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Kastrati L, Raeisi-Dehkordi H, Llanaj E, Quezada-Pinedo HG, Khatami F, Ahanchi NS, Llane A, Meçani R, Muka T, Ioannidis JPA. Agreement Between Mega-Trials and Smaller Trials: A Systematic Review and Meta-Research Analysis. JAMA Netw Open 2024; 7:e2432296. [PMID: 39240561 PMCID: PMC11380108 DOI: 10.1001/jamanetworkopen.2024.32296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/07/2024] Open
Abstract
Importance Mega-trials can provide large-scale evidence on important questions. Objective To explore how the results of mega-trials compare with the meta-analysis results of trials with smaller sample sizes. Data Sources ClinicalTrials.gov was searched for mega-trials until January 2023. PubMed was searched until June 2023 for meta-analyses incorporating the results of the eligible mega-trials. Study Selection Mega-trials were eligible if they were noncluster nonvaccine randomized clinical trials, had a sample size over 10 000, and had a peer-reviewed meta-analysis publication presenting results for the primary outcome of the mega-trials and/or all-cause mortality. Data Extraction and Synthesis For each selected meta-analysis, we extracted results of smaller trials and mega-trials included in the summary effect estimate and combined them separately using random effects. These estimates were used to calculate the ratio of odds ratios (ROR) between mega-trials and smaller trials in each meta-analysis. Next, the RORs were combined using random effects. Risk of bias was extracted for each trial included in our analyses (or when not available, assessed only for mega-trials). Data analysis was conducted from January to June 2024. Main Outcomes and Measures The main outcomes were the summary ROR for the primary outcome and all-cause mortality between mega-trials and smaller trials. Sensitivity analyses were performed with respect to the year of publication, masking, weight, type of intervention, and specialty. Results Of 120 mega-trials identified, 41 showed a significant result for the primary outcome and 22 showed a significant result for all-cause mortality. In 35 comparisons of primary outcomes (including 85 point estimates from 69 unique mega-trials and 272 point estimates from smaller trials) and 26 comparisons of all-cause mortality (including 70 point estimates from 65 unique mega-trials and 267 point estimates from smaller trials), no difference existed between the outcomes of the mega-trials and smaller trials for primary outcome (ROR, 1.00; 95% CI, 0.97-1.04) nor for all-cause mortality (ROR, 1.00; 95% CI, 0.97-1.04). For the primary outcomes, smaller trials published before the mega-trials had more favorable results than the mega-trials (ROR, 1.05; 95% CI, 1.01-1.10) and subsequent smaller trials published after the mega-trials (ROR, 1.10; 95% CI, 1.04-1.18). Conclusions and Relevance In this meta-research analysis, meta-analyses of smaller studies showed overall comparable results with mega-trials, but smaller trials published before the mega-trials gave more favorable results than mega-trials. These findings suggest that mega-trials need to be performed more often given the relative low number of mega-trials found, their low significant rates, and the fact that smaller trials published prior to mega-trial report more beneficial results than mega-trials and subsequent smaller trials.
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Affiliation(s)
- Lum Kastrati
- Meta-Research Innovation Center at Stanford (METRICS), Stanford University, Stanford, California
- Institute of Social and Preventive Medicine (ISPM), University of Bern, Bern, Switzerland
- Graduate School for Health Sciences, University of Bern, Bern, Switzerland
- Department of Diabetes, Endocrinology, Nutritional Medicine and Metabolism, Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - Hamidreza Raeisi-Dehkordi
- Department of Global Public Health and Bioethics, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Erand Llanaj
- Epistudia, Bern, Switzerland
- Department of Molecular Epidemiology, German Institute of Human Nutrition Potsdam-Rehbrücke, Nuthetal, Germany
- German Centre for Diabetes Research (DZD), München-Neuherberg, Germany
| | - Hugo G Quezada-Pinedo
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
| | - Farnaz Khatami
- Institute of Social and Preventive Medicine (ISPM), University of Bern, Bern, Switzerland
- Graduate School for Health Sciences, University of Bern, Bern, Switzerland
- Community Medicine Department, Tehran University of Medical Sciences, Tehran, Iran
| | - Noushin Sadat Ahanchi
- Institute of Social and Preventive Medicine (ISPM), University of Bern, Bern, Switzerland
- Graduate School for Health Sciences, University of Bern, Bern, Switzerland
- Department of Internal Medicine, Lausanne University Hospital, University of Lausanne, Lausanne, Switzerland
| | | | - Renald Meçani
- Epistudia, Bern, Switzerland
- Division of Endocrinology and Diabetology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Taulant Muka
- Meta-Research Innovation Center at Stanford (METRICS), Stanford University, Stanford, California
- Epistudia, Bern, Switzerland
| | - John P A Ioannidis
- Meta-Research Innovation Center at Stanford (METRICS), Stanford University, Stanford, California
- Stanford Prevention Research Center, Department of Medicine, Stanford University School of Medicine, Stanford, California
- Department of Epidemiology and Population Health, Stanford University School of Medicine, Stanford, California
- Department of Biomedical Data Science, Stanford University School of Medicine, Stanford, California
- Department of Statistics, Stanford University School of Humanities and Sciences, Stanford, California
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da Costa GG, Neves K, Amaral O. Estimating the replicability of highly cited clinical research (2004-2018). PLoS One 2024; 19:e0307145. [PMID: 39110675 PMCID: PMC11305584 DOI: 10.1371/journal.pone.0307145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Accepted: 07/01/2024] [Indexed: 08/10/2024] Open
Abstract
INTRODUCTION Previous studies about the replicability of clinical research based on the published literature have suggested that highly cited articles are often contradicted or found to have inflated effects. Nevertheless, there are no recent updates of such efforts, and this situation may have changed over time. METHODS We searched the Web of Science database for articles studying medical interventions with more than 2000 citations, published between 2004 and 2018 in high-impact medical journals. We then searched for replications of these studies in PubMed using the PICO (Population, Intervention, Comparator and Outcome) framework. Replication success was evaluated by the presence of a statistically significant effect in the same direction and by overlap of the replication's effect size confidence interval (CIs) with that of the original study. Evidence of effect size inflation and potential predictors of replicability were also analyzed. RESULTS A total of 89 eligible studies, of which 24 had valid replications (17 meta-analyses and 7 primary studies) were found. Of these, 21 (88%) had effect sizes with overlapping CIs. Of 15 highly cited studies with a statistically significant difference in the primary outcome, 13 (87%) had a significant effect in the replication as well. When both criteria were considered together, the replicability rate in our sample was of 20 out of 24 (83%). There was no evidence of systematic inflation in these highly cited studies, with a mean effect size ratio of 1.03 [95% CI (0.88, 1.21)] between initial and subsequent effects. Due to the small number of contradicted results, our analysis had low statistical power to detect predictors of replicability. CONCLUSION Although most studies did not have eligible replications, the replicability rate of highly cited clinical studies in our sample was higher than in previous estimates, with little evidence of systematic effect size inflation. This estimate is based on a very select sample of studies and may not be generalizable to clinical research in general.
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Affiliation(s)
- Gabriel Gonçalves da Costa
- Institute of Medical Biochemistry Leopoldo de Meis, Federal University of Rio de Janeiro, Rio de Janeiro, Rio de Janeiro, Brazil
| | - Kleber Neves
- Institute of Medical Biochemistry Leopoldo de Meis, Federal University of Rio de Janeiro, Rio de Janeiro, Rio de Janeiro, Brazil
| | - Olavo Amaral
- Institute of Medical Biochemistry Leopoldo de Meis, Federal University of Rio de Janeiro, Rio de Janeiro, Rio de Janeiro, Brazil
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Russo GT, Giandalia A, Ceriello A, Di Bartolo P, Di Cianni G, Fioretto P, Giorda CB, Manicardi V, Pontremoli R, Viazzi F, Lucisano G, Nicolucci A, De Cosmo S. A prediction model to assess the risk of egfr loss in patients with type 2 diabetes and preserved kidney function: The amd annals initiative. Diabetes Res Clin Pract 2022; 192:110092. [PMID: 36167264 DOI: 10.1016/j.diabres.2022.110092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Revised: 09/05/2022] [Accepted: 09/19/2022] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To develop and validate a model for predicting 5-year eGFR-loss in type 2 diabetes mellitus (T2DM) patients with preserved renal function at baseline. RESEARCH DESIGN AND METHODS A cohort of 504.532 T2DM outpatients participating to the Medical Associations of Diabetologists (AMD) Annals Initiative was splitted into the Learning and Validation cohorts, in which the predictive model was respectively developed and validated. A multivariate Cox proportional hazard regression model including all baseline characteristics was performed to identify predictors of eGFR-loss. A weight derived from regression coefficients was assigned to each variable and the overall sum of weights determined the 0 to 8-risk score. RESULTS A set of demographic, clinical and laboratory parameters entered the final model. The eGFR-loss score showed a good performance in the Validation cohort. Increasing score values progressively identified a higher risk of GFR loss: a score ≥ 8 was associated with a HR of 13.48 (12.96-14.01) in the Learning and a HR of 13.45 (12.93-13.99) in the Validation cohort. The 5 years-probability of developing the study outcome was 55.9% higher in subjects with a score ≥ 8. CONCLUSIONS In the large AMD Annals Initiative cohort, we developed and validated an eGFR-loss prediction model to identify T2DM patients at risk of developing clinically meaningful renal complications within a 5-years time frame.
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Affiliation(s)
- G T Russo
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy.
| | - A Giandalia
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy.
| | - A Ceriello
- Department of Cardiovascular and Metabolic Diseases, IRCCS Gruppo Multimedica, MI, Italy.
| | | | - G Di Cianni
- Diabetes and Metabolic Diseases Unit, Health Local Unit North-West Tuscany, Livorno, Italy.
| | - P Fioretto
- Department of Medicine, University of Padua, Unit of Medical Clinic 3, Hospital of Padua, Padua, Italy.
| | - C B Giorda
- Diabetes and Metabolism Unit ASL Turin 5 Chieri (TO), Italy.
| | - V Manicardi
- Diabetes Consultant, Salus Hospital, Reggio Emilia, Italy.
| | - R Pontremoli
- Università degli Studi and IRCCS Ospedale Policlinico San Martino, Genova, Italy.
| | - F Viazzi
- Università degli Studi and IRCCS Ospedale Policlinico San Martino, Genova, Italy.
| | - G Lucisano
- Center for Outcomes Research and Clinical Epidemiology, CORESEARCH, Pescara, Italy.
| | - A Nicolucci
- Center for Outcomes Research and Clinical Epidemiology, CORESEARCH, Pescara, Italy.
| | - S De Cosmo
- Department of Medical Sciences, Scientific Institute "Casa Sollievo della Sofferenza", San Giovanni Rotondo (FG), Italy.
