An Evidence-Based Medicine Approach to Antihyperglycemic Therapy in Diabetes Mellitus to Overcome Overtreatment

Availability of Cardioprotective Medications for Type 2 Diabetes in the Medicaid Program

BACKGROUND

Sodium-glucose cotransporter-2 inhibitors (SGLT2is) and glucagon-like peptide-1 receptor agonists (GLP-1 RAs) are the only type 2 diabetes medications that reduce cardiovascular disease and death, yet their availability in Medicaid is unclear.

OBJECTIVE

To assess the unrestricted availability of SGLT2is and GLP-1 RAs, using dipeptidyl peptidase-4 inhibitors (DPP4is) as a benchmark.

DESIGN

National cross-sectional study using publicly available data.

SETTING

All 50 state Medicaid fee-for-service (FFS) plans and 273 nonelderly adult managed care organization (MCO) plans with comprehensive coverage in March 2024.

PARTICIPANTS

Medicaid plans and enrollees with diabetes in those plans as of March 2024.

MEASUREMENTS

Unrestricted availability was defined as having at least 1 medication in each class listed on the preferred drug list without prior authorization or step therapy.

RESULTS

Of 50 FFS plans (including Washington, DC, and excluding 1 state, which had 5 MCO plans), 40 (80%) had unrestricted availability of SGLT2is, 30 (60%) of GLP-1 RAs, 41 (82%) of either, 29 (58%) of both, and 42 (84%) of DPP4is. Among 273 MCO plans (39 states; median, 6 plans [range, 2 to 24 plans]), 182 (67%) had availability of SGLT2is, 131 (48%) of GLP-1 RAs, 184 (67%) of either, 129 (47%) of both, and 204 (75%) of DPP4is. The proportion of MCO enrollees with availability varied markedly among states (SGLT2i range, 24% to 100%; GLP-1 RA range, 0% to 99%; DPP4i range, 41% to 100%). Primarily because of more MCO restrictions, 1.7 million enrollees (lower to upper bound, 1.33 million to 2.17 million enrollees; 25%) had restricted SGLT2i availability, 2.72 million (lower to upper bound, 2.12 million to 3.45 million; 40%) had restricted GLP-1 RA availability, and 1.5 million (lower to upper bound, 1.17 million to 1.90 million; 22%) had restricted DPP4i availability. Availability increased from 2020 to 2024, especially in FFS, but MCO GLP-1 RA availability has plateaued at below 60% since 2022. Tirzepatide was almost entirely restricted.

LIMITATIONS

Diabetes enrollment was estimated using plan size and state and national prevalence data. The appropriateness of prior authorization restrictions was unknown.

CONCLUSION

Many Medicaid enrollees have restricted access to cardioprotective medications, particularly in MCO plans for GLP-1 RA medications, with substantial state variation. Formulary coverage is a potential lever to increase availability of these medications while balancing pharmaceutical costs.

PRIMARY FUNDING SOURCE

University of California, San Francisco, Action Research Center for Health Equity.

In-hospital linagliptin for management simplification and hypoglycemia reduction in very old patients with type 2 diabetes

INTRODUCTION AND OBJECTIVES

The role of in-hospital dipeptidyl peptidase-4 inhibitors in very old patients has not been widely described. This work analyzes the simplification of in-hospital antihyperglycemic management (less insulin use) and reductions in hypoglycemia events using linagliptin in patients aged≥80 years with type 2 diabetes.

PATIENTS AND METHODS

This real-world observational study included hospitalized patients≥80 years with type 2 diabetes treated with an antihyperglycemic protocol of either basal-bolus insulin or linagliptin between January 2016 and December 2023. A 1:1 propensity score matching analysis was performed.

RESULTS

Post-matching, 944 patients were included in each group. The total and basal insulin doses and number of daily injections were significantly lower in the linagliptin group than the basal-bolus insulin group with no differences in glycemic efficacy. Regarding safety, patients on the basal-bolus insulin regimen had more hypoglycemic events. The use of basal-bolus insulin regimen (odds ratio: 4.22; 95% confidence interval: 2.14-6.28; p<0.001), a higher total insulin dose (odds ratio: 3.55; 95% confidence interval: 2.02-5.36; p<0.001) and the number of insulin injections (odds ratio: 2.86; 95% confidence interval: 1.50-4.12; p=0.002) were associated with a greater risk of hypoglycemia. Other hypoglycemia risk factors were older age, moderate-severe functional dependence, moderate-severe dementia, polypharmacy, and complex health status.

CONCLUSIONS

The linagliptin regimen simplified in-hospital antihyperglycemic management and reduced hypoglycemia events compared to basal-bolus insulin regimen in patients with type 2 diabetes aged≥80 years. Basal-bolus insulin use and clinical factors were associated with hypoglycemia. The linagliptin regimen could be considered as standard of care for older adult type 2 diabetes patients in the hospital setting.

Disparities in Use of Novel Diabetes Medications by Insurance: A Nationally Representative Cohort Study

BACKGROUND

Minority racial and ethnic populations have the highest prevalence of type 2 diabetes mellitus but lower use of sodium-glucose co-transporter-2 inhibitors (SGLT2i) and glucagon-like peptide-1 receptor agonists (GLP1ra), novel medications that reduce morbidity and mortality. Observed disparities may be due to differences in insurance coverage, which have variable cost-sharing, prior authorization, and formulary restrictions that influence medication access.

OBJECTIVE

To assess whether racial/ethnic differences in SGLT2i and GLP1ra use differ by payer.

DESIGN

Cross-sectional analysis of 2018 and 2019 Medical Expenditure Panel Survey data.

PARTICIPANTS

Adults ≥ 18 years old with diabetes.

