation of the renal function after discharge from hospital and its effects on drug dosing in elderly patients--study protocol. BMC Nephrol 2015; 16:95. [PMID: 26149449 PMCID: PMC4492070 DOI: 10.1186/s12882-015-0095-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2015] [Accepted: 06/25/2015] [Indexed: 11/10/2022] Open
Abstract
Background Chronic kidney disease (CKD) is associated with an increased mortality rate, risk of cardiovascular events and morbidity. Impaired renal function is common in elderly patients, and their glomerular filtration rate (GFR) should be taken into account when prescribing renally excreted drugs. In a hospital care setting the GFR may fluctuate substantially, so that the renal function group and therefore the recommended dose, can change within a few days. The magnitude and prevalence of the fluctuation of renal function in daily clinical practice and its potential effects on appropriateness of drug prescriptions after discharge from the hospital is unknown. Methods/design This is a prospective observational study. Patients ≥ 70 years with renal impairment (eGFR <60 ml/min/1.73 m2) admitted to a geriatric ward are eligible to participate. Participants undergo blood sample collection to measure serum creatinine level at three time points: at discharge from hospital, 14 days, and 2 months after discharge. At these time points the actual medication of the participants is assessed and the number of incorrect prescriptions according to the Dutch guidelines in relation to their estimated renal function is measured. In addition, for a hypothetical selection of drugs, the need for drug dose adaptation in relation to renal function is measured. The outcome of interest is the percentage of patients that changes from renal function group after discharge from hospital compared to the renal function at discharge. In addition, the percentages of patients whose actual medications are incorrectly prescribed and for the hypothetical selection of drugs that would have required dose adaptation will be determined at discharge, 14 days and 2 months after discharge. For each outcome, risk factors which may lead to increased risk for fluctuation of renal function and/or incorrect drug prescribing will also be identified and analysed. Discussion This study will provide data on changes in renal function in elderly patients after discharge from the hospital with a focus on the medications used. The benefits for healthcare professionals comprise of the creation, adjustment or confirmation of recommendations for the monitoring of the renal function after discharge from hospital of elderly patients.
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Affiliation(s)
- Willemijn L Eppenga
- Radboud University Medical Center, Radboud Institute for Health Sciences, IQ healthcare, Postbus 9101, 114, 6500 HB, Nijmegen, The Netherlands.
| | - Wietske N Wester
- Department of Geriatric Medicine, Jeroen Bosch Hospital, 's-Hertogenbosch, The Netherlands.
| | - Hieronymus J Derijks
- ZANOB, 's-Hertogenbosch, The Netherlands. .,Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute of Pharmaceutical Sciences, Utrecht, The Netherlands.
| | - Rein M J Hoedemakers
- Laboratory of Clinical Chemistry and Haematology, Jeroen Bosch Hospital, 's-Hertogenbosch, The Netherlands.
| | - Michel Wensing
- Radboud University Medical Center, Radboud Institute for Health Sciences, IQ healthcare, Postbus 9101, 114, 6500 HB, Nijmegen, The Netherlands.
| | - Peter A G M De Smet
- Radboud University Medical Center, Radboud Institute for Health Sciences, IQ healthcare, Postbus 9101, 114, 6500 HB, Nijmegen, The Netherlands. .,Radboud University Medical Center, Department of Pharmacy, Nijmegen, The Netherlands.
| | - Rob J Van Marum
- Department of Geriatric Medicine, Jeroen Bosch Hospital, 's-Hertogenbosch, The Netherlands. .,Department of General Practice and Elderly Care Medicine, VU University Medical Center Amsterdam, Amsterdam, The Netherlands.