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Hoek AG, van Oort S, Elders PJM, Beulens JWJ. Causal Association of Cardiovascular Risk Factors and Lifestyle Behaviors With Peripheral Artery Disease: A Mendelian Randomization Approach. J Am Heart Assoc 2022; 11:e025644. [PMID: 35929454 PMCID: PMC9496309 DOI: 10.1161/jaha.122.025644] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Background We investigated the causal associations between the genetic liability to cardiovascular and lifestyle risk factors and peripheral artery disease (PAD), using a Mendelian randomization approach. Methods and Results We performed a 2‐sample inverse‐variance weighted Mendelian randomization analysis, multiple sensitivity analyses to assess pleiotropy and multivariate Mendelian randomization analyses to assess mediating/confounding factors. European‐ancestry genomic summary data (P<5×10−8) for type 2 diabetes, lipid‐fractions, smoking, alcohol and coffee consumption, physical activity, sleep, and education level were selected. Genetic associations with PAD were extracted from the Million‐Veteran‐Program genome‐wide association studies (cases=31 307, controls=211 753, 72% European‐ancestry) and the GoLEAD‐SUMMIT genome‐wide association studies (11 independent genome‐wide association studies, European‐ancestry, cases=12 086, controls=449 548). Associations were categorized as robust (Bonferroni‐significant (P<0.00294), consistent over PAD‐cohorts/sensitivity analyses), suggestive (P value: 0.00294–0.05, associations in 1 PAD‐cohort/inconsistent sensitivity analyses) or not present. Robust evidence for genetic liability to type 2 diabetes, smoking, insomnia, and inverse associations for higher education level with PAD were found. Suggestive evidence for the genetic liability to higher low‐density lipoprotein cholesterol, triglyceride‐levels, alcohol consumption, and inverse associations for high‐density lipoprotein cholesterol, and increased sleep duration were found. No associations were found for physical activity and coffee consumption. However, effects fully attenuated for low‐density lipoprotein cholesterol and triglycerides after correcting for apoB, and for insomnia after correcting for body mass index and lipid‐fractions. Nonsignificant attenuation by potential mediators was observed for education level and type 2 diabetes. Conclusions Detrimental effects of smoking and type 2 diabetes, but not of low‐density lipoprotein cholesterol and triglycerides, on PAD were confirmed. Lower education level and insomnia were identified as novel risk factors for PAD; however, complete mediation for insomnia and incomplete mediation for education level by downstream risk factors was observed.
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Affiliation(s)
- Anna G Hoek
- Amsterdam UMC location Vrije Universiteit Amsterdam Epidemiology and Data Science Amsterdam The Netherlands.,Amsterdam Cardiovascular Sciences Amsterdam The Netherlands
| | - Sabine van Oort
- Amsterdam UMC location Vrije Universiteit Amsterdam Epidemiology and Data Science Amsterdam The Netherlands.,Amsterdam UMC location Vrije Universiteit Amsterdam General Practice Amsterdam The Netherlands
| | - Petra J M Elders
- Amsterdam UMC location Vrije Universiteit Amsterdam General Practice Amsterdam The Netherlands.,Amsterdam Public Health, Methodology Amsterdam The Netherlands
| | - Joline W J Beulens
- Amsterdam UMC location Vrije Universiteit Amsterdam Epidemiology and Data Science Amsterdam The Netherlands.,Amsterdam Cardiovascular Sciences Amsterdam The Netherlands.,Amsterdam Public Health, Methodology Amsterdam The Netherlands.,University Medical Centre Utrecht Utrecht University, Julius Center for Health Sciences and Primary Care Utrecht The Netherlands
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Mannucci E, Candido R, Monache LD, Gallo M, Giaccari A, Masini ML, Mazzone A, Medea G, Pintaudi B, Targher G, Trento M, Turchetti G, Lorenzoni V, Monami M. Italian guidelines for the treatment of type 2 diabetes. Acta Diabetol 2022; 59:579-622. [PMID: 35288805 PMCID: PMC8995274 DOI: 10.1007/s00592-022-01857-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Accepted: 01/20/2022] [Indexed: 12/20/2022]
Affiliation(s)
- Edoardo Mannucci
- Diabetology, Azienda Ospedaliero-Universitaria Careggi, Careggi Hospital, University of Florence, Largo Brambilla, 50134, Florence, Italy.
| | | | | | - Marco Gallo
- Endocrinology and Metabolic Diseases, Hospital of Alessandria, Alessandria, Italy
| | - Andrea Giaccari
- Endocrinology and Metabolic Diseases, Gemelli Hospital, Catholic University of Rome, Rome, Italy
| | | | - Angela Mazzone
- Retired, Formerly Diabetology, San Martino Hospital, Genova, Italy
| | - Gerardo Medea
- Società Italiana Di Medicina Generale (SIMG), Firenze, Italy
| | | | - Giovanni Targher
- Endocrinology, Diabetology and Metabolic Diseases, University of Verona, Verona, Italy
| | - Marina Trento
- Laboratory of Clinical Pedagogy, University of Turin, Torino, Italy
| | | | | | - Matteo Monami
- Diabetology, Azienda Ospedaliero-Universitaria Careggi, Careggi Hospital, University of Florence, Largo Brambilla, 50134, Florence, Italy
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6
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Mannucci E, Candido R, Delle Monache L, Gallo M, Giaccari A, Masini ML, Mazzone A, Medea G, Pintaudi B, Targher G, Trento M, Turchetti G, Lorenzoni V, Monami M. Italian guidelines for the treatment of type 2 diabetes. Nutr Metab Cardiovasc Dis 2022; 32:770-814. [PMID: 35227550 DOI: 10.1016/j.numecd.2022.01.027] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Revised: 01/25/2022] [Accepted: 01/27/2022] [Indexed: 11/21/2022]
Affiliation(s)
| | | | | | - Marco Gallo
- Endocrinology and Metabolic Diseases, Hospital of Alessandria, Italy
| | - Andrea Giaccari
- Fondazione Policlinico Universitario A. Gemelli IRCCS and Università Cattolica del Sacro Cuore, Rome, Italy
| | | | - Angela Mazzone
- Formerly Diabetology, San Martino Hospital, Genova, Italy
| | | | | | - Giovanni Targher
- Endocrinology, Diabetology and Metabolic Diseases, University of Verona, Italy
| | - Marina Trento
- Laboratory of Clinical Pedagogy, University of Turin, Italy
| | | | | | - Matteo Monami
- Diabetology, Careggi Hospital, University of Florence, Italy
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7
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Rodríguez-Gutiérrez R, Millan-Alanis JM, Barrera FJ, McCoy RG. Value of Patient-Centered Glycemic Control in Patients with Type 2 Diabetes. Curr Diab Rep 2021; 21:63. [PMID: 34902079 PMCID: PMC8693335 DOI: 10.1007/s11892-021-01433-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/20/2021] [Indexed: 12/15/2022]
Abstract
PURPOSE OF REVIEW Present the value of a person-centered approach in diabetes management and review current evidence supporting its practice. RECENT FINDINGS Early evidence from glycemic control trials in diabetes resulted in most practice guidelines adopting a glucose-centric intensive approach for management of the disease, consistently relying on HbA1c as a marker of metabolic control and success. This paradigm has been recently dispelled by new evidence that shows that intensive glycemic control does not provide a significant benefit regarding patient-important microvascular and macrovascular hard outcomes when compared to moderate glycemic targets. The goals of diabetes therapy are to reduce the risks of acute and chronic complications and increase quality of life while incurring least burden of treatment and disruption to the patient's life. A person-centered approach to diabetes management is achieved through shared decision making, integration of evidence-based care and patient´s needs, values and preferences, and minimally disruptive approaches to diabetes care and at the same time offer practical guidance to clinicians and patients on achieving this type of care.
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Affiliation(s)
- René Rodríguez-Gutiérrez
- Plataforma INVEST Medicina UANL-KER Unit Mayo Clinic (KER Unit México), Universidad Autónoma de Nuevo León, Monterrey, Mexico.
- Endocrinology Division, Department of Internal Medicine, University Hospital "Dr. José E. González", Universidad Autónoma de Nuevo León, Francisco I. Madero y Av. Gonzalitos s/n, Mitras Centro, Monterrey, 64460, México.
- Knowledge and Evaluation Research Unit in Endocrinology, Mayo Clinic, Rochester, MN, USA.
| | - Juan Manuel Millan-Alanis
- Plataforma INVEST Medicina UANL-KER Unit Mayo Clinic (KER Unit México), Universidad Autónoma de Nuevo León, Monterrey, Mexico
| | - Francisco J Barrera
- Plataforma INVEST Medicina UANL-KER Unit Mayo Clinic (KER Unit México), Universidad Autónoma de Nuevo León, Monterrey, Mexico
| | - Rozalina G McCoy
- Knowledge and Evaluation Research Unit in Endocrinology, Mayo Clinic, Rochester, MN, USA
- Division of Community Internal Medicine, Department of Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
- Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, 200 First Street SW, Rochester, MN, 55905, USA
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A valid self-help tool to measure the role of spousal support in the care of persons with diabetes mellitus. Int J Diabetes Dev Ctries 2021. [DOI: 10.1007/s13410-021-01001-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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9
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Slieker RC, van der Heijden AAWA, Siddiqui MK, Langendoen-Gort M, Nijpels G, Herings R, Feenstra TL, Moons KGM, Bell S, Elders PJ, 't Hart LM, Beulens JWJ. Performance of prediction models for nephropathy in people with type 2 diabetes: systematic review and external validation study. BMJ 2021; 374:n2134. [PMID: 34583929 PMCID: PMC8477272 DOI: 10.1136/bmj.n2134] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVES To identify and assess the quality and accuracy of prognostic models for nephropathy and to validate these models in external cohorts of people with type 2 diabetes. DESIGN Systematic review and external validation. DATA SOURCES PubMed and Embase. ELIGIBILITY CRITERIA Studies describing the development of a model to predict the risk of nephropathy, applicable to people with type 2 diabetes. METHODS Screening, data extraction, and risk of bias assessment were done in duplicate. Eligible models were externally validated in the Hoorn Diabetes Care System (DCS) cohort (n=11 450) for the same outcomes for which they were developed. Risks of nephropathy were calculated and compared with observed risk over 2, 5, and 10 years of follow-up. Model performance was assessed based on intercept adjusted calibration and discrimination (Harrell's C statistic). RESULTS 41 studies included in the systematic review reported 64 models, 46 of which were developed in a population with diabetes and 18 in the general population including diabetes as a predictor. The predicted outcomes included albuminuria, diabetic kidney disease, chronic kidney disease (general population), and end stage renal disease. The reported apparent discrimination of the 46 models varied considerably across the different predicted outcomes, from 0.60 (95% confidence interval 0.56 to 0.64) to 0.99 (not available) for the models developed in a diabetes population and from 0.59 (not available) to 0.96 (0.95 to 0.97) for the models developed in the general population. Calibration was reported in 31 of the 41 studies, and the models were generally well calibrated. 21 of the 64 retrieved models were externally validated in the Hoorn DCS cohort for predicting risk of albuminuria, diabetic kidney disease, and chronic kidney disease, with considerable variation in performance across prediction horizons and models. For all three outcomes, however, at least two models had C statistics >0.8, indicating excellent discrimination. In a secondary external validation in GoDARTS (Genetics of Diabetes Audit and Research in Tayside Scotland), models developed for diabetic kidney disease outperformed those for chronic kidney disease. Models were generally well calibrated across all three prediction horizons. CONCLUSIONS This study identified multiple prediction models to predict albuminuria, diabetic kidney disease, chronic kidney disease, and end stage renal disease. In the external validation, discrimination and calibration for albuminuria, diabetic kidney disease, and chronic kidney disease varied considerably across prediction horizons and models. For each outcome, however, specific models showed good discrimination and calibration across the three prediction horizons, with clinically accessible predictors, making them applicable in a clinical setting. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42020192831.