MAIN MEASURES

We defined insurance as private, Medicare, or Medicaid using ≥ 7 months of coverage in the calendar year. We defined race/ethnicity as White (non-Hispanic) vs non-White (including Hispanic). The primary outcome was use of ≥ 1 SGLT2i or GLP1ra medication. We used multivariable logistic regression to assess the interaction between payer and race/ethnicity adjusted for cardiovascular, socioeconomic, and healthcare access factors.

KEY RESULTS

We included 4997 adults, representing 24.8 million US adults annually with diabetes (mean age 63.6 years, 48.8% female, 38.8% non-White; 33.5% private insurance, 56.8% Medicare, 9.8% Medicaid). In our fully adjusted model, White individuals with private insurance had significantly more medication use versus non-White individuals (16.1% vs 8.3%, p < 0.001), which was similar for Medicare beneficiaries but more attenuated (14.7% vs 11.0%, p = 0.04). Medication rates were similar among Medicaid beneficiaries (10.0% vs 9.0%, p = 0.74).

CONCLUSIONS

Racial/ethnic disparities in novel diabetes medications were the largest among those with private insurance. There was no disparity among Medicaid enrollees, but overall prescription rates were the lowest. Given that disparities vary considerably by payer, differences in insurance coverage may account for the observed disparities in SGLT2i and GLP1ra use. Future studies are needed to assess racial/ethnic differences in novel diabetes use by insurance formulary restrictions and out-of-pocket cost-sharing.

Therapeutic Inertia in the Management of Type 2 Diabetes: A Narrative Review

Adequate glycemic control is key to prevent morbi-mortality from type 2 diabetes (T2D). Despite the increasing availability of novel, effective, and safe medications for the treatment of T2D, and periodically updated guidelines on its management, the overall rate of glycemic goal attainment remains low (around 50%) and has not improved in the past decade. Therapeutic inertia (TI), defined as the failure to advance or de-intensify medical therapy when appropriate to do so, has been identified as a central contributor to the lack of progress in the rates of HbA1c goal attainment. The time to treatment intensification in patients not meeting glycemic goals has been estimated to be between 1 and 7 years from the time HbA1c exceeded 7%, and often, even when an intervention is carried out, it proves insufficient to achieve glycemic goals, which led to the concept of intensification inertia. Therefore, finding strategies to overcome all forms of TI in the management of T2D is a fundamental initiative, likely to have an enormous impact in health outcomes for people with T2D. There are several factors that have been described in the literature leading to TI, including clinician-related, patient-related, and healthcare system-related factors, which are discussed in this review. Likewise, several interventions addressing TI had been tested, most of them proving limited efficacy. Within the most effective interventions, there appear to be two common factors. First, they involve a team-based effort, including nurses, pharmacists, and diabetes educators. Second, they were built upon a framework based on results of qualitative studies conducted in the same context where they were later implemented, as will be discussed in this article. Given the complex nature of TI, it is crucial to use a research method that allows for an in-depth understanding of the phenomenon. Most of the literature on TI is focused on quantitatively describing its consequences; unfortunately, however, not many study groups have undertaken qualitative studies to deeply investigate the drivers of TI in their diverse contexts. This is particularly true in the United States, where there is an abundance of publications exploring the effects of different strategies to overcome TI in type 2 diabetes, but a severe shortage of qualitative studies aiming to truly understand the phenomenon.

Simplification of Complex Insulin Regimens with IdegLira in People with Type 2 Diabetes: Literature Review and Clinical Recommendations

INTRODUCTION

This study developed a simple algorithm based on clinical results described in medical literature and which allows one to simplify complex insulin regimes with IdegLira to avoid adverse events related to the complexity of some insulin treatments.

METHODS

We conducted a systematic review of the literature that allowed us to identify studies that evaluated the clinical result of simplifying complex insulin regimes. The authors reviewed the common factors these simpler regimes had, including the type of patients who used them.

RESULTS

We found nine clinical studies published between 2017 and 2022, eight performed in Europe and one in Latin America. The monitoring time of the studies ranged between 3 and 18 months. The size of the study populations was between 61 and 611 patients (the latter was in five countries). In all studies, HbA1c decreased by 0.6-1.7% and the weight decreased by 0.1-3.11 kg.

CONCLUSIONS

On the basis of the findings of these studies, we made some recommendations for clinical practice to simplify treatment. The results of these studies support an algorithm that simplifies the treatment of complex insulin regimens.

Management of older hospitalized patients with type 2 diabetes using linagliptin: Lina-Older study

BACKGROUND

Older patients managed with intensive antidiabetic therapy are more likely to be harmed. Our study's primary endpoint was to analyze the safety and efficacy of linagliptin in combination with basal insulin versus basal-bolus insulin in patients with 75 years of age or older hospitalized in medicine and surgery departments in real-world clinical practice.

METHODS

We retrospectively enrolled non-critically patients ≥75 years with type 2 diabetes admitted to medicine and non-cardiac surgery departments with admission glycated hemoglobin <8%, admission blood glucose <240 mg/dL, and without at-home injectable therapies managed with our hospital's antihyperglycemic protocol (basal-bolus or linagliptin-basal regimens) between January 2016 and December 2018. To match each patient who started on the basal-bolus regimen with a patient who started on the linagliptin-basal regimen, a propensity matching analysis was used.

RESULTS

Postmatching, 198 patients were included in each group. There were no significant differences in mean daily blood glucose levels after admission (P=0.203); patients with mean blood glucose 100-140mg/dL (P=0.134), 140-180mg/dL (P=0.109), or >200mg/dL (P=0.299); and number and day of treatment failure (P=0.159 and P=0.175, respectively). The total insulin dose and the number of daily injections were significantly lower in the linagliptin-basal group (both, P<0.001). Patients on the basal-bolus insulin regimen had more total hypoglycemic events than patients on the linagliptin-basal insulin regimen (P<0.001).