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Ferrannini E, DeFronzo RA. Impact of glucose-lowering drugs on cardiovascular disease in type 2 diabetes. Eur Heart J 2015; 36:2288-96. [PMID: 26063450 DOI: 10.1093/eurheartj/ehv239] [Citation(s) in RCA: 182] [Impact Index Per Article: 20.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2015] [Accepted: 05/16/2015] [Indexed: 12/11/2022] Open
Abstract
Type 2 diabetes mellitus (T2DM) is characterized by multiple pathophysiologic abnormalities. With time, multiple glucose-lowering medications are commonly required to reduce and maintain plasma glucose concentrations within the normal range. Type 2 diabetes mellitus individuals also are at a very high risk for microvascular complications and the incidence of heart attack and stroke is increased two- to three-fold compared with non-diabetic individuals. Therefore, when selecting medications to normalize glucose levels in T2DM patients, it is important that the agent not aggravate, and ideally even improve, cardiovascular risk factors (CVRFs) and reduce cardiovascular morbidity and mortality. In this review, we examine the effect of oral (metformin, sulfonylureas, meglitinides, thiazolidinediones, DPP4 inhibitors, SGLT2 inhibitors, and α-glucosidase inhibitors) and injectable (glucagon-like peptide-1 receptor agonists and insulin) glucose-lowering drugs on established CVRFs and long-term studies of cardiovascular outcomes. Firm evidence that in T2DM cardiovascular disease can be reversed or prevented by improving glycaemic control is still incomplete and must await large, long-term clinical trials in patients at low risk using modern treatment strategies, i.e., drug combinations designed to maximize HbA1c reduction while minimizing hypoglycaemia and excessive weight gain.
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Affiliation(s)
- Ele Ferrannini
- Institute of Clinical Physiology, National Research Council (CNR), Pisa, Italy
| | - Ralph A DeFronzo
- Diabetes Division, University of Texas Health Science Center, San Antonio, TX, USA
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Penfornis A, Fiquet B, Blicklé JF, Dejager S. Potential glycemic overtreatment in patients ≥75 years with type 2 diabetes mellitus and renal disease: experience from the observational OREDIA study. Diabetes Metab Syndr Obes 2015; 8:303-13. [PMID: 26170705 PMCID: PMC4498726 DOI: 10.2147/dmso.s83897] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Few data exist examining the management of elderly patients with type 2 diabetes mellitus and renal impairment (RI). This observational study assessed the therapeutic management of this fragile population. METHODS Cross-sectional study: data from 980 diabetic patients ≥75 years with renal disease are presented. RESULTS Patients had a mean age of 81 years (range 75-101) with long-standing diabetes (15.4 years) often complicated (half with macrovascular disease). Mean estimated glomerular filtration rate was 43 mL/min/1.73 m(2) and 20% had severe RI. Mean hemoglobin A1c was 7.4%. Anti-diabetic therapy was oral based for 51% of patients (60% ≥2 oral anti-diabetic drugs [OAD]) and insulin based for 49% (combined with OAD in 59%). OAD included metformin (47%), sulfonylureas (26%), glinides (19%), and DPP-4 inhibitors (31%). Treatments were adjusted to increasing RI, with less use of metformin, sulfonylureas, and DPP-4 inhibitors, and more glinides and insulin in severe RI. In all, 579 (60%) of these elderly patients with comorbidities had hemoglobin A1c <7.5% (mean 6.7%) while being intensively treated: 69% under insulin-secretagogues and/or insulin, putting them at high risk for severe hypoglycemia. Only one-fourth were under oral monotherapy. CONCLUSION In clinical practice, a substantial proportion of elderly patients may be overtreated. RI is insufficiently taken into account when prescribing OAD.