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Affiliation(s)
- Roderick C Slieker
- Department of Epidemiology and Data Science, Amsterdam Public Health Institute, Amsterdam Cardiovascular Sciences Institute, Amsterdam UMC, Location VUmc, 1081 HV, Amsterdam, Netherlands
- Department of Cell and Chemical Biology, Leiden University Medical Center, Leiden, Netherlands
| | - Amber A W A van der Heijden
- Department of General Practice, Amsterdam Public Health Institute, Amsterdam UMC, Location VUmc, Amsterdam, Netherlands
| | - Moneeza K Siddiqui
- Division of Population Health and Genomics, School of Medicine, University of Dundee, Dundee, UK
| | - Marlous Langendoen-Gort
- Department of General Practice, Amsterdam Public Health Institute, Amsterdam UMC, Location VUmc, Amsterdam, Netherlands
| | - Giel Nijpels
- Department of General Practice, Amsterdam Public Health Institute, Amsterdam UMC, Location VUmc, Amsterdam, Netherlands
| | - Ron Herings
- Department of Epidemiology and Data Science, Amsterdam Public Health Institute, Amsterdam Cardiovascular Sciences Institute, Amsterdam UMC, Location VUmc, 1081 HV, Amsterdam, Netherlands
- PHARMO Institute for Drug Outcomes Research, Utrecht, Netherlands
| | - Talitha L Feenstra
- Groningen Research Institute of Pharmacy, University of Groningen, Groningen, Netherlands
- Centre for Nutrition, Prevention and Health Services, Institute for Public Health and the Environment, Bilthoven, Netherlands
| | - Karel G M Moons
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
- Cochrane Netherlands, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
| | - Samira Bell
- Division of Population Health and Genomics, School of Medicine, University of Dundee, Dundee, UK
| | - Petra J Elders
- Department of General Practice, Amsterdam Public Health Institute, Amsterdam UMC, Location VUmc, Amsterdam, Netherlands
| | - Leen M 't Hart
- Department of Epidemiology and Data Science, Amsterdam Public Health Institute, Amsterdam Cardiovascular Sciences Institute, Amsterdam UMC, Location VUmc, 1081 HV, Amsterdam, Netherlands
- Department of Cell and Chemical Biology, Leiden University Medical Center, Leiden, Netherlands
- Molecular Epidemiology section, Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, Netherlands
| | - Joline W J Beulens
- Department of Epidemiology and Data Science, Amsterdam Public Health Institute, Amsterdam Cardiovascular Sciences Institute, Amsterdam UMC, Location VUmc, 1081 HV, Amsterdam, Netherlands
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
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Yang T, Fu P, Chen J, Fu X, Xu C, Liu X, Niu T. Increased risk of adverse cardiovascular events by strict glycemic control after percutaneous coronary intervention (HbA1c < 6.5% at 2 years) in type 2 diabetes mellitus combined with acute coronary syndrome: a 5-years follow-up study. Curr Med Res Opin 2021; 37:1517-1528. [PMID: 34166166 DOI: 10.1080/03007995.2021.1947219] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVE This study assessed the association between HbA1c level measured 2 years after percutaneous coronary intervention (PCI) and long-term clinical outcomes in type 2 diabetes mellitus combined with acute coronary syndrome (ACS) who underwent PCI. METHODS This prospective observational study analyzed 2877 ACS patients with type 2 diabetes mellitus whose baseline HbA1c ≥ 7.0% and underwent PCI. All patients were divided into 6 groups according to the HbA1c level at 2 years after PCI. The clinical outcome was major adverse cardiovascular events (MACEs), defined as all-cause death, all myocardial infarction, any revascularization, congestive heart failure, ischemic stroke. The median follow-up duration was 4.1 years. RESULTS All 2877 patients were divided into 6 groups: 2-year after PCI HbA1c < 6.0% (n = 219), 6.0-6.5% (n = 348), 6.5-7.0% (n = 882), 7.0-7.5% (n = 567), 7.5-8.0% (n = 441), ≥8.0% (n = 420). The 5-year incidence rate of MACEs in HbA1c <6.0% and 6.0-6.5% groups were similar to 7.5-8.0% and ≥8.0% groups, which were significantly higher than in 6.5-7.0% and 7.0-7.5% groups (p = .044). The cumulative incidence rate of MACEs significantly differed among the groups (p = .046). Multivariate Cox regression analysis revealed a U-shaped relationship between 2-year HbA1c level after PCI and risk of MACEs. 2-year HbA1c <6.5% after PCI was an independent risk factor for MACEs in type 2 diabetes mellitus combined with ACS who underwent PCI (p < .001). CONCLUSIONS The findings indicated an increased risk of MACEs by strict glycemic control after PCI (2-year HbA1c < 6.5% after PCI) in type 2 diabetes mellitus combined with ACS who underwent PCI.
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Affiliation(s)
- Tiangui Yang
- Shengjing Hospital of China Medical University, Shenyang, Liaoning, China
| | - Peng Fu
- Shengjing Hospital of China Medical University, Shenyang, Liaoning, China
| | - Jie Chen
- Shengjing Hospital of China Medical University, Shenyang, Liaoning, China
| | - Xi Fu
- Shengjing Hospital of China Medical University, Shenyang, Liaoning, China
| | - Changlu Xu
- Shengjing Hospital of China Medical University, Shenyang, Liaoning, China
| | - Xiaoxia Liu
- Shengjing Hospital of China Medical University, Shenyang, Liaoning, China
| | - Tiesheng Niu
- Shengjing Hospital of China Medical University, Shenyang, Liaoning, China
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11
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Emanuelsson F, Benn M. LDL-Cholesterol versus Glucose in Microvascular and Macrovascular Disease. Clin Chem 2021; 67:167-182. [PMID: 33221847 DOI: 10.1093/clinchem/hvaa242] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Accepted: 09/10/2020] [Indexed: 01/06/2023]
Abstract
BACKGROUND The causal relationships between increased concentrations of low density lipoprotein (LDL)-cholesterol and glucose and risk of ischemic heart disease are well established. The causal contributions of LDL-cholesterol and glucose to risk of peripheral micro- and macrovascular diseases are less studied, especially in prediabetic stages and in a general population setting. CONTENT This review summarizes the current evidence for a causal contribution of LDL-cholesterol and glucose to risk of a spectrum of peripheral micro- and macrovascular diseases and reviews possible underlying disease mechanisms, including differences between vascular compartments, and finally discusses the clinical implications of these findings, including strategies for prevention and treatment. SUMMARY Combined lines of evidence suggest that LDL-cholesterol has a causal effect on risk of peripheral arterial disease and chronic kidney disease, both of which represent manifestations of macrovascular disease due to atherosclerosis and accumulation of LDL particles in the arterial wall. In contrast, there is limited evidence for a causal effect on risk of microvascular disease. Glucose has a causal effect on risk of both micro- and macrovascular disease. However, most evidence is derived from studies of individuals with diabetes. Further studies in normoglycemic and prediabetic individuals are warranted. Overall, LDL-cholesterol-lowering reduces risk of macrovascular disease, while evidence for a reduction in risk of microvascular disease is inconsistent. Glucose-lowering has a beneficial effect on risk of microvascular diseases and on risk of chronic kidney disease and estimated glomerular filtration rate (eGFR) in some studies, while results on risk of peripheral arterial disease are conflicting.
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Affiliation(s)
- Frida Emanuelsson
- Department of Clinical Biochemistry, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark.,The Copenhagen General Population Study, Herlev and Gentofte Hospital, Copenhagen University Hospital, Copenhagen, Denmark.,The Copenhagen City Heart Study, Frederiksberg Hospital, Copenhagen University Hospital, Copenhagen, Denmark.,Faculty of Health and Medical Sciences, Institute of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Marianne Benn
- Department of Clinical Biochemistry, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark.,The Copenhagen General Population Study, Herlev and Gentofte Hospital, Copenhagen University Hospital, Copenhagen, Denmark.,The Copenhagen City Heart Study, Frederiksberg Hospital, Copenhagen University Hospital, Copenhagen, Denmark.,Faculty of Health and Medical Sciences, Institute of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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12
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Benn M, Emanuelsson F, Tybjærg-Hansen A, Nordestgaard BG. Impact of high glucose levels and glucose lowering on risk of ischaemic stroke: a Mendelian randomisation study and meta-analysis. Diabetologia 2021; 64:1492-1503. [PMID: 33765180 DOI: 10.1007/s00125-021-05436-0] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Accepted: 01/26/2021] [Indexed: 10/21/2022]
Abstract
AIMS/HYPOTHESIS It is unclear whether glucose per se has a causal impact on risk of stroke and whether glucose-lowering drugs reduce this risk. This is important for the choice of treatment for individuals at risk. We tested the hypotheses that high plasma glucose has a causal impact on increased risk of ischaemic stroke, and that glucose-lowering drugs reduce this risk. METHODS Using a Mendelian randomisation design, we examined 118,838 individuals from two Copenhagen cohorts, the Copenhagen General Population Study and the Copenhagen City Heart Study, and 440,328 individuals from the MEGASTROKE study. Effects of eight glucose-lowering drugs on risk of stroke were summarised by meta-analyses. RESULTS In genetic, causal analyses, a 1 mmol/l higher plasma glucose had a risk ratio of 1.48 (95% CI 1.04, 2.11) for ischaemic stroke in the Copenhagen studies. The corresponding risk ratio from the MEGASTROKE study combined with the Copenhagen studies was 1.74 (1.31, 2.18). In meta-analyses of glucose-lowering drugs, the risk ratio for stroke was 0.85 (0.77, 0.94) for glucagon-like peptide-1 receptor agonists and 0.82 (0.69, 0.98) for thiazolidinediones, while sulfonylureas, dipeptidyl peptidase-4 inhibitors, sodium-glucose cotransporter 2 inhibitors, α-glucosidase inhibitors, meglitinides and metformin individually lacked statistical evidence of an effect on stroke risk. CONCLUSIONS/INTERPRETATION Genetically high plasma glucose has a causal impact on increased risk of ischaemic stroke. Treatment with glucose-lowering glucagon-like peptide-1 receptor agonists and thiazolidinediones reduces this risk. These results may guide clinicians in the treatment of individuals at high risk of ischaemic stroke.
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Affiliation(s)
- Marianne Benn
- Department of Clinical Biochemistry, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark.
- The Copenhagen General Population Study, Herlev and Gentofte Hospital, Copenhagen University Hospital, Copenhagen, Denmark.