CONCLUSIONS

The linagliptin-basal insulin regimen was an effective alternative with fewer hypoglycemic events and daily insulin injections than intensive basal-bolus insulin in very old patients with type 2 diabetes with mild-to-moderate hyperglycemia treated at home without injectable therapies.

Effect of the nurse-led program on blood glucose control and microalbuminuria development in type 2 diabetic populations

Current study was to evaluate whether the nurse-led program can improve glycated hemoglobin (HbA1c) control and reduce the incidence of microalbuminuria in type 2 diabetic mellitus (DM2) populations. A total of 150 DM2 subjects were randomly assigned to the usual-care group and nurse-led program group. Study endpoints included the HbA1c value, the percentage of subjects with HbA1c < 7.0%, the incidence of microalbuminuria, and the rate of adhering to antidiabetic drug at 6 months' follow-up. At baseline, there was no difference in fasting plasma glucose, HbA1c, proportion of subjects with HbA1c < 7.0%, the use of antidiabetic drug, and urinary albumin-creatinine ratio between these two groups. After 6 months' follow-up, the mean fasting plasma glucose and HbA1c were lower in the nurse-led program group, as was the proportion of subjects with HbA1c < 7.0%. The median urinary albumin-creatinine ratio and rate of incident microalbuminuria were also lower in the nurse-led program. The nurse-led program was associated with higher odds of achieving HbA1c < 7.0% and a lower incidence of microalbuminuria. After adjusted for covariates, the nurse-led program was still associated with 32% higher odds of achieving HbA1c < 7.0% and 11% lower incidence of microalbuminuria. These benefits were consistent by sex and age, while greater in those with obesity or hypertension (P interaction < .05). The nurse-led program is beneficial for blood glucose control and prevention of microalbuminuria.

Potential Risk of Overtreatment in Patients with Type 2 Diabetes Aged 75 Years or Older: Data from a Population Database in Catalonia, Spain

Aim: To assess the potential risk of overtreatment in patients with type 2 diabetes (T2DM) aged 75 years or older in primary care. Methods: Electronic health records retrieved from the SIDIAP database (Catalonia, Spain) in 2016. Variables: age, gender, body mass index, registered hypoglycemia, last HbA1c and glomerular filtration rates, and prescriptions for antidiabetic drugs. Potential overtreatment was defined as having HbA1c < 7% or HbA1c < 6.5% in older patients treated with insulin, sulfonylureas, or glinides. Results: From a total population of 138,374 T2DM patients aged 75 years or older, 123,515 had at least one HbA1c available. An HbA1c below 7.0% was present in 59.1% of patients, and below 6.5% in 37.7%. Overall, 23.0% of patients were treated with insulin, 17.8% with sulfonylureas, and 6.6% with glinides. Potential overtreatment (HbA1c < 7%) was suspected in 26.6% of patients treated with any high-risk drug, 47.8% with sulfonylureas, 43.5% with glinides, and 28.1% with insulin. Using the threshold of HbA1c < 6.5%, these figures were: 21.6%, 24.4%, 17.9%, and 12.3%, respectively. Conclusion: One in four older adults with T2DM treated with antidiabetic drugs associated with a high risk of hypoglycemia might be at risk of overtreatment. This risk is higher in those treated with sulfonylureas or glinides than with insulin.

A Cross-Sectional study on risk factors for severe hypoglycemia among Insulin-Treated elderly type 2 diabetes Mellitus (T2DM) patients in Singapore

OBJECTIVE

This study investigates the risk factors for severe hypoglycemia among Southeast Asian T2DM patients.

METHODS

Insulin-treated T2DM patients greater than 65 years old with HbA1c < 8% were recruited. They completed questionnaires detailing their experience of hypoglycemia and presence of impaired hypoglycemia awareness (IAH). Data on insulin treatment regimens, glycated haemoglobin (Hba1c) and comorbidities were also collected.

RESULTS

Of the 92 participants, 15.2% had at least one episode of severe hypoglycemia over the past year. Comparison between both groups showed that patients with severe hypoglycemia had lower Hba1c, higher Gold score (3.9 ± 1.9 vs. 2.5 ± 1.4; p < .05) and higher Hypoglycemia Fear Survey (HFS) worry score (39.1 ± 14.3 vs. 31.8 ± 11.8; p < .05). There were no significant differences in duration of diabetes and insulin treatment, treatment regimens and diabetes associated comorbidities except peripheral vascular disease. Furthermore, no significant differences were noted in HFS behavior score, hypoglycemia risk modifying behavior and social economic status.

CONCLUSIONS

Patients with severe hypoglycemia had tighter glycemic control, greater IAH and higher worry scores regardless of treatment regimens. Clinicians may play a significant role in tightening glycemic control and influencing the risk of severe hypoglycemia. Standard structured diabetes education may help reduce the risk of severe hypoglycemia among this group of patients.

Efficacy and Safety of Semaglutide for the Management of Obese Patients With Type 2 Diabetes and Chronic Heart Failure in Real-World Clinical Practice

BACKGROUND

The impact of glucagon-like peptide-1 receptor agonists on patients with heart failure has not been fully described. Our main objective was to evaluate the safety and clinical and glycemic efficacy of once-weekly semaglutide in obese patients with type 2 diabetes and heart failure.

METHODS

In this observational, retrospective, real-world study, we enrolled outpatients with type 2 diabetes, obesity, and heart failure who started semaglutide and were followed-up on at 3, 6, and 12 months.