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Affiliation(s)
- Alfred Penfornis
- Department of Endocrinology and Diabetology, Centre Hospitalier Sud Francilien, Corbeil-Essonnes Cedex, France
| | - Béatrice Fiquet
- Clinical Affairs, Novartis Pharma SAS, Rueil-Malmaison, France
| | - Jean Frédéric Blicklé
- Department of Internal Medicine and Diabetology, Strasbourg University Hospital, Strasbourg, France
| | - Sylvie Dejager
- Clinical Affairs, Novartis Pharma SAS, Rueil-Malmaison, France
- Department of Diabetology, Metabolism and Endocrinology, Pitié-Salpétrière Hospital, Paris, France
- Correspondence: Sylvie Dejager, Clinical Affairs, Novartis Pharma SAS, 10 rue Lionel Terray, 92506 Rueil-Malmaison, France, Tel +33 1 5547 6339, Fax +33 1 5547 6593, Email
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Inzucchi SE, Lipska KJ, Mayo H, Bailey CJ, McGuire DK. Metformin in patients with type 2 diabetes and kidney disease: a systematic review. JAMA 2014; 312:2668-75. [PMID: 25536258 PMCID: PMC4427053 DOI: 10.1001/jama.2014.15298] [Citation(s) in RCA: 370] [Impact Index Per Article: 37.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
IMPORTANCE Metformin is widely viewed as the best initial pharmacological option to lower glucose concentrations in patients with type 2 diabetes mellitus. However, the drug is contraindicated in many individuals with impaired kidney function because of concerns of lactic acidosis. OBJECTIVE To assess the risk of lactic acidosis associated with metformin use in individuals with impaired kidney function. EVIDENCE ACQUISITION In July 2014, we searched the MEDLINE and Cochrane databases for English-language articles pertaining to metformin, kidney disease, and lactic acidosis in humans between 1950 and June 2014. We excluded reviews, letters, editorials, case reports, small case series, and manuscripts that did not directly pertain to the topic area or that met other exclusion criteria. Of an original 818 articles, 65 were included in this review, including pharmacokinetic/metabolic studies, large case series, retrospective studies, meta-analyses, and a clinical trial. RESULTS Although metformin is renally cleared, drug levels generally remain within the therapeutic range and lactate concentrations are not substantially increased when used in patients with mild to moderate chronic kidney disease (estimated glomerular filtration rates, 30-60 mL/min per 1.73 m2). The overall incidence of lactic acidosis in metformin users varies across studies from approximately 3 per 100,000 person-years to 10 per 100,000 person-years and is generally indistinguishable from the background rate in the overall population with diabetes. Data suggesting an increased risk of lactic acidosis in metformin-treated patients with chronic kidney disease are limited, and no randomized controlled trials have been conducted to test the safety of metformin in patients with significantly impaired kidney function. Population-based studies demonstrate that metformin may be prescribed counter to prevailing guidelines suggesting a renal risk in up to 1 in 4 patients with type 2 diabetes mellitus--use which, in most reports, has not been associated with increased rates of lactic acidosis. Observational studies suggest a potential benefit from metformin on macrovascular outcomes, even in patients with prevalent renal contraindications for its use. CONCLUSIONS AND RELEVANCE Available evidence supports cautious expansion of metformin use in patients with mild to moderate chronic kidney disease, as defined by estimated glomerular filtration rate, with appropriate dosage reductions and careful follow-up of kidney function.
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Affiliation(s)
- Silvio E Inzucchi
- Section of Endocrinology, Yale University School of Medicine, New Haven, Connecticut
| | - Kasia J Lipska
- Section of Endocrinology, Yale University School of Medicine, New Haven, Connecticut
| | - Helen Mayo
- Health Sciences Digital Library and Learning Center, University of Texas Southwestern Medical Center, Dallas
| | - Clifford J Bailey
- School of Life & Health Sciences, Aston University, Birmingham, United Kingdom
| | - Darren K McGuire
- Division of Cardiology, University of Texas Southwestern Medical Center, Dallas
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Valencia WM, Florez H. Pharmacological treatment of diabetes in older people. Diabetes Obes Metab 2014; 16:1192-203. [PMID: 25073699 DOI: 10.1111/dom.12362] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2014] [Revised: 07/23/2014] [Accepted: 07/23/2014] [Indexed: 12/21/2022]
Abstract
The pharmacological management of diabetes in older people is complex and challenging. It requires a comprehensive understanding of the individual beyond the diabetes itself. Through the ageing years, the older individual presents with diabetes-related and non-related comorbidities and complications, develops functional limitations and psychological issues, and may lack social support and access to care. A disturbance in these categories, known as the four geriatric domains, will negatively affect diabetes self-management and self-efficacy, leading to poor outcomes and complications. Furthermore, older people with diabetes may be more interested in the management of other chronic conditions such as pain or impaired mobility, and diabetes may be lower in their list of priorities. Proper education must be provided to the older individual and caregivers, with continuous monitoring and counselling, especially when pharmacological interventions offer risks of side effects, adverse reactions and interactions with other medications. Informed shared medical decisions will help to improve adherence to the regimen; however, such discussions ought to be based on the best evidence available, which is unfortunately limited in this age group. We performed a review focused on pharmacological agents and summarize current evidence on their use for the treatment of diabetes in older people. We encourage clinicians to investigate and incorporate the four geriatrics domains in the selection and monitoring of these agents.