- Faculty of Health and Medical Sciences, Institute of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark.
| | - Frida Emanuelsson
- Department of Clinical Biochemistry, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- Faculty of Health and Medical Sciences, Institute of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Anne Tybjærg-Hansen
- Department of Clinical Biochemistry, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- The Copenhagen General Population Study, Herlev and Gentofte Hospital, Copenhagen University Hospital, Copenhagen, Denmark
- Faculty of Health and Medical Sciences, Institute of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- The Copenhagen City Heart Study, Frederiksberg Hospital, Copenhagen University Hospital, Copenhagen, Denmark
| | - Børge G Nordestgaard
- The Copenhagen General Population Study, Herlev and Gentofte Hospital, Copenhagen University Hospital, Copenhagen, Denmark
- Faculty of Health and Medical Sciences, Institute of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- The Copenhagen City Heart Study, Frederiksberg Hospital, Copenhagen University Hospital, Copenhagen, Denmark
- Department of Clinical Biochemistry, Herlev and Gentofte Hospital, Copenhagen University Hospital, Copenhagen, Denmark
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13
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Sinha B, Ghosal S. A Target HbA1c Between 7 and 7.7% Reduces Microvascular and Macrovascular Events in T2D Regardless of Duration of Diabetes: a Meta-Analysis of Randomized Controlled Trials. Diabetes Ther 2021; 12:1661-1676. [PMID: 33895981 PMCID: PMC8179883 DOI: 10.1007/s13300-021-01062-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Accepted: 04/13/2021] [Indexed: 10/29/2022] Open
Abstract
INTRODUCTION The target glycated haemoglobin (HbA1c) at which micro- and macrovascular benefits may be derived in type 2 diabetes (T2D) has never been clearly outlined. This meta-analysis was conducted on 15 randomized controlled trials to highlight the association of HbA1c range with outcomes. METHODS The association of different HbA1c cluster (intention-to-treat (ITT) and end-of-study [EOS]) ranges (≤ 6.5%, 6.6-7.0%, 7.1-7.7%) with micro- and macrovascular complications and also the combined effect of T2D duration (< 10 years or ≥ 10 years) and HbA1c levels was assessed. RESULTS An intensive glucose-lowering strategy resulted in a significant 17% (95% CI: 0.73-0.93, P < 0.01) reduction in retinopathy, 18% reduction in macroalbuminuria (95% CI 0.62-0.83, P < 0.01), 32% reduction in end-stage renal disease (ESRD) (95% CI 0.36-0.92, P = 0.02) and 13% reduction in non-fatal myocardial infarction (NFMI) (95% CI 0.78-0.96, P < 0.01). Based on HbA1c achieved at EOS, a significant 46% reduction in retinopathy, 52% reduction in macroalbuminuria, 36% reduction in (NFS) non-fatal stroke and a 22% reduction in all-cause mortality (ACM) were observed in the group with HbA1c in the 7.1-7.7% range. In the cohort, with diabetes duration ≥ 10 years, reduction of HbA1c to ≤ 7.0% and significant improvements in new-onset retinopathy (24%) and macroalbuminuria (30%) were offset by an increase in ACM (21%) and NFMI (17%). CONCLUSION Contrasting with most recommendations, this meta-analysis including recent studies suggests that the optimal HbA1c range for T2D is 7.1-7.7% regardless of diabetes duration.
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14
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Katsiki N, Kotsa K, Stoian AP, Mikhailidis DP. Hypoglycaemia and Cardiovascular Disease Risk in Patients with Diabetes. Curr Pharm Des 2021; 26:5637-5649. [PMID: 32912117 DOI: 10.2174/1381612826666200909142658] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Accepted: 08/09/2020] [Indexed: 12/12/2022]
Abstract
Hypoglycaemia represents an important side effect of insulin therapy and insulin secretagogues. It can occur in both type 1 and type 2 diabetes mellitus patients. Also, some associations between hypoglycaemia and cardiovascular (CV) risk have been reported. Several mechanisms may be involved, including the sympathoadrenal system, hypokalaemia, endothelial dysfunction, coagulation, platelets, inflammation, atherothrombosis and impaired autonomic cardiac reflexes. This narrative review discusses the associations of hypoglycaemia with CV diseases, including coronary heart disease (CHD), cardiac arrhythmias, stroke, carotid disease and peripheral artery disease (PAD), as well as with dementia. Severe hypoglycaemia has been related to CHD, CV and all-cause mortality. Furthermore, there is evidence supporting an association between hypoglycaemia and cardiac arrhythmias, potentially predisposing to sudden death. The data linking hypoglycaemia with stroke, carotid disease and PAD is limited. Several factors may affect the hypoglycaemia-CV relationships, such as the definition of hypoglycaemia, patient characteristics, co-morbidities (including chronic kidney disease) and antidiabetic drug therapy. However, the association between hypoglycaemia and dementia is bilateral. Both the disorders are more common in the elderly; thus, glycaemic goals should be carefully selected in older patients. Further research is needed to elucidate the impact of hypoglycaemia on CV disease.
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Affiliation(s)
- Niki Katsiki
- Division of Endocrinology and Metabolism, Diabetes Center, First Department of Internal Medicine, Medical School, Aristotle University of Thessaloniki, AHEPA University Hospital, Thessaloniki, Greece
| | - Kalliopi Kotsa
- Division of Endocrinology and Metabolism, Diabetes Center, First Department of Internal Medicine, Medical School, Aristotle University of Thessaloniki, AHEPA University Hospital, Thessaloniki, Greece
| | - Anca P Stoian
- Diabetes, Nutrition and Metabolic diseases Department, "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania
| | - Dimitri P Mikhailidis
- Department of Clinical Biochemistry, Royal Free Hospital Campus, University College London Medical School, University College London (UCL), London, United Kingdom
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15
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Araki E, Tanaka A, Inagaki N, Ito H, Ueki K, Murohara T, Imai K, Sata M, Sugiyama T, Ishii H, Yamane S, Kadowaki T, Komuro I, Node K. Diagnosis, prevention, and treatment of cardiovascular diseases in people with type 2 diabetes and prediabetes: a consensus statement jointly from the Japanese Circulation Society and the Japan Diabetes Society. Diabetol Int 2021; 12:1-51. [PMID: 33479578 PMCID: PMC7790968 DOI: 10.1007/s13340-020-00471-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Indexed: 01/08/2023]
Affiliation(s)
- Eiichi Araki
- Department of Metabolic Medicine, Faculty of Life Sciences, Kumamoto University, Kumamoto, Japan
| | - Atsushi Tanaka
- Department of Cardiovascular Medicine, Saga University, 5-1-1 Nabeshima, Saga, 849-8501 Japan
| | - Nobuya Inagaki
- Department of Diabetes, Endocrinology and Nutrition, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Hiroshi Ito
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Kohjiro Ueki
- Diabetes Research Center, Research Institute, National Center for Global Health and Medicine, Tokyo, Japan
| | - Toyoaki Murohara
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Kenjiro Imai
- Diabetes and Metabolism Information Center, Research Institute, National Center for Global Health and Medicine, Tokyo, Japan
| | - Masataka Sata
- Department of Cardiovascular Medicine, Tokushima University Graduate School, Tokushima, Japan
| | - Takehiro Sugiyama
- Diabetes and Metabolism Information Center, Research Institute, National Center for Global Health and Medicine, Tokyo, Japan
| | - Hideki Ishii
- Department of Cardiology, Fujita Health University Bantane Hospital, Nagoya, Japan
| | - Shunsuke Yamane
- Department of Diabetes, Endocrinology and Nutrition, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | | | - Issei Komuro
- Department of Cardiovascular Medicine, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Koichi Node
- Department of Cardiovascular Medicine, Saga University, 5-1-1 Nabeshima, Saga, 849-8501 Japan
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16
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Koskinas K, Melmer A, Steiner N, Gübeli A, Wilhelm M, Laimer M. [Diagnosis, Prevention and Treatment of Cardiovascular Disease in People with Diabetes and Prediabetes]. PRAXIS 2021; 110:37-47. [PMID: 33406932 DOI: 10.1024/1661-8157/a003589] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
Diagnosis, Prevention and Treatment of Cardiovascular Disease in People with Diabetes and Prediabetes Abstract. Diabetes is associated with an increased cardiovascular risk. In addition to optimizing glycemia, timely diagnosis and stringent control of cardiovascular risk factors is essential for individuals with diabetes. Therapeutic options include lifestyle-optimization, individualized drug therapy and targeted treatment of concomitant or secondary cardiovascular disease. Cardiovascular disease occurs more often in individuals with diabetes and includes heart failure, atrial fibrillation, coronary heart disease and sudden cardiac death. The correct choice of antidiabetic drugs and interventions can control cardiovascular risk factors, reduce cardiovascular risk and treat concomitant or secondary diseases in a targeted manner. This review is intended to provide guidance on diagnosis, treatment and choice of therapy for individuals with type 2 diabetes without and with concomitant or secondary cardiovascular disease.
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Affiliation(s)
- Konstantinos Koskinas
- Zentrum für Präventive Kardiologie, Universitätsklinik für Kardiologie, Interdisziplinäres Zentrum für Sport- & Bewegungsmedizin, Inselspital, Universitätsspital und Universität Bern
| | - Andreas Melmer
- Universitätsklinik für Diabetologie, Endokrinologie, klinische Ernährung und Metabolismus (UDEM), Inselspital, Universitätsspital und Universität Bern
| | - Nicole Steiner
- Universitätsklinik für Diabetologie, Endokrinologie, klinische Ernährung und Metabolismus (UDEM), Inselspital, Universitätsspital und Universität Bern
| | - Andreas Gübeli
- Universitätsklinik für Diabetologie, Endokrinologie, klinische Ernährung und Metabolismus (UDEM), Inselspital, Universitätsspital und Universität Bern
| | - Matthias Wilhelm
- Zentrum für Präventive Kardiologie, Universitätsklinik für Kardiologie, Interdisziplinäres Zentrum für Sport- & Bewegungsmedizin, Inselspital, Universitätsspital und Universität Bern
| | - Markus Laimer
- Universitätsklinik für Diabetologie, Endokrinologie, klinische Ernährung und Metabolismus (UDEM), Inselspital, Universitätsspital und Universität Bern
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17
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Araki E, Tanaka A, Inagaki N, Ito H, Ueki K, Murohara T, Imai K, Sata M, Sugiyama T, Ishii H, Yamane S, Kadowaki T, Komuro I, Node K. Diagnosis, Prevention, and Treatment of Cardiovascular Diseases in People With Type 2 Diabetes and Prediabetes - A Consensus Statement Jointly From the Japanese Circulation Society and the Japan Diabetes Society. Circ J 2020; 85:82-125. [PMID: 33250455 DOI: 10.1253/circj.cj-20-0865] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Affiliation(s)
- Eiichi Araki
- Department of Metabolic Medicine, Faculty of Life Sciences, Kumamoto University
| | | | - Nobuya Inagaki
- Department of Diabetes, Endocrinology and Nutrition, Kyoto University Graduate School of Medicine
| | - Hiroshi Ito
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences
| | - Kohjiro Ueki
- Diabetes Research Center, Research Institute, National Center for Global Health and Medicine
| | - Toyoaki Murohara
- Department of Cardiology, Nagoya University Graduate School of Medicine
| | - Kenjiro Imai
- Diabetes and Metabolism Information Center, Research Institute, National Center for Global Health and Medicine
| | - Masataka Sata
- Department of Cardiovascular Medicine, Tokushima University Graduate School
| | - Takehiro Sugiyama
- Diabetes and Metabolism Information Center, Research Institute, National Center for Global Health and Medicine
| | - Hideki Ishii
- Department of Cardiology, Fujita Health University Bantane Hospital
| | - Shunsuke Yamane
- Department of Diabetes, Endocrinology and Nutrition, Kyoto University Graduate School of Medicine
| | | | - Issei Komuro
- Department of Cardiovascular Medicine, Graduate School of Medicine, The University of Tokyo
| | - Koichi Node
- Department of Cardiovascular Medicine, Saga University
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Abstract
BACKGROUND Intensive insulin therapy (IIT) aims at achieving near-normal glycemic control and usually uses a basal-bolus (BB) schema to mimic physiologic insulin secretion. AREAS OF UNCERTAINTY The treatment burden of IIT should be outweighed by improved glycemic control and reduction of chronic complications, but reviews summarizing the effects of IIT in subjects with T1DM and T2DM in glycated hemoglobin, hypoglycemia, insulin doses, and weight are limited. DATA SOURCES We performed a PubMed search to identify relevant randomized control trials (RCTs) comparing IIT and conventional insulin treatment in T1DM and T2DM subjects and addressing glycated hemoglobin, hypoglycemia, insulin requirements, and weight. THERAPEUTIC ADVANCES We have identified 11 RCTs in T1DM subjects, published years ago and very heterogenous in design. Throughout the studies there was a consistent superiority of IIT in glycated hemoglobin reduction, a higher rate of severe hypoglycemia and more weight gain in the IIT group without a clear effect on insulin doses. We have identified 2 RCTs in T2DM subjects, only one of them using a definite BB schema in the IIT group. IIT induced more hypoglycemia and better HbA1c, but not more weight gain. CONCLUSIONS IIT is the best option for treatment of subjects with T1DM in HbA1c reduction with a cost in the rate of hypoglycemia and weight gain. In subjects with T2DM, IIT also yields improvement in HbA1c versus conventional treatment, also at the cost of more hypoglycemic episodes, but not of higher weight gain. RCT treatment arms did not only differ in the insulin schema, but also in treatment goals, therapeutic education, and frequency of clinical visits among other characteristics. However, most evidence was gained using a BB insulin schema in the intensive arm and it is likely that the insulin schema had a relevant contribution in the results.