RESULTS

A total of 136 patients were included. From baseline to 12 months, there was a significant improvement on the Kansas City Cardiomyopathy Questionnaire total symptom score (59.0 ± 24.1 vs 79.9 ± 28.4 points, p<0.01), a reduction in the proportion of patients with New York Heart Association functional class III (40.4% to 16.2%, p<0.01), and a reduction in N-terminal pro-brain natriuretic peptide levels (969.5 ± 653.5 vs 577.4 ± 322.1 pg/mL, p<0.01). Emergency department visits due to heart failure, hospitalizations due to heart failure, and all-cause hospitalizations also declined. Additionally, significant reductions in glycated hemoglobin (-1.4%) and body weight (-12.7 kilograms) were observed as well as a de-intensification of antidiabetic therapy. Moreover, semaglutide was safe and well-tolerated.

CONCLUSION

In obese patients with type 2 diabetes and heart failure, the use of once-weekly semaglutide was safe and clinically efficacious, improving health and functional status. Nevertheless, more strong evidence on glucagon-like peptide-1 receptor agonists in heart failure is required.

DR1 activation promotes vascular smooth muscle cell apoptosis via up-regulation of CSE/H2 S pathway in diabetic mice

The important role of hydrogen sulfide (H₂ S) as a novel gasotransmitter in inhibiting proliferation and promoting apoptosis of vascular smooth muscle cells (VSMCs) has been widely recognized. The dopamine D1 receptor (DR1), a G protein coupled receptor, inhibits atherosclerosis by suppressing VSMC proliferation. However, whether DR1 contributes to VSMC apoptosis via the induction of endogenous H₂ S in diabetic mice is unclear. Here, we found that hyperglycemia decreased the expressions of DR1 and cystathionine-γ-lyase (CSE, a key enzyme for endogenous H₂ S production) and reduced endogenous H₂ S generation in mouse arteries and cultured VSMCs. DR1 agonist SKF38393 increased DR1 and CSE expressions and stimulated endogenous H₂ S generation. Sodium hydrosulfide (NaHS, a H₂ S donor) increased CSE expressions and H₂ S generation but had no effect on DR1 expression. In addition, high glucose (HG) increased VSMC apoptosis, up-regulated IGF-1-IGF-1R and HB-EGF-EGFR, and stimulated ERK1/2 and PI3K-Akt pathways. Overexpression of DR1, the addition of SKF38393 or supply of NaHS further promoted VSMC apoptosis and down-regulated the above pathways. Knock out of CSE or the addition of the CSE inhibitor poly propylene glycol diminished the effect of SKF38393. Moreover, calmodulin (CaM) interacted with CSE in VSMCs; HG increased intracellular Ca²⁺ concentration and induced CaM expression, further strengthened the interaction of CaM with CSE in VSMCs, which were further enhanced by SKF38393. CaM inhibitor W-7, inositol 1,4,5-trisphosphate (IP₃ ) inhibitor 2-APB, or ryanodine receptor inhibitor tetracaine abolished the stimulatory effect of SKF38393 on CaM expression and intracellular Ca²⁺ concentration. Taken together, these results suggest that DR1 up-regulates CSE/H₂ S signaling by inducing the Ca²⁺ -CaM pathway followed by down-regulations of IGF-1-IGF-1R and HB-EGF-EGFR and their downstream ERK1/2 and PI3K-Akt, finally promoting the apoptosis of VSMCs in diabetic mice.

Overtreatment and undertreatment in a sample of elderly people with diabetes

AIMS

In older adults with type 2 diabetes (T2D), overtreatment remains prevalent and undertreatment ignored. The main objective is to estimate the prevalence and examine factors associated with potential overtreatment and undertreatment.

METHOD

Observational study conducted within an administrative database of older adults with T2D who registered in 2018 at the Portuguese Diabetes Association. Participants were categorized either as potentially overtreated (HbA1c ≤ 7.5%), appropriately on target (HbA1c ≥7.5 to ≤9%), or potentially undertreated (HbA1c > 9%).

RESULTS

The study included 444 participants: potential overtreatment and undertreatment were found in 60.5% and 12.6% of the study population. Taking the patients on target as a comparator, the group of potentially overtreated showed to be more men (61.3% vs 52.2%), less-obese (34.1% vs 39.2), higher cardiovascular diseases (13.7% vs 11%), peripheral vascular diseases (16.7% vs 12.8%), diabetic foot (10% vs 4.5%), and severe kidney disease (5.2% vs 4.5%). Conversely, the potentially undertreated participants were more women (64.2% vs 47.7%), obese (49% vs 39.2%), had more dyslipidemia (69% vs 63.1%), peripheral vascular disease (14.2% vs 12.8%), diabetic foot (8.9% vs 4.5%), and infections (14.2% vs 11.9%). The odds of potential overtreatment were mostly decreased by 59% of women, 73.5% in those with retinopathy, and 86.3% in insulin, 65.4% sulfonylureas, and 66.8% in SGLT2 inhibitors users. Contrariwise, an increase in the odds of potential undertreatment was more than 4.8 times higher in insulin, and more than 3.1 times higher in sulfonylureas users.

CONCLUSION

Potential overtreatment and undertreatment in older adults with T2D in routine clinical practice should guide the clinicians to balance the use of newer oral antidiabetic agents considering its safety profile regarding hypoglycemia.

Skype Supervised, Individualized, Home-Based Rehabilitation Programs for Individuals With Rett Syndrome and Their Families - Parental Satisfaction and Point of View

Individuals with Rett syndrome (RTT) experience impaired gross motor skills limiting their capacity. Therefore, they need support to participate in physical activities, and it is crucial to work with primary caregivers when developing appropriate strategies, thereby leading to an active lifestyle. There is limited evidence supporting the effectiveness of remotely supported physical activity interventions. This project aimed to evaluate the effects of a skype-based, telehealth-delivered physical activity program carried out by participants’ parents at home. This article will focus on parental points of view. A mixed-methods design evaluating parental satisfaction was conducted. Forty participants with a confirmed genetic diagnosis of RTT and their families were recruited. The intervention included a 12-week individualized daily physical activity program carried out by participants’ parents and bi-weekly supervised by expert therapists. Parents’ impressions and feelings related to the program implementation were collected throughout semi-structured interviews, and an ad hoc developed questionnaire and discussed. The current project results suggest that a remote physical rehabilitation program, supported fortnightly by video calls, represents an effective way of conducting a remote physical therapy intervention for this population and that it can be easily carried out at home by primary caregivers, promoting positive functional changes, without bringing feelings of frustration due to the required workload. The strategies that families have learned during the program to support the motor activities of their daughters represent an easily performed set of tools that they can maintain and use in everyday life even after the cessation of the program.