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Affiliation(s)
- W M Valencia
- Geriatrics Research, Education and Clinical Center, Miami Bruce W. Carter VA Medical Center, Miami, FL, USA; Department of Public Health Sciences, Division of Epidemiology, University of Miami Miller School of Medicine, Miami, FL, USA
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Venos ES, Sigal RJ. My patient's diabetic kidney disease has progressed to stage 4; should I discontinue metformin? Can J Diabetes 2014; 38:296-9. [PMID: 25284696 DOI: 10.1016/j.jcjd.2014.07.225] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2014] [Revised: 07/30/2014] [Accepted: 07/31/2014] [Indexed: 11/17/2022]
Affiliation(s)
- Erik S Venos
- Division of Endocrinology, Departments of Medicine and Community Health Sciences, Faculty of Medicine, University of Calgary, Calgary, Alberta, Canada.
| | - Ronald J Sigal
- Division of Endocrinology, Departments of Medicine and Community Health Sciences, Faculty of Medicine, University of Calgary, Calgary, Alberta, Canada; Department of Cardiac Sciences and Institute of Public Health, Faculties of Medicine and Kinesiology, University of Calgary, Calgary, Alberta, Canada
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Adam WR, O'Brien RC. A justification for less restrictive guidelines on the use of metformin in stable chronic renal failure. Diabet Med 2014; 31:1032-8. [PMID: 24909998 DOI: 10.1111/dme.12515] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2014] [Accepted: 06/03/2014] [Indexed: 11/30/2022]
Abstract
AIM The aim was to justify less restrictive use of metformin in stable chronic renal failure, because a literature review reveals metformin is associated with a significantly lower incidence of cardiovascular events and mortality compared with other hypoglycaemic agents, and metformin-associated lactic acidosis is rare and causation uncertain. Studies on intentional metformin overdose and metformin bioavailability, renal clearance and plasma metformin in renal impairment provide evidence in support of a less restrictive use of metformin. METHODS In metformin overdose (n = 22), lactic acidosis was not inevitable with a plasma metformin > 40 mg/l (therapeutic level c. 1 mg/l): Severe lactic acidosis (pH ≤ 7.21, plasma lactate ≥ 11 mmol/l, n = 8) did not occur unless plasma metformin was > 40 mg/l. Plasma lactate was a more consistent predictor of pH than plasma metformin, with plasma lactate ≤ 4.7 being associated with a pH ≥ 7.34. A likely 'safe' plasma lactate is < 3.5 mmol/l and plasma metformin < 10 mg/l. RESULTS Plasma metformin can be predicted from estimated glomerular filtration rate and metformin dose. Reported plasma metformin in renal failure was always less than predicted plasma metformin. Predicted plasma metformin (mg/l), with an estimated glomerular filtration rate of 30 ml/min and metformin 2000 mg/day was 6.8; an estimated glomerular filtration rate of 20 ml/min and metformin 1500 mg/day was 5.1; an estimated glomerular filtration rate of 10 ml/min and metformin 500 mg/day was 4.4. CONCLUSION Metformin accumulates in renal failure and, although accumulation does not always lead to lactic acidosis, dose modification to achieve a predicted plasma metformin < 10 mg/l is suggested. As plasma metformin is not routinely available, plasma lactate should be useful in monitoring the use of metformin in renal failure.
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Affiliation(s)
- W R Adam
- Rural Health Academic Centre, Shepparton
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Pugliese G, Solini A, Bonora E, Fondelli C, Orsi E, Nicolucci A, Penno G. Chronic kidney disease in type 2 diabetes: lessons from the Renal Insufficiency And Cardiovascular Events (RIACE) Italian Multicentre Study. Nutr Metab Cardiovasc Dis 2014; 24:815-822. [PMID: 24780515 DOI: 10.1016/j.numecd.2014.02.013] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2013] [Revised: 02/17/2014] [Accepted: 02/18/2014] [Indexed: 11/25/2022]
Abstract
The Renal Insufficiency And Cardiovascular Events (RIACE) Italian Multicentre Study is an ongoing observational survey that examines the role of estimated glomerular filtration rate (eGFR) as an independent predictor of cardiovascular and renal outcomes in 15,773 Italian subjects with type 2 diabetes. The analysis of data collected at the enrollment visit provided a picture of chronic kidney disease (CKD) and its association with other complications, risk factors for cardiovascular disease (CVD) and treatments in a large contemporary cohort. Main results of this analysis were that (a) non-albuminuric renal impairment is the predominant clinical phenotype in patients, particularly women, with reduced eGFR; (b) concordance between CKD and diabetic retinopathy is low, with only a minority of patients with renal dysfunction presenting with any or advanced retinal lesions; (c) the non-albuminuric form is associated with a significant prevalence of CVD, especially at the level of the coronary vascular bed; (d) CKD is associated with hemoglobin (Hb) A1c variability more than with average HbA1c, whereas retinopathy and CVD are not; (e) in elderly individuals with moderate-to-severe eGFR reduction, use of agents which are not recommended, such as sulphonylureas and metformin, is still frequent; and (f) though complications are generally more prevalent in men (except non-albuminuric renal impairment) women show a less favorable CVD risk profile and achieve therapeutic targets to a lesser extent than men, despite the fact that treatment intensity is not lower. These data update existing information on the natural history of CKD in patients with type 2 diabetes.