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19
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Shao H, Yang S, Stoecker C, Fonseca V, Hong D, Shi L. Addressing Regional Differences in Diabetes Progression: Global Calibration for Diabetes Simulation Model. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2019; 22:1402-1409. [PMID: 31806197 PMCID: PMC9115837 DOI: 10.1016/j.jval.2019.08.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/29/2019] [Revised: 07/25/2019] [Accepted: 08/08/2019] [Indexed: 06/10/2023]
Abstract
OBJECTIVES To develop a practical solution for modeling diabetes progression and account for the variations in risks of diabetes complications in different regions of the world, which is critical for model-based evaluations on the value of diabetes intervention across populations from different regions globally. METHODS A literature search was conducted to identify eligible clinical trials to support calibration. The Building, Relating, Assessing, and Validating Outcomes (BRAVO) model was employed to simulate diabetes complications using the baseline characteristics of each clinical trial cohort. We utilized regression methods to estimate regional variations across the United States, Europe, Asia, and other regions (eg, Latin America, Africa) in 6 outcomes: myocardial infarction (MI), congestive heart failure (CHF), stroke, angina, revascularization, and mortality. RESULTS Regional variations were detected in 4 outcomes. Compared with other regions, individuals from the United States had higher risks of MI (hazard ratio [HR] 1.64; 95% confidence interval [CI]1.41-1.91) and revascularization (HR 3.6; 95% CI 2.94-4.41). Individuals from Europe had a lower risk of stroke (HR 0.61; 95% CI 0.46-0.81), and individuals from other regions outside of the United States, Europe, and Asia had a lower risk of CHF (HR 0.18; 95% CI 0.06-0.58). Finally, the simulated outcomes were regressed on observed outcomes using an ordinary least squares model, with an intercept (0.026), slope (1.005), and R-squared value (0.789) indicating good prediction accuracy. CONCLUSION Recalibrating the BRAVO model's diabetes risk engine to account for regional differences shows improved prediction accuracy when the model is applied to multi-region populations commonly recruited for clinical trials.
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Affiliation(s)
- Hui Shao
- College of Pharmacy, University of Florida, Gainesville, FL, USA
| | - Shuang Yang
- School of Public Health and Tropical Medicine, Tulane University, New Orleans, LA, USA
| | - Charles Stoecker
- School of Public Health and Tropical Medicine, Tulane University, New Orleans, LA, USA
| | - Vivian Fonseca
- School of Medicine, Tulane University, New Orleans, LA, USA
| | - Dongzhe Hong
- School of Public Health and Tropical Medicine, Tulane University, New Orleans, LA, USA
| | - Lizheng Shi
- School of Public Health and Tropical Medicine, Tulane University, New Orleans, LA, USA.
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Rodriguez-Gutierrez R, Gonzalez-Gonzalez JG, Zuñiga-Hernandez JA, McCoy RG. Benefits and harms of intensive glycemic control in patients with type 2 diabetes. BMJ 2019; 367:l5887. [PMID: 31690574 DOI: 10.1136/bmj.l5887] [Citation(s) in RCA: 69] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Diabetes is a major and costly health concern worldwide, with high morbidity, disability, mortality, and impaired quality of life. The vast majority of people living with diabetes have type 2 diabetes. Historically, the main strategy to reduce complications of type 2 diabetes has been intensive glycemic control. However, the body of evidence shows no meaningful benefit of intensive (compared with moderate) glycemic control for microvascular and macrovascular outcomes important to patients, with the exception of reduced rates of non-fatal myocardial infarction. Intensive glycemic control does, however, increase the risk of severe hypoglycemia and incurs additional burden by way of polypharmacy, side effects, and cost. Additionally, data from cardiovascular outcomes trials showed that cardiovascular, kidney, and mortality outcomes may be improved with use of specific classes of glucose lowering drugs largely independently of their glycemic effects. Therefore, delivering evidence based, patient centered care to people with type 2 diabetes requires a paradigm shift and departure from the predominantly glucocentric view of diabetes management. Instead of prioritizing intensive glycemic control, the focus needs to be on ensuring access to adequate diabetes care, aligning glycemic targets to patients' goals and situations, minimizing short term and long term complications, reducing the burden of treatment, and improving quality of life.
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Affiliation(s)
- René Rodriguez-Gutierrez
- Plataforma INVEST Medicina UANL - KER Unit (KER Unit México), Subdireccion de Investigacion, Universidad Autónoma de Nuevo León, Monterrey, 64460, Mexico
- Knowledge and Evaluation Research Unit in Endocrinology, Mayo Clinic, Rochester, MN 55905, USA
- Endocrinology Division, Department of Internal Medicine, University Hospital "Dr José E González," Universidad Autonoma de Nuevo Leon, Monterrey, 64460, Mexico
| | - José Gerardo Gonzalez-Gonzalez
- Plataforma INVEST Medicina UANL - KER Unit (KER Unit México), Subdireccion de Investigacion, Universidad Autónoma de Nuevo León, Monterrey, 64460, Mexico
- Endocrinology Division, Department of Internal Medicine, University Hospital "Dr José E González," Universidad Autonoma de Nuevo Leon, Monterrey, 64460, Mexico
| | - Jorge A Zuñiga-Hernandez
- Plataforma INVEST Medicina UANL - KER Unit (KER Unit México), Subdireccion de Investigacion, Universidad Autónoma de Nuevo León, Monterrey, 64460, Mexico
- Endocrinology Division, Department of Internal Medicine, University Hospital "Dr José E González," Universidad Autonoma de Nuevo Leon, Monterrey, 64460, Mexico
| | - Rozalina G McCoy
- Division of Community Internal Medicine, Department of Medicine, Mayo Clinic, Rochester, MN 55905, USA
- Division of Health Care Policy and Research, Department of Health Sciences Research, Mayo Clinic, Rochester, MN 55905, USA
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21
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Eckel RH, Farooki A, Henry RR, Koch GG, Leiter LA. Cardiovascular Outcome Trials in Type 2 Diabetes: What Do They Mean for Clinical Practice? Clin Diabetes 2019; 37:316-337. [PMID: 31660005 PMCID: PMC6794224 DOI: 10.2337/cd19-0001] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
IN BRIEF Cardiovascular disease is the leading cause of morbidity and mortality in people with diabetes, and deaths from heart disease are two to four times higher among adults with type 2 diabetes. Trials such as the U.K. Prospective Diabetes Study, ACCORD (Action to Control Cardiovascular Risk in Diabetes), ADVANCE (Action in Diabetes and Vascular Disease: Preterax and Diamicron MR Controlled Evaluation), and VADT (Veteran's Affairs Diabetes Trial) produced mixed findings regarding whether intensive glycemic control results in improved cardiovascular (CV) outcomes for patients with diabetes. In response to concerns, including the CV safety of the thiazolidinedione rosiglitazone, the U.S. Food and Drug Administration and subsequently the European Medicines Agency issued guidance that trials should be conducted to prove that antihyperglycemic agents have acceptable CV risk profiles. In this article, the authors review the study designs and results of CV outcomes trials conducted with sodium-glucose cotransporter 2 inhibitors and glucagon-like peptide 1 receptor agonists and discuss how these may affect clinical practice.
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Affiliation(s)
| | - Azeez Farooki
- Memorial Sloan Kettering Cancer Center, New York, NY
| | - Robert R. Henry
- University of California San Diego and VA San Diego Healthcare System, San Diego, CA
| | | | - Lawrence A. Leiter
- Li Shing Knowledge Institute, St. Michael’s Hospital, University of Toronto, Toronto, Ontario, Canada
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22
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Secrest MH, Azoulay L, Dahl M, Clemens KK, Durand M, Hu N, Targownik L, Turin TC, Dormuth CR, Filion KB. A population-based analysis of antidiabetic medications in four Canadian provinces: Secular trends and prescribing patterns. Pharmacoepidemiol Drug Saf 2019; 29 Suppl 1:86-92. [PMID: 31464069 DOI: 10.1002/pds.4878] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2018] [Revised: 05/14/2019] [Accepted: 07/09/2019] [Indexed: 11/08/2022]
Abstract
PURPOSE To use the Canadian Network for Observational Drug Effect Studies (CNODES) to describe drug utilization of antidiabetic medications in four Canadian provinces. METHODS With the use of data from CNODES, we constructed cohorts of patients with type 2 diabetes in four Canadian provinces (Manitoba, Ontario, Quebec, and Saskatchewan) who received their first-ever prescription for a noninsulin antidiabetic medication during the study period, defined as the earliest date of data availability in each province (range: 1993-1998) to the latest date of the data extraction in each province (range: 2013-2014). Prescriptions rates were calculated for all prescriptions by class and described over time. RESULTS Across provinces, we identified 650 830 patients who initiated antidiabetic medications during the study period. In most provinces, the overall prescription rate of antidiabetic medications increased during the last two decades. Metformin particularly increased in popularity, surpassing sulfonylureas in all provinces as the most widely prescribed antidiabetic medication by the early 2000s. Thiazolidinediones grew in popularity from the onset of their availability until 2006 to 2007, at which point they rapidly declined. Dipeptidyl peptidase-4 inhibitors saw substantial growth in several provinces following their addition to provincial formularies in 2008 to 2012, while glucagon-like peptide-1 agonists experienced modest growth. Insulin prescription rates remained constant or steadily increased over the last two decades. CONCLUSIONS CNODES can be used for cross-jurisdictional drug utilization studies. In Canada, trends in antidiabetic medication prescriptions followed changing guidelines reflecting up-to-date knowledge of drug effectiveness and safety.