De-Intensification of Antidiabetic Treatment Using Canagliflozin in Patients with Heart Failure and Type 2 Diabetes: Cana-Switch-HF Study

Canagliflozin is a sodium-glucose co-transporter 2 inhibitor that reduces glycemia as well as the risk of cardiovascular events. Our main objective was to analyze antidiabetic treatment de-intensification and the glycemic efficacy of replacing antidiabetic agents (excluding metformin) with canagliflozin in patients with heart failure and type 2 diabetes with poor glycemic control. In this observational, retrospective, real-world study, we selected patients treated with metformin in combination with ≥2 non-insulin antidiabetic agents or metformin in combination with basal insulin plus ≥1 non-insulin antidiabetic agent. Non-insulin antidiabetic agents were replaced with canagliflozin. Patients were followed-up on at three, six, and 12 months after the switch and a wide range of clinical variables were recorded. A total of 121 patients were included. From baseline to 12 months, the number of antidiabetic agents (3.1 ± 1.0 vs. 2.1 ± 0.8, p < 0.05), basal insulin dose (20.1 ± 9.8 vs. 10.1 ± 6.5 units, p < 0.01), and percentage of patients who used basal insulin (47.9% vs. 31.3%, p < 0.01) decreased. The proportion of patients who used diuretics also declined significantly. In addition, we observed improvement in glycemic control, with an increase in the proportion of patients with glycated hemoglobin <7% from 16.8% at three months to 63.5% at 12 (p < 0.001). Canagliflozin use was also beneficial in terms of body weight, blood pressure, heart failure status, functional class, and cardiovascular-renal risk. There were also reductions in the number of emergency department visits and hospitalizations for heart failure. Moreover, canagliflozin was well-tolerated, with a low rate of drug-related discontinuation. Mounting evidence from randomized controlled trials and real-world studies point to the beneficial profile of sodium-glucose co-transporter type 2 inhibitors such as canagliflozin in patients with heart failure.

Dietary Intervention Impacts Immune Cell Functions and Dynamics by Inducing Metabolic Rewiring

Accumulating evidence has shown that nutrient metabolism is closely associated with the differentiation and functions of various immune cells. Cellular metabolism, including aerobic glycolysis, fatty acid oxidation, and oxidative phosphorylation, plays a key role in germinal center (GC) reaction, B-cell trafficking, and T-cell-fate decision. Furthermore, a quiescent metabolic status consolidates T-cell-dependent immunological memory. Therefore, dietary interventions such as calorie restriction, time-restricted feeding, and fasting potentially manipulate immune cell functions. For instance, intermittent fasting prevents the development of experimental autoimmune encephalomyelitis. Meanwhile, the fasting response diminishes the lymphocyte pool in gut-associated lymphoid tissue to minimize energy expenditure, leading to the attenuation of Immunoglobulin A (IgA) response. The nutritional status also influences the dynamics of several immune cell subsets. Here, we describe the current understanding of the significance of immunometabolism in the differentiation and functionality of lymphocytes and macrophages. The underlying molecular mechanisms also are discussed. These experimental observations could offer new therapeutic strategies for immunological disorders like autoimmunity.

Inclusion of Performance Parameters and Patient Context in the Clinical Practice Guidelines for Heart Failure

BACKGROUND

To facilitate evidence-based medicine (EBM) on an individual level, it may be important for clinical practice guidelines (CPGs) to incorporate the performance parameters of diagnostic studies and therapeutic interventions (such as likelihood ratio and absolute benefit or harm), and to incorporate relevant patient contexts that may influence decision-making. We sought to determine the extent to which heart failure CPGs currently incorporate this information.

METHODS

We reviewed the American College of Cardiology Foundation/American Heart Association (ACCF/AHA) 2013 Heart Failure CPG, the 2017 ACCF/AHA/HFSA update, and European Society of Cardiology (ESC) 2016 Heart Failure CPG. We abstracted variables for each CPG recommendation from the following domains: quality of evidence, strength of recommendation, diagnostic and therapeutic performance parameters, and patient context.

RESULTS

We examined 169 recommendations from the ACCF/AHA 2013 CPGs and 2017 update and 187 recommendations from the 2016 ESC CPGs. Performance parameters for diagnostic studies (2013 ACCF/AHA: 13%; 2017 ACCF/AHA/HFSA update: 0%; 2016 ESC: 0%) and therapeutic interventions (2013 ACCF/AHA: 65%; 2017 ACCF/AHA/HFSA update: 64%; 2016 ESC: 16%) were not commonly included in CPGs. Patient context was included in about half of ACCF/AHA recommendations and a quarter of ESC recommendations.

CONCLUSIONS

The majority of recommendations from heart failure CPGs lack information on diagnostic and therapeutic performance parameters and patient context. Given the importance of these components to effectively implement EBM, particularly for a heterogeneous heart failure population, innovative strategies are needed to optimize CPGs so they provide comprehensive yet succinct recommendations that can improve population-level outcomes and ensure optimal patient-centered care.