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Affiliation(s)
- G Pugliese
- Department of Clinical and Molecular Medicine, "La Sapienza" University, Via di Grottarossa, 1035-1039, 00189 Rome, Italy.
| | - A Solini
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - E Bonora
- Division of Endocrinology and Metabolic Diseases, University of Verona, Verona, Italy
| | - C Fondelli
- Diabetes Unit, Department of Internal Medicine, Endocrine and Metabolic Sciences and Biochemistry, University of Siena, Siena, Italy
| | - E Orsi
- Endocrinology and Diabetes Unit, Department of Medical Sciences, Fondazione IRCCS "Cà Granda - Ospedale Maggiore Policlinico", Milan, Italy
| | - A Nicolucci
- Department of Clinical Pharmacology and Epidemiology, Consorzio Mario Negri Sud, S. Maria Imbaro, Chieti, Italy
| | - G Penno
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
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de Miguel-Yanes JM, Inglada-Galiana L, Gómez-Huelgas R. Prioritization of patient-related factors according to renal function in antidiabetic drug selection: the REDIM Project. Diabetes Res Clin Pract 2014; 105:199-205. [PMID: 24890859 DOI: 10.1016/j.diabres.2014.04.030] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2014] [Revised: 04/25/2014] [Accepted: 04/27/2014] [Indexed: 01/15/2023]
Abstract
AIMS Few studies have evaluated how physicians prioritize renal function among other patient-related factors when stepping-up in antidiabetic treatment. METHODS The REDIM Spanish national online survey included 550 internists. We firstly tested proficiency in chronic kidney disease (Agrawal's Questionnaire) and motivation in diabetes (DAS-3p Questionnaire). We then analyzed how physicians prioritized renal function, age, weight, glycemic control, non-renal co-morbidities and patient perceptions in five varying fictitious clinical scenarios (generic; ambulatory vs. high cardiovascular risk hospitalized patient, for estimated glomerular filtration rates (eGFRs)=50 vs. 25 ml/min/1.73 m(2)). We assigned every item a score (from 5 to 0, highest to lowest relevance) per-physician and compared mean values between clinical scenarios using the t-test for independent means (nominal significance at p<0.05). RESULTS Completion rate was 57.5% (N=316; mean age, 46.3 years; men, 71%). Average scores were 22.6 ± 3.9 (possible range [0-30]) for Agrawal's Questionnaire and 4.1 ± 0.6 (range [1-5]) for DAS-3p Questionnaire. In the generic scenario, renal function had the highest priority (mean=3.36 ± 1.66, range [0-5]). When eGFR was set at 50 ml/min/1.73 m(2), physicians prioritized glycemic control for ambulatory (mean=3.23 ± 1.59) and non-renal co-morbidities for hospitalized patients (mean=3.20 ± 1.68) over renal function (mean=3.18 ± 1.77 for ambulatory, p=0.032; mean=3.11 ± 1.65 for hospitalized patients, p=0.002). When eGFR was subsequently lowered to 25 ml/min/1.73 m(2), renal function again led priorities (mean values=3.73 ± 2.05 for ambulatory and 3.75 ± 1.96 for hospitalized patients; both p<0.001). CONCLUSIONS Knowledge of the degree of renal function impairment induced physicians to prioritize patient-related factors differently when adding a second antidiabetic drug. Renal function led priorities when severely impaired.
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