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Affiliation(s)
- Matthew H Secrest
- Centre for Clinical Epidemiology, Lady Davis Research Institute, Jewish General Hospital, McGill University, Montreal, Quebec, Canada
| | - Laurent Azoulay
- Centre for Clinical Epidemiology, Lady Davis Research Institute, Jewish General Hospital, McGill University, Montreal, Quebec, Canada.,Gerald Bronfman Department of Oncology, McGill University, Montreal, Quebec, Canada.,Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Quebec, Canada
| | - Matthew Dahl
- Department of Community Health Sciences, Manitoba Centre for Health Policy, Winnipeg, Manitoba, Canada
| | - Kristin K Clemens
- Department of Medicine, and Epidemiology and Biostatistics, Western University, London, Ontario, Canada.,Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada.,Lawson Health Research Institute, London, Ontario, Canada
| | - Madeleine Durand
- Internal Medicine Service, Centre Hospitalier Universitaire de Montreal (CHUM), Montreal, Quebec, Canada
| | - Nianping Hu
- The Health Quality Council, Saskatoon, Saskatchewan, Canada
| | - Laura Targownik
- Department of Community Health Sciences, Manitoba Centre for Health Policy, Winnipeg, Manitoba, Canada.,Section of Gastroenterology, Division of Internal Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Tanvir C Turin
- Department of Family Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Colin R Dormuth
- Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Kristian B Filion
- Centre for Clinical Epidemiology, Lady Davis Research Institute, Jewish General Hospital, McGill University, Montreal, Quebec, Canada.,Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Quebec, Canada.,Department of Medicine, McGill University, Montreal, Quebec, Canada
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Tromp J, Ferreira JP, Janwanishstaporn S, Shah M, Greenberg B, Zannad F, Lam CS. Heart failure around the world. Eur J Heart Fail 2019; 21:1187-1196. [DOI: 10.1002/ejhf.1585] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Revised: 05/23/2019] [Accepted: 07/17/2019] [Indexed: 12/19/2022] Open
Affiliation(s)
- Jasper Tromp
- National Heart Centre Singapore Singapore
- Duke‐NUS Medical School Singapore
- Department of Cardiology University Medical Centre Groningen, University of Groningen Groningen The Netherlands
| | - João Pedro Ferreira
- Université de Lorraine, Inserm, Centre d'Investigations Cliniques‐ Plurithématique 14‐33, and Inserm U1116, CHRU, F‐CRIN INI‐CRCT (Cardiovascular and Renal Clinical Trialists) Nancy France
| | - Satit Janwanishstaporn
- Division of Cardiology, Department of Medicine, Faculty of Medicine Siriraj Hospital Mahidol University Bangkok Thailand
| | | | - Barry Greenberg
- Division of Cardiovascular Medicine UC San Diego Health System La Jolla NC USA
| | - Faiez Zannad
- Université de Lorraine, Inserm, Centre d'Investigations Cliniques‐ Plurithématique 14‐33, and Inserm U1116, CHRU, F‐CRIN INI‐CRCT (Cardiovascular and Renal Clinical Trialists) Nancy France
| | - Carolyn S.P. Lam
- National Heart Centre Singapore Singapore
- Duke‐NUS Medical School Singapore
- Department of Cardiology University Medical Centre Groningen, University of Groningen Groningen The Netherlands
- The George Institute for Global Health Sydney Australia
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Dailey G, Bajaj HS, Dex T, Groleau M, Stager W, Vinik A. Post hoc efficacy and safety analysis of insulin glargine/lixisenatide fixed- ratio combination in North American patients compared with the rest of world. BMJ Open Diabetes Res Care 2019; 7:e000581. [PMID: 31114694 PMCID: PMC6501856 DOI: 10.1136/bmjdrc-2018-000581] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2018] [Revised: 12/07/2018] [Accepted: 12/09/2018] [Indexed: 01/20/2023] Open
Abstract
Objective To assess the efficacy and safety of iGlarLixi (titratable fixed-ratio combination of insulin glargine (iGlar) and lixisenatide) in patients with type 2 diabetes (T2D) living in North America (NA; USA and Canada) compared with the rest of the world (RoW). Research design and methods Post hoc analysis included patient-level data from 509 sites/centers across two phase III trials: LixiLan-O (NCT02058147; insulin-naive patients; NA, n=371; RoW, n=796) and LixiLan-L (NCT02058160; inadequately controlled patients on basal insulin; NA, n=196; RoW, n=535). Efficacy outcomes were: change from baseline to Week 30 in glycated hemoglobin (HbA1c), postprandial glucose (PPG), PPG excursions, fasting plasma glucose (FPG) and body weight; proportion of patients achieving HbA1c <42 mmol/mol (<7.0%); proportion of patients achieving composite endpoint: HbA1c <42 mmol/mol (<7.0%), no weight gain or symptomatic hypoglycemia (blood glucose ≤3.9 mmol/L (≤70 mg/dL)). Safety endpoints included incidence of documented symptomatic hypoglycemia and gastrointestinal (GI) adverse events. Results Significantly larger reductions (p≤0.003) in HbA1c from baseline to Week 30 were achieved with iGlarLixi, compared with iGlar or lixisenatide, in NA and RoW patients in LixiLan-O (iGlarLixi vs iGlar: -0.31 and -0.29, respectively; iGlarLixi vs lixisenatide: -0.84 and -0.69, respectively) and in LixiLan-L (iGlarLixi vs iGlar: -0.5 and -0.51, respectively). Documented symptomatic hypoglycemia was similar between NA and RoW patients. iGlarLixi resulted in significant weight benefits versus iGlar (change from baseline -1.58 and -1.29 kg for NA and RoW patients, respectively; p<0.001). GI adverse events were similar for iGlarLixi and iGlar, but significantly higher for lixisenatide. Conclusions iGlarLixi improved glycemic parameters versus iGlar or lixisenatide alone in both NA and RoW patients, with beneficial weight effects versus iGlar. iGlarLixi treatment responses, hypoglycemia risk and GI adverse events in NA patients were comparable with patients in the RoW. Trial registry Clinicaltrials.gov NCT02058147 and NCT02058160.
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Affiliation(s)
- George Dailey
- Division of Diabetes and Endocrinology, Scripps Whittier Diabetes Institute, San Diego, California, USA
| | - Harpreet S Bajaj
- LMC Diabetes and Endocrinology, Brampton, Ontario, Canada
- Leadership Sinai Centre for Diabetes, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Terry Dex
- Sanofi US, Bridgewater, New Jersey, USA
| | | | | | - Aaron Vinik
- Eastern Virginia Medical School, Norfolk, Virginia, USA
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25
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Abstract
Treatment of older adults with type 2 diabetes (T2D) is complex because they represent a heterogeneous group with a broad range of comorbidities, functional abilities, socioeconomic status, and life expectancy. Older adults with T2D are at high risk of recurring hypoglycemia, a condition associated with marked morbidity and mortality, because their counter-regulatory mechanism to hypoglycemia is attenuated, and recurring hypoglycemic episodes can lead to hypoglycemia unawareness. In addition, polypharmacy, a result of multiple chronic comorbidities (including heart disease, stroke, and chronic kidney disease), can increase the risk of severe hypoglycemia, especially when patients are taking sulfonylureas or insulin. Often the signs of hypoglycemia are nonspecific (sweating, dizziness, confusion, visual disturbances) and are mistaken for neurological symptoms or dementia. Consequences of hypoglycemia include acute and long-term cognitive changes, cardiac arrhythmia and myocardial infarction, serious falls, frailty, and death, often resulting in hospitalization, which come at a high economic cost. The American Diabetes Association has recently added three new recommendations regarding hypoglycemia in the elderly, highlighting individualized pharmacotherapy with glucose-lowering agents with a low risk of hypoglycemia and proven cardiovascular safety, avoidance of overtreatment, and simplifying treatment regimens while maintaining HbA1c targets. Thus, glycemic goals can be relaxed in the older population as part of individualized care, and physicians must make treatment decisions that best serve their patients' circumstances. This article highlights the issues faced by older people with T2D, the risk factors for hypoglycemia in this population, and the challenges faced by health care providers regarding glycemic management in this patient group.
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Affiliation(s)
- Jeffrey Freeman
- a Department of Internal Medicine, Division of Endocrinology and Metabolism , Philadelphia College of Osteopathic Medicine , Philadelphia , PA , USA
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26
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Kazemi AH, Wang W, Wang Y, Khodaie F, Rezaeizadeh H. Therapeutic effects of acupuncture on blood glucose level among patients with type-2 diabetes mellitus: A randomized clinical trial. JOURNAL OF TRADITIONAL CHINESE MEDICAL SCIENCES 2019. [DOI: 10.1016/j.jtcms.2019.02.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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27
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Pintat S, Fenici P, Hammar N, Ji L, Khunti K, Medina J, Tang F, Wittbrodt E, Surmont F. Eligibility of patients with type 2 diabetes for sodium-glucose cotransporter 2 inhibitor cardiovascular outcomes trials: a global perspective from the DISCOVER study. BMJ Open Diabetes Res Care 2019; 7:e000627. [PMID: 31114700 PMCID: PMC6501855 DOI: 10.1136/bmjdrc-2018-000627] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2018] [Revised: 01/08/2019] [Accepted: 01/16/2019] [Indexed: 01/24/2023] Open
Abstract
OBJECTIVE To assess the eligibility of patients participating in DISCOVER (a 3-year, prospective, observational study program of 15 992 patients with type 2 diabetes [T2D] initiating a second-line glucose-lowering therapy across 38 countries) for four cardiovascular outcomes trials (CVOTs) of sodium-glucose cotransporter 2 inhibitors (CANagliflozin cardioVascular Assessment Study [CANVAS], Dapagliflozin effect on CardiovascuLAR Events trial [DECLARE-TIMI 58], EMPAgliflozin cardiovascular OUTCOME event trial [EMPA-REG OUTCOME], and eValuation of ERTugliflozin effIcacy and Safety CardioVascular outcomes trial [VERTIS-CV]). RESEARCH DESIGN AND METHODS In this cross-sectional analysis, baseline characteristics of DISCOVER patients were compared with the inclusion and exclusion criteria of the CVOTs to assess patient eligibility, overall and in four regions (Asia-Pacific, Europe, Latin America, and Middle East and Africa). RESULTS Overall, 11 385 patients (71.2%) had sufficient data for the analysis; 56.1% were men. The mean age and time since T2D diagnosis were 57.4 and 5.6 years, respectively. The mean glycated hemoglobin level was 8.3%. DISCOVER patients were younger, and fewer had a history of cardiovascular disease, than those enrolled in the CVOTs. Eligibility varied across the CVOTs; the proportion of eligible DISCOVER patients was highest for DECLARE-TIMI 58 (40.5%), followed by CANVAS (19.9%), VERTIS-CV (7.2%), and EMPA-REG OUTCOME (7.1%); 54.6% of patients were not eligible for any CVOT. Eligibility for each CVOT varied across regions, which was explained by the differing proportions of patients with established cardiovascular disease. CONCLUSIONS In a large, international population of patients with T2D initiating a second-line glucose-lowering therapy, DECLARE-TIMI 58 was the most inclusive CVOT, suggesting that its study population will be more representative of patients encountered in routine clinical practice than those of CANVAS, EMPA-REG OUTCOME, and VERTIS-CV.
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Affiliation(s)
| | | | - Niklas Hammar
- Institute of Environmental Medicine, Karolinska Institute, Stockholm, Sweden
| | - Linong Ji
- Peking University People's Hospital, Beijing, China
| | - Kamlesh Khunti
- Diabetes Research Centre, University of Leicester, Leicester, UK
| | | | - Fengming Tang
- Saint Luke's Mid America Heart Institute, Kansas City, Missouri, USA
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Abstract
Stroke remains the second leading cause of death in the world, and its prevalence is projected to rise in the United States and globally. The main driver for increased stroke prevalence is aging of the population; however, best evidenced-based strategies for stroke treatment and prevention are not always followed for older patients. Furthermore, considerable gaps in knowledge exist for stroke prevention and treatment in elderly and very elderly patients. In this chapter, we discuss various aspects of stroke care in the elderly, including the evidence that guides stroke prevention and treatment. We focus on the challenges in managing stroke in the very elderly including the paucity of data to guide management. The sections span the continuum of stroke care, from primary prevention to management of stroke complications. Finally, we highlight the most significant unanswered questions regarding stroke care in the elderly.