Clinical inertia is the enemy of therapeutic success in the management of diabetes and its complications: a narrative literature review

Diabetes mellitus is a chronic disease characterized by high social, economic and health burden, mostly due to the high incidence and morbidity of diabetes complications. Numerous studies have shown that optimizing metabolic control may reduce the risk of micro and macrovascular complications related to the disease, and the algorithms suggest that an appropriate and timely step of care intensification should be proposed after 3 months from the failure to achieve metabolic goals. Nonetheless, many population studies show that glycemic control in diabetic patients is often inadequate. The phenomenon of clinical inertia in diabetology, defined as the failure to start a therapy or its intensification/de-intensification when appropriate, has been studied for almost 20 years, and it is not limited to diabetes care, but also affects other specialties. In the present manuscript, we have documented the issue of inertia in its complexity, assessing its dimensions, its epidemiological weight, and its burden over the effectiveness of care. Our main goal is the identification of the causes of clinical inertia in diabetology, and the quantification of its social and health-related consequences through the adoption of appropriate indicators, in an effort to advance possible solutions and proposals to fight and possibly overcome clinical inertia, thus improving health outcomes and quality of care.

The Clinical Course after Long-Term Acute Care Hospital Admission among Older Medicare Beneficiaries

OBJECTIVES

Long-term acute care (LTAC) hospitals provide extended complex post-acute care to more than 120 000 Medicare beneficiaries annually, with the goal of helping patients to regain independence and recover. Because little is known about patients' long-term outcomes, we sought to examine the clinical course after LTAC admission.

DESIGN

Nationally representative 5-year cohort study using 5% Medicare data from 2009 to 2013.

SETTING

LTAC hospitals.

PARTICIPANTS

Hospitalized Medicare fee-for-service beneficiaries 65 years of age or older who were transferred to an LTAC hospital.

MEASUREMENTS

Mortality, recovery (defined as achieving 60 consecutive days alive without inpatient care), time spent in an inpatient facility following LTAC hospital admission, receipt of an artificial life-prolonging procedure (feeding tube, tracheostomy, hemodialysis), and palliative care physician consultation.

RESULTS

Of 14 072 hospitalized older adults transferred to an LTAC hospital, median survival was 8.3 months, and 1- and 5-year survival rates were 45% and 18%, respectively. Following LTAC admission, 53% never achieved a 60-day recovery. The median time of their remaining life a patient spent as an inpatient after LTAC admission was 65.6% (interquartile range = 21.4%-100%). More than one-third (36.9%) died in an inpatient setting, never returning home after the LTAC admission. During the preceding hospitalization and index LTAC admission, 30.9% received an artificial life-prolonging procedure, and 1% had a palliative care physician consultation.

CONCLUSION

Hospitalized older adults transferred to LTAC hospitals have poor survival, spend most of their remaining life as an inpatient, and frequently undergo life-prolonging procedures. This prognostic understanding is essential to inform goals of care discussions and prioritize healthcare needs for hospitalized older adults admitted to LTAC hospitals. Given the exceedingly low rates of palliative care consultations, future research is needed to examine unmet palliative care needs in this population. J Am Geriatr Soc 67:2282-2288, 2019.

Relationship between diet/exercise and pharmacotherapy to enhance the GLP-1 levels in type 2 diabetes

The rapid rise in the prevalence of type 2 diabetes mellitus (T2DM) poses a huge healthcare burden across the world. Although there are several antihyperglycaemic agents (AHAs) available including addition of new drug classes to the treatment algorithm, more than 50% of patients with T2DM do not achieve glycaemic targets, suggesting an urgent need for treatment strategies focusing on prevention and progression of T2DM and its long-term complications. Lifestyle changes including implementation of healthy diet and physical activity are cornerstones for the management of T2DM. The positive effects of diet and exercise on incretin hormones such as glucagon-like peptide-1 (GLP-1) have been reported. We hypothesize an IDEP concept (Interaction between Diet/Exercise and Pharmacotherapy) aimed at modifying the diet and lifestyle, along with pharmacotherapy to enhance the GLP-1 levels, would result in good glycaemic control in patients with T2DM. Consuming protein-rich food, avoiding saturated fatty acids and making small changes in eating habits such as eating slowly with longer mastication time can have a positive impact on the GLP-1 secretion and insulin levels. Further the type of physical activity (aerobic/resistance training), intensity of exercise, duration, time and frequency of exercise have shown to improve GLP-1 levels. Apart from AHAs, a few antihypertensive drugs and lipid-lowering drugs have also shown to increase endogenous GLP-1 levels, however, due to quick degradation of GLP-1 by dipeptidyl peptidase-4 (DPP-4) enzyme, treatment with DPP-4 inhibitors would protect GLP-1 from degradation and prolong its activity. Thus, IDEP concept can be a promising treatment strategy, which positively influences the GLP-1 levels and provide additive benefits in terms of improving metabolic parameters in patients with T2DM and slowing the progression of T2DM and its associated complications.

Evidence-Based Medicine and the American Thoracic Society Clinical Practice Guidelines

This study assesses whether American Thoracic Society clinical practice guidelines are substantiated by high-quality evidence and can be used to promote evidence-based medicine.

Diabetes: Setting and achieving glycemic goals

Implementing lifestyle changes can be a substantial challenge for patients with diabetes. This article offers nursing strategies to help patients set and meet glycemic goals and manage their own therapy.

Impact of health education on knowledge, attitude, practices and glycemic control in type 2 diabetes mellitus

BACKGROUND

Effective health education consequently improves knowledge, attitude, and practices (KAP) leading to better glycemic control and is widely accepted as an integral part of comprehensive diabetes care for affected individuals and their families in primary care settings.

AIMS

To assess the impact of health education on knowledge, attitude, practices, and glycemic control in type 2 diabetes mellitus patients.

SETTINGS AND DESIGN

This case control study was conducted in the department of Medicine of a tertiary care teaching hospital.

