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Jan A, Saeed M, Mothana RA, Muhammad T, Rahman N, Alanzi AR, Akbar R. Association of CYP2C9*2 Allele with Sulphonylurea-Induced Hypoglycaemia in Type 2 Diabetes Mellitus Patients: A Pharmacogenetic Study in Pakistani Pashtun Population. Biomedicines 2023; 11:2282. [PMID: 37626778 PMCID: PMC10452755 DOI: 10.3390/biomedicines11082282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Revised: 08/02/2023] [Accepted: 08/12/2023] [Indexed: 08/27/2023] Open
Abstract
Polymorphism in cytochrome P450 (CYP) 2C9 enzyme is known to cause significant inter-individual differences in drug response and occurrence of adverse drug reactions. Different alleles of the CYP2C9 gene have been identified, but the notable alleles responsible for reduced enzyme activity are CYP2C9*2 and CYP2C9*3. No pharmacogenetic data are available on CYP2C9*2 and CYP2C9*3 alleles in the Pakistani population. In Pakistan, pharmacogenetics, which examines the relationship between genetic factors and drug response, are in the early stages of development. We, for the first time, investigated the association between the CYP2C9 variant alleles CYP2C9*2 and CYP2C9*3 and the incidence of hypoglycaemia in patients with Type 2 diabetes mellitus (T2DM) receiving sulphonylurea medications. A total of n = 400 individuals of Pashtun ethnicity were recruited from 10 different districts of Khyber Pakhtunkhwa, Pakistan to participate in the study. The study participants were divided into two distinct groups: the case group (n = 200) and the control group (n = 200). The case group consisted of individuals with T2DM who were receiving sulphonylurea medications and experienced hypoglycaemia with it, whereas the control group included individuals with T2DM who were receiving sulphonylurea medication but did not experience sulphonylurea-induced hypoglycaemia (SIH). Blood samples were obtained from study participants following informed consent. DNA was isolated from whole blood samples using a Wiz-Prep DNA extraction kit. Following DNA isolation, CYP2C9 alleles were genotyped using MassARRAY sequencing platform at the Centre of Genomics at the Rehman Medical Institute (RMI). The frequency of CYP2C9*2 (low-activity allele) was more frequent in the diabetic patients with SIH compared to the control group (17.5% vs. 6.0%, p = 0.021). The frequency of its corresponding genotype CYP2C9*1/*2 was higher in cases compared to the control group (10% vs. 6% with p = 0.036); the same was true for genotype CYP2C9*2/*2 (7% vs. 3.5% with p = 0.028). Logistic regression analysis evidenced potential association of CYP2C9*2 allele and its genotypes with SIH. When adjusted for confounding factors such as age, weight, sex, mean daily dose of sulphonylurea, and triglyceride level, the association between the CYP2C9*2 allele and hypoglycaemia remained consistent. Confounding factors played no role in SIH (insignificant p-value) because both groups (cases and controls) were closely matched in term of age, weight, sex, mean daily dose of sulphonylurea, and triglyceride levels. Our study suggests that genetic information about a patient's CYP2C9 gene/enzyme can potentially assist physicians in prescribing the most suitable and safest drug, based on their genetic make-up.
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Affiliation(s)
- Asif Jan
- Department of Pharmacy, University of Peshawar, Peshawar 25000, Pakistan;
- District Headquarter Hospital (DHQH) Charsadda, Charsadda 24430, Pakistan
| | - Muhammad Saeed