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Affiliation(s)
- Anjail Sharrief
- Department of Neurology, McGovern Medical School, University of Texas Health Science Center, Houston, TX, United States
| | - James C Grotta
- Clinical Innovation and Research Institute, Memorial Hermann Hospital, Houston, TX, United States.
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29
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Tayek CJ, Cherukuri L, Hamal S, Tayek JA. Importance of fasting blood glucose goals in the management of type 2 diabetes mellitus: a review of the literature and a critical appraisal. ACTA ACUST UNITED AC 2018; 5:113-117. [PMID: 31404422 PMCID: PMC6688759 DOI: 10.15406/jdmdc.2018.05.00148] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Prandial insulin has been essential for the improved management of the type 1 diabetic patient. Interestingly, many studies
have evaluated the addition of prandial insulin to the type 2 diabetic patients with improved control. The greatest drop in A1c
with the use of various type of prandial insulins have resulted in the decrease of 1.3% in the A1c measurement. Interestingly,
none of the published trials with goal of fasting blood glucose (FBG) have ever obtained the goal A1c. Since a drop in FBG of
28.7mg/dl is equal to a 1% drop in A1c, a simple approach to obtain a target A1c would be to focus on the FBG (per ADA: Average
Blood Glucose = A1c (%) x 28.7 - 46.7mg/d). However, average blood glucose requires multiple measurements and may be less accurate
then using just a FBG. Since prandial insulin clinical trials have only demonstrated a drop in A1c by 0.3-1.3% the use of only a
FBG to help patients get to goal may be easier to teach and to obtain. It might save time and money. Our hypothesis is that if
patient obtain a FBG <100 mg/dl for 2-3 months then 70% will be at an A1c goal <7.0%. After a few months of good
fasting glucose control the provider can use this equation (FBG+80)/30 to estimate A1c. For example, a FBG of 130mg/dl would be
(130 + 80)/30 = 7.0%; or a FBG of 190 would be (190+80)/30 =eA1c 9% (estimate of A1c). While type 1 diabetes has a very complex
daily glucose pattern, the approach to type 2 diabetics on insulin could become simplified.
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Affiliation(s)
- Chandler J Tayek
- Department of Internal Medicine, Los Angeles Bio-Medical Research Institute, USA
| | - Lavanya Cherukuri
- Department of Internal Medicine, Los Angeles Bio-Medical Research Institute, USA
| | - Sajad Hamal
- Department of Internal Medicine, Los Angeles Bio-Medical Research Institute, USA
| | - John A Tayek
- Department of Internal Medicine, Los Angeles Bio-Medical Research Institute, USA
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Brugos-Larumbe A, Aldaz-Herce P, Guillen-Grima F, Garjón-Parra FJ, Bartolomé-Resano FJ, Arizaleta-Beloqui MT, Pérez-Ciordia I, Fernández-Navascués AM, Lerena-Rivas MJ, Berjón-Reyero J, Jusué-Rípodas L, Aguinaga-Ontoso I. Assessing variability in compliance with recommendations given by the International Diabetes Federation (IDF) for patients with type 2 diabetes in primary care using electronic records. The APNA study. Prim Care Diabetes 2018; 12:34-44. [PMID: 28732655 DOI: 10.1016/j.pcd.2017.06.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2016] [Revised: 02/01/2017] [Accepted: 06/15/2017] [Indexed: 01/02/2023]
Abstract
OBJECTIVE Assess compliance with the IDF recommendations for patients with Diabetes Type2 (DM2), and its variability, by groups of doctors and nurses who provide primary care services in Navarre (Spain). MATERIALS AND METHODOLOGIES A cross-sectional study of a population of 462,568 inhabitants, aged ≥18 years in 2013, attended by 381 units of doctor/nurse (quota). Clinical data were collected retrospectively through electronic records. Using cluster analysis, we identified two groups of units according to the score for each indicator. We calculated the Odds Ratio, adjusted for age sex, BMI, socioeconomic status and smoking, for complying with each recommendation whether a patient was treated by one of the quota from the highest score to the lowest. 30,312 patients with DM2 were identified: prevalence: 6.39%; coefficient of variation between UDN: 22.8%; biggest cluster 7.7% and smallest 5.3%; OR=1.54 (1.50-1.58). The HbA1c control at ≤8% was 82.8% (82.2-83.3) and >9% was 7.6% (7.3-8.0), with OR 1.79 (1.69-1.89) and 2.62 (2.36-2.91) respectively. Control of BP and LDL-C show significant differences between the clusters. CONCLUSIONS An important variability was identified according to the doctor treating patients. The average HbA1c control is acceptable being limited in BP and LDL-C.
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Affiliation(s)
| | - Pablo Aldaz-Herce
- Primary Health Care, Navarra Health Service, Pamplona, Navarra, Spain.
| | - Francisco Guillen-Grima
- Dept. of Health Sciences, Public University of Navarra, Preventive Medicine University of Navarra Clinic, IdiSNA (Navarra Institute for Health Research), Pamplona, Navarra, Spain.
| | | | | | | | | | | | | | - Jesús Berjón-Reyero
- Hospital Complex of Navarra, Navarra Health Service, Pamplona, Navarra, Spain.
| | | | - Ines Aguinaga-Ontoso
- Dept. of Health Sciences, Public University of Navarra, Pamplona, Navarra, Spain.
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Rastogi A, Bhansali A. SGLT2 Inhibitors Through the Windows of EMPA-REG and CANVAS Trials: A Review. Diabetes Ther 2017; 8:1245-1251. [PMID: 29076040 PMCID: PMC5688986 DOI: 10.1007/s13300-017-0320-1] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2017] [Indexed: 12/13/2022] Open
Abstract
EMPA-REG OUTCOME and CANVAS trials were designed to study the cardiovascular safety of empagliflozin and canagliflozin, respectively. Both studies were sufficiently powered to study the non-inferiority for cardiovascular (CV) outcomes in patients with type 2 diabetes mellitus (DM) and showed superiority for major adverse cardiovascular events and composite renal outcomes independent of glycemic control. Further, all patients in EMPA-REG had prior CV events (secondary prevention), compared to CANVAS that also included subjects with no prior CV events, indicating the beneficial effects of canagliflozin in primary prevention of CV events as well. Moreover, there seems to be ethnic variations in response to sodium-glucose cotransporter 2 inhibitors (SGLT2i) regarding CV benefits, as Blacks fared better with canagliflozin and Asians with empagliflozin. Increases in lower extremity amputation and fracture incidence were observed with canagliflozin in CANVAS and this needs further substantiation, though these events were not systematically captured in the EMPA-REG study.
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Affiliation(s)
- Ashu Rastogi
- Department of Endocrinology, PGIMER, Chandigarh, 160012, India
| | - Anil Bhansali
- Department of Endocrinology, PGIMER, Chandigarh, 160012, India.
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32
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Lamas GA, Issa OM. Edetate Disodium-Based Treatment for Secondary Prevention in Post-Myocardial Infarction Patients. Curr Cardiol Rep 2016; 18:20. [PMID: 26797807 DOI: 10.1007/s11886-015-0690-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
An abundance of data, known for decades, is available linking metals, such as lead and cadmium, with cardiovascular disease. However, the idea that these toxic metals could be a modifiable risk factor for atherosclerosis did not become apparent clinically until the completion of the Trial to Assess Chelation Therapy in 2012. This pivotal study was the first double-blind, randomized, controlled trial of its kind to demonstrate a clear improvement in cardiovascular outcomes with edetate disodium therapy in a secondary prevention, post-myocardial infarction population. This effect size was most striking in diabetic patients, where the efficacy of edetate disodium was comparable, if not superior, to that of current guideline-based therapies. Given the economic burden of diabetes and cardiovascular disease, the potential impact of this therapy could be enormous if the results of this study are replicated.
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Affiliation(s)
- Gervasio A Lamas
- Columbia University Division of Cardiology, Mount Sinai Medical Center, Miami Beach FL, 4300 Alton Road, Miami Beach, FL, 33140, USA.
| | - Omar M Issa
- Columbia University Division of Cardiology, Mount Sinai Medical Center, Miami Beach FL, 4300 Alton Road, Miami Beach, FL, 33140, USA
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Tanner MJ, Wang J, Ying R, Suboc TB, Malik M, Couillard A, Branum A, Puppala V, Widlansky ME. Dynamin-related protein 1 mediates low glucose-induced endothelial dysfunction in human arterioles. Am J Physiol Heart Circ Physiol 2016; 312:H515-H527. [PMID: 27923790 DOI: 10.1152/ajpheart.00499.2016] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2016] [Revised: 12/01/2016] [Accepted: 12/01/2016] [Indexed: 11/22/2022]
Abstract
Intensive glycemic regulation has resulted in an increased incidence of hypoglycemia. Hypoglycemic burden correlates with adverse cardiovascular complications and contributes acutely and chronically to endothelial dysfunction. Prior data indicate that mitochondrial dysfunction contributes to hypoglycemia-induced endothelial dysfunction, but the mechanisms behind this linkage remain unknown. We attempt to determine whether clinically relevant low-glucose (LG) exposures acutely induce endothelial dysfunction through activation of the mitochondrial fission process. Characterization of mitochondrial morphology was carried out in cultured endothelial cells by using confocal microscopy. Isolated human arterioles were used to explore the effect LG-induced mitochondrial fission has on the formation of detrimental reactive oxygen species (ROS), bioavailability of nitric oxide (NO), and endothelial-dependent vascular relaxation. Fluorescence microscopy was employed to visualize changes in mitochondrial ROS and NO levels and videomicroscopy applied to measure vasodilation response. Pharmacological disruption of the profission protein Drp1 with Mdivi-1 during LG exposure reduced mitochondrial fragmentation among vascular endothelial cells (LG: 0.469; LG+Mdivi-1: 0.276; P = 0.003), prevented formation of vascular ROS (LG: 2.036; LG+Mdivi-1: 1.774; P = 0.005), increased the presence of NO (LG: 1.352; LG+Mdivi-1: 1.502; P = 0.048), and improved vascular dilation response to acetylcholine (LG: 31.6%; LG+Mdivi-1; 78.5% at maximum dose; P < 0.001). Additionally, decreased expression of Drp1 via siRNA knockdown during LG conditions also improved vascular relaxation. Exposure to LG imparts endothelial dysfunction coupled with altered mitochondrial phenotypes among isolated human arterioles. Disruption of Drp1 and subsequent mitochondrial fragmentation events prevents impaired vascular dilation, restores mitochondrial phenotype, and implicates mitochondrial fission as a primary mediator of LG-induced endothelial dysfunction.NEW & NOTEWORTHY Acute low-glucose exposure induces mitochondrial fragmentation in endothelial cells via Drp1 and is associated with impaired endothelial function in human arterioles. Targeting of Drp1 prevents fragmentation, improves vasofunction, and may provide a therapeutic target for improving cardiovascular complications among diabetics.Listen to this article's corresponding podcast @ http://ajpheart.podbean.com/e/mitochondrial-dynamics-impact-endothelial-function/.