METHODS

The study was conducted on 100 diabetic subjects aged more than 40 years comprising of 50 cases and 50 controls. Cases were given education on their disease, drugs, dietary, and lifestyle modifications along with patient education leaflet at baseline and at first follow-up, while controls received neither of these. Subjects were assessed for KAP by administering KAP questionnaire and for glycemic control by measuring glycated hemoglobin (HbA1C) at baseline and at the end of the study.

RESULTS

In this study, end mean knowledge, attitude, practice, and KAP SUM scores of cases (10.28 ± 1.78, 3.46 ± 0.93, 3.14 ± 0.86, and 16.82 ± 3.40, respectively) showed significant increase from the baseline (3.86 ± 0.93, 1.00 ± 0.83, 0.40 ± 0.64, and 5.26 ± 2.10, respectively) compared to controls, accompanied by significant reduction in HbA1C of cases at the end of the study compared to the controls.

CONCLUSIONS

Effective health education improves knowledge, attitude, and practices, particularly with regard to lifestyle modifications and dietary management, culminating into better glycemic control that can slow down the progression of diabetes and prevent downstream complications.

Glycaemic control and mortality in older people with type 2 diabetes: The Fremantle Diabetes Study Phase II

AIM

To investigate whether tight glycaemic control achieved with metformin, insulin or sulphonylurea-based pharmacotherapy increases all-cause mortality in older people with type 2 diabetes.

MATERIALS AND METHODS

We conducted a prospective cohort study of individuals with known diabetes recruited between 2008 and 2011 and followed until 2016. The impact of baseline glycated haemoglobin (HbA1c) on mortality hazards was investigated in participants aged ≥75 years. Proportional hazards models for time to death were constructed from the baseline clinical assessment, then the variables of interest (HbA1c, treatment category and their interactions) were entered.

RESULTS

There were 367 participants (mean age 80.1 ± 3.9 years, median [interquartile range] HbA1c 50 [45-56] mmol/mol or 6.7 [6.3-7.3]%) who were followed for a median (interquartile range) 6.7 (4.5-7.7) years, during which 40.9% of the participants died. At baseline, 60.4% were on metformin-based treatment, 35.3% on sulphonylurea-based treatment and 23.2% on treatment including insulin. Baseline HbA1c was significantly associated with mortality in a model that included interactions between HbA1c and the three treatment-based groups compared with non-pharmacological treatment. The metformin treatment group had higher mortality when HbA1c levels were <48 mmol/mol (<6.5%) and the sulphonylurea and insulin treatment groups had higher mortality when HbA1c levels were <52 mmol/mol (<7.0%), with hazard ratios of 2.63 (95% confidence interval [CI] 1.39-4.97), 2.49 (95% CI 1.14-5.44) and 2.22 (95% CI 1.12-4.43), respectively.

CONCLUSIONS

Tight glycaemic control may be hazardous in older people with type 2 diabetes when achieved with pharmacotherapy with metformin, and especially with insulin or sulphonylureas. These data confirm that overtreatment is likely to be an important clinical problem in this vulnerable population.

Hypoglycemia Among Patients with Type 2 Diabetes: Epidemiology, Risk Factors, and Prevention Strategies

PURPOSE OF REVIEW

Hypoglycemia is the most common and often treatment-limiting serious adverse effect of diabetes therapy. Despite being potentially preventable, hypoglycemia in type 2 diabetes incurs substantial personal and societal burden. We review the epidemiology of hypoglycemia in type 2 diabetes, discuss key risk factors, and introduce potential prevention strategies.

RECENT FINDINGS

Reported rates of hypoglycemia in type 2 diabetes vary widely as there is marked heterogeneity in how hypoglycemia is defined, measured, and reported. In randomized controlled trials, rates of severe hypoglycemia ranged from 0.7 to 12 per 100 person-years. In observational studies, hospitalizations or emergency department visits for hypoglycemia were experienced by 0.2 (patients treated without insulin or sulfonylurea) to 2.0 (insulin or sulfonylurea users) per 100 person-years. Patient-reported hypoglycemia is much more common. Over the course of 6 months, 1-4% non-insulin users reported need for medical attention for hypoglycemia; 1-17%, need for any assistance; and 46-58%, any hypoglycemia symptoms. Similarly, over a 12-month period, 4-17% of insulin-treated patients reported needing assistance and 37-64% experienced any hypoglycemic symptoms. Hypoglycemia is most common among older patients with multiple or advanced comorbidities, patients with long diabetes duration, or patients with a prior history of hypoglycemia. Insulin and sulfonylurea use, food insecurity, and fasting also increase hypoglycemia risk. Clinical decision support tools may help identify at-risk patients. Prospective trials of efforts to reduce hypoglycemia risk are needed, and there is emerging evidence supporting multidisciplinary interventions including treatment de-intensification, use of diabetes technologies, diabetes self-management, and social support. Hypoglycemia among patients with type 2 diabetes is common. Patient-centered multidisciplinary care may help proactively identify at-risk patients and address the multiplicity of factors contributing to hypoglycemia occurrence.

Deintensification of hypoglycaemic medications-use of a systematic review approach to highlight safety concerns in older people with type 2 diabetes

IMPORTANCE

Intensive treatment of older people with diabetes is common placing them at increased risk of adverse events such as hypoglycaemia and hospitalisation for drug errors. Little is known about when, how or for whom to deintensify hypoglycaemic medications.

OBJECTIVE

To explore the characteristics of patients for whom deintensification is appropriate and to determine the outcome of deintensification.

EVIDENCE REVIEW

Medline, Google scholar and EmBase search from 1997 to present was performed using keywords relating to diabetes mellitus, polypharmacy, hypoglycaemia, hospitalisation, deintensification, deprescribing and reduction, simplification or withdrawal of hypoglycaemic medications. Only English language articles were selected. Articles were reviewed for relevance by abstract. A manual review of citations in retrieved articles was performed in addition to the electronic literature search.

FINDINGS

Those who are over treated appear to be of older age group, frail with weight loss and have multiple medical morbidities especially renal impairment and dementia. Simplification, reduction or even complete withdrawal of hypoglycaemic medications in these patients appears to be feasible without deterioration of glycaemic control.

CONCLUSIONS

Over treatment is common in frail older people with multiple comorbidities and deintensification appears safe in this group of patients. Current recommendations emphasise preventing underuse rather than overuse of medications, and therefore, a change in guidelines advice may be warranted.

Control of glycemia and blood pressure in British adults with diabetes mellitus and subsequent therapy choices: a comparison across health states

Background

To examine the intensity of glycemic and blood pressure control in British adults with diabetes mellitus and whether control levels or treatment deintensification rates differ across health states.

Methods

Retrospective cohort study using primary care electronic medical records (the United Kingdom Health Improvement Network Database) for adults with diabetes diagnosed at least 6 months before the index HbA1C and systolic blood pressure (SBP) measurements (to give their primary care physicians time to achieve treatment goals). We used prescribing records for 6 months pre/post the index measurements to determine who had therapy subsequently deintensified (based on “glycemic therapy score” and “antihypertensive therapy score” derived from number and dosage of medications).

Results

Of 292,170 individuals with diabetes, HbA1C < 6% or SBP < 120 mmHg after at least 6 months of management was less common in otherwise fit patients (15.0 and 12.7%) than in those who were mildly frail (16.6 and 13.2%) or moderately–severely frail (20.2 and 17.0%, both p < 0.0001). In the next 6 months, only 44.7% of those with HbA1C < 6% had glycemic therapy reduced (44.4% of fit, 47.1% of mildly frail, and 41.5% of moderate-severely frail patients) and 39.8% of those with SBP < 120 had their antihypertensives decreased (39.3% of fit, 43.0% of mildly frail, and 46.7% of moderate-severely frail patients). On the other hand, more individuals exhibited higher than recommended levels for HbA1C or SBP after the first 6 months of therapy (37.3, 33.4, and 31.3% of fit, mildly frail, and moderately–severely frail patients had HbA1C > 7.5% and 46.6, 51.4, and 48.5% had SBP > 140 mmHg). The proportions of patients with HbA1C or SBP out of recommended treatment ranges changed little 6 months later despite frequent (median 14 per year) primary care visits.

Conclusions

Glycemic and hypertensive control exhibited statistically significant but small magnitude differences across frailty states. Medication deintensification was uncommon, even in frail patients below SBP and HbA1C targets. SBP levels were more likely to be outside recommended treatment ranges than glycemic levels.

Trial registration As this study is a retrospective secondary analysis of electronic medical record data and not a health care intervention trial it was not registered

Electronic supplementary material

The online version of this article (10.1186/s12933-018-0673-4) contains supplementary material, which is available to authorized users.

Treatment Deintensification Is Uncommon in Adults With Type 2 Diabetes Mellitus: A Retrospective Cohort Study

BACKGROUND

Whether treatment deintensification in Americans with diabetes mellitus varies by glycemic control, health status, and calendar year (before/after February 2008 when safety concerns about intensive glucose control were reported in the ACCORD trial [Action to Control Cardiovascular Risk in Diabetes]) is unclear.

METHODS AND RESULTS

We defined deintensification as discontinuation or dosage decrease of at least 1 glycemic medication without addition of, or uptitration of, another agent in the 120 days after the index glycosylated hemoglobin (HbA1C) measurement. Of 99 694 individuals (mean age 54 years) in this retrospective cohort study being actively treated for new diabetes mellitus (50% 1 drug, 33% 2 drugs, and 17% ≥3 drugs), 12 921 (13.0%) had HbA1C <6% after 1 year, 19 670 (19.7%) had HbA1C 6.0% to 6.4%, 35 012 (35.1%) had HbA1C 6.5% to 7.5%, and 32 091 (32.2%) had HbA1C >7.5%. Glycemic therapy was deintensified in 18.3% of patients (21.2% of frail patients, 19.4% of those with multiple comorbidities, and 17.7% of otherwise healthy patients) with no gradient across glycemia levels (20.6% of those with HbA1C<6%, 17.3% of those with HbA1C 6.0%-6.4%, 17.7% of those with HbA1C 6.5%-7.5%, and 18.6% of those with HbA1C>7.5%). Similar proportions were seen even after exclusion of 26 985 patients being treated with metformin monotherapy: 23.3%, 20.4%, 20.3%, and 20% across the HbA1C strata. Therapy was deintensified in 22.5% of patients with index HbA1C <6.0% before February 2008 compared with 19.5% after (P<0.001).

CONCLUSIONS

Among frail patients or those with multiple comorbidities, over three quarters with low HbA1C did not have their glycemic therapy deintensified, even after safety concerns were raised in the ACCORD trial.

Minimally Disruptive Medicine for Patients with Diabetes

PURPOSE OF REVIEW

Patients with diabetes must deal with the burden of symptoms and complications (burden of illness). Simultaneously, diabetes care demands practical and emotional work from patients and their families, work to access and use healthcare and to enact self-care (burden of treatment). Patient work must compete with the demands of family, job, and community life. Overwhelmed patients may not have the capacity to access care or enact self-care and will thus experience suboptimal diabetes outcomes.

RECENT FINDINGS

Minimally disruptive medicine (MDM) is a patient-centered approach to healthcare that prioritizes patients' goals for life and health while minimizing the healthcare disruption on patients' lives. In patients with diabetes, particularly in those with complex lives and multimorbidity, MDM coordinates healthcare and community responses to improve outcomes, reduce treatment burden, and enable patients to pursue their life's hopes and dreams.