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Affiliation(s)
- Michael J Tanner
- Division of Cardiovascular Medicine, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Jingli Wang
- Division of Cardiovascular Medicine, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Rong Ying
- Division of Cardiovascular Medicine, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Tisha B Suboc
- Division of Cardiovascular Medicine, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Mobin Malik
- Division of Cardiovascular Medicine, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Allison Couillard
- Division of Cardiovascular Medicine, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Amberly Branum
- Division of Cardiovascular Medicine, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Venkata Puppala
- Division of Cardiovascular Medicine, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Michael E Widlansky
- Division of Cardiovascular Medicine, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
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Rutten GEHM, Tack CJ, Pieber TR, Comlekci A, Ørsted DD, Baeres FMM, Marso SP, Buse JB. LEADER 7: cardiovascular risk profiles of US and European participants in the LEADER diabetes trial differ. Diabetol Metab Syndr 2016; 8:37. [PMID: 27274772 PMCID: PMC4891842 DOI: 10.1186/s13098-016-0153-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2016] [Accepted: 05/26/2016] [Indexed: 01/18/2023] Open
Abstract
AIMS To determine whether US and European participants in the Liraglutide Effect and Action in Diabetes: Evaluation of cardiovascular outcome Results (LEADER) trial differ regarding risk factors for cardiovascular mortality and morbidity. METHODS Baseline data, stratified for prior cardiovascular disease (CVD), were compared using multivariable logistic regression analysis to establish whether region is an independent determinant of achieved targets for glycated hemoglobin (HbA1c), blood pressure (BP), and low-density lipoprotein (LDL)-cholesterol. RESULTS Independent of CVD history, US participants were more often of non-White origin and had a longer history of type 2 diabetes, higher body weight, and higher baseline HbA1c. They had substantially lower systolic and diastolic BP, and a marginally lower LDL-cholesterol level. Fewer US participants were diagnosed with left ventricular dysfunction. In the largest group of patients, those with prior CVD and the highest cardiovascular risk, US participants were more often female, had a higher waist circumference, and had a decreased estimated glomerular filtration rate, but less frequently prior myocardial infarction or angina pectoris. CONCLUSIONS There were baseline differences between US and European participants. These differences may result from variation in regional targets for cardiovascular risk factor management, and should be considered in the analysis and reporting of the trial results. Clinical trial identifier: ClinicalTrials.gov, NCT01179048.
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Affiliation(s)
- Guy E. H. M. Rutten
- />Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, STR 6.131, P.O. Box 85500, 3508 GA Utrecht, The Netherlands
| | - Cees J. Tack
- />Department of Internal Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Thomas R. Pieber
- />Division of Endocrinology and Metabolism, Medical University of Graz, Graz, Austria
| | - Abdurrahman Comlekci
- />Division of Endocrinology, Dokuz Eylul University Medical School, Inciralti, Izmir, Turkey
| | | | | | - Steven P. Marso
- />Department of Internal Medicine, UT Southwestern, Dallas, TX USA
| | - John B. Buse
- />Department of Medicine, The University of North Carolina School of Medicine, Chapel Hill, NC USA
| | - on behalf of the LEADER Investigators
- />Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, STR 6.131, P.O. Box 85500, 3508 GA Utrecht, The Netherlands
- />Department of Internal Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
- />Division of Endocrinology and Metabolism, Medical University of Graz, Graz, Austria
- />Division of Endocrinology, Dokuz Eylul University Medical School, Inciralti, Izmir, Turkey
- />Novo Nordisk, Søborg, Denmark
- />Department of Internal Medicine, UT Southwestern, Dallas, TX USA
- />Department of Medicine, The University of North Carolina School of Medicine, Chapel Hill, NC USA
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Middleton P, Crowther CA, Simmonds L. Different intensities of glycaemic control for pregnant women with pre-existing diabetes. Cochrane Database Syst Rev 2016; 2016:CD008540. [PMID: 27142841 PMCID: PMC6486104 DOI: 10.1002/14651858.cd008540.pub4] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND The optimal glycaemic control target in pregnant women with pre-existing diabetes is unclear, although there is a clear link between high glucose concentrations and adverse birth outcomes. OBJECTIVES To assess the effects of different intensities of glycaemic control in pregnant women with pre-existing type 1 or type 2 diabetes. SEARCH METHODS We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 January 2016) and planned to search reference lists of retrieved studies. SELECTION CRITERIA We included randomised controlled trials comparing different glycaemic control targets in pregnant women with pre-existing diabetes. DATA COLLECTION AND ANALYSIS Two review authors independently assessed trials for inclusion, conducted data extraction, assessed risk of bias and checked for accuracy. We assessed the quality of the evidence using the GRADE approach. MAIN RESULTS We included three trials, all in women with type 1 diabetes (223 women and babies). All three trials were at high risk of bias due to lack of blinding, unclear methods of randomisation and selective reporting of outcomes. Two trials compared very tight (3.33 to 5.0 mmol/L fasting blood glucose (FBG)) with tight-moderate (4.45 to 6.38 mmol/L) glycaemic control targets, with one trial of 22 babies reporting no perinatal deaths orserious perinatal morbidity (evidence graded low for both outcomes). In the same trial, there were two congenital anomalies in the very tight, and none in the tight-moderate group, with no significant differences in caesarean section between groups (risk ratio (RR) 0.92, 95% confidence interval (CI) 0.49 to 1.73; evidence graded very low). In these two trials, glycaemic control was not significantly different between the very tight and tight-moderate groups by the third trimester, although one trial of 22 women found significantly less maternal hypoglycaemia in the tight-moderate group.In a trial of 60 women and babies comparing tight (≤ 5.6 mmol/L FBG); moderate (5.6 to 6.7 mmol/L); and loose (6.7 to 8.9 mmol/L) glycaemic control targets, there were two neonatal deaths in the loose and none in the tight or moderate groups (evidence graded very low). There were significantly fewer women with pre-eclampsia (evidence graded low), fewer caesarean sections (evidence graded low) and fewer babies with birthweights greater than 90th centile (evidence graded low) in the combined tight-moderate compared with the loose group.The quality of the evidence was graded low or very low for important outcomes, because of design limitations to the studies, the small numbers of women included, and wide confidence intervals crossing the line of no effect. Many of the important outcomes were not reported in these studies. AUTHORS' CONCLUSIONS In a very limited body of evidence, few differences in outcomes were seen between very tight and tight-moderate glycaemic control targets in pregnant women with pre-existing type 1 diabetes, including actual glycaemic control achieved. There is evidence of harm (increased pre-eclampsia, caesareans and birthweights greater than 90th centile) for 'loose' control (FBG above 7 mmol/L). Future trials comparing interventions, rather than glycaemic control targets, may be more feasible. Trials in pregnant women with pre-existing type 2 diabetes are required.
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Affiliation(s)
- Philippa Middleton
- Healthy Mothers, Babies and Children, South Australian Health and Medical Research InstituteWomen's and Children's Hospital72 King William RoadAdelaideSouth AustraliaAustralia5006
| | - Caroline A Crowther
- The University of AucklandLiggins InstitutePrivate Bag 9201985 Park RoadAucklandNew Zealand
| | - Lucy Simmonds
- University of South AustraliaEhrenberg‐Bass InstituteAdelaideSouth AustraliaAustralia5000
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Seidu S, Achana FA, Gray LJ, Davies MJ, Khunti K. Effects of glucose-lowering and multifactorial interventions on cardiovascular and mortality outcomes: a meta-analysis of randomized control trials. Diabet Med 2016; 33:280-9. [PMID: 26282461 DOI: 10.1111/dme.12885] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/11/2015] [Indexed: 01/05/2023]
Abstract
INTRODUCTION The effect of intensive glycaemic control alone or as part of a multifactorial intervention on cardiovascular and mortality outcomes is not fully understood. In addition, the interaction of duration of diabetes diagnosis on cardiovascular and mortality outcomes is unclear. AIM To quantify the effect of intensive treatment (i.e. intensive glucose lowering either alone or as part of a multifactorial intervention) on non-fatal myocardial infarction (MI), non-fatal stroke, cardiovascular disease (CV) mortality and all-cause mortality in patients with Type 2 diabetes. A secondary objective was to investigate the association between the treatment effect and trial-level characteristics such as average age, duration of Type 2 diabetes, the percentage male and the baseline event rate. METHODS We searched MEDLINE, Embase and the Cochrane Central Register of Controlled Trials without language restrictions from inception to 13 May 2015. We included randomized controlled trials (RCTs) that evaluated intensive treatment in adult patients with Type 2 diabetes. The review was registered on PROSPERO (registration number 42014013860). We pooled rates across studies using random effects meta-analysis and investigated study-level covariate associations using Bayesian meta-regression. RESULTS A total of 19 RCTs were included: 16 examined non-fatal MI (n = 79 595), 14 non-fatal stroke (n = 78 568), 18 cardiovascular mortality (n = 83 938) and 18 all-cause mortality (n = 84 266). There was evidence to suggest that compared with standard care, intensive treatment reduced the risk of non-fatal MI [risk ratio (RR) 0.90, 95% confidence interval (CI) 0.83-0.96], but not non-fatal stroke (RR 0.96, 95% CI 0.86-1.07), CV mortality (RR 1.00, 95% CI 0.90-1.11) or all-cause mortality (RR 1.00, 95% CI 0.94-1.06). Compared with standard care, multifactorial interventions alone reduced non-fatal stroke (RR 0.53, 95% CI 0.32-0.0.87) but not non-fatal MI (RR 0.66, 95% CI 0.38-1.03), CV mortality (RR 0.72, 95% CI 0.46-1.14) or all-cause mortality (RR 0.82, 95% CI 0.64-1.05). There was no evidence to suggest that the effect of intensive treatment on cardiovascular and mortality outcomes was associated with mean age, mean duration of Type 2 diabetes and percentage of male patients across trials. There was evidence to suggest that the effectiveness of intensive treatment to reduce mortality outcomes increases as the baseline incidence of cardiovascular mortality [ratio of hazard = 0.82, 95% credible interval (CrI) 0.65-0.99] increased across trials, but not baseline incidence of non-fatal MI, non-fatal stroke and all-cause mortality. Intensive glucose-lowering and multifactorial interventions are predicted to have the desired beneficial effect of reducing CVD mortality in populations where the incidence rate is greater than about 6.3 CVD deaths per 1000 person-years or an average 10-year CVD risk of 6.3%. CONCLUSIONS Apart from non-fatal MIs, there was no evidence that intensive glucose-lowering and multifactorial interventions reduced or increased the risk of cardiovascular and mortality outcomes. Intensive glucose-lowering and multifactorial interventions are likely to be beneficial in populations with a higher baseline incidence of CV mortality, but there was no evidence of an association with the mean duration of Type 2 diabetes. Multifactorial interventions had a much greater impact on non-fatal MI and non-fatal strokes. (PROSPERO registration no.: 42014013860).
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Affiliation(s)
- S Seidu
- Leicester Diabetes Centre, Leicester General Hospital, Leicester, UK
- Diabetes Research Centre, University of Leicester, Leicester, UK
| | - F A Achana
- Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK
| | - L J Gray
- Leicester Diabetes Centre, Leicester General Hospital, Leicester, UK
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - M J Davies
- Leicester Diabetes Centre, Leicester General Hospital, Leicester, UK
- Diabetes Research Centre, University of Leicester, Leicester, UK
| | - K Khunti
- Leicester Diabetes Centre, Leicester General Hospital, Leicester, UK
- Diabetes Research Centre, University of Leicester, Leicester, UK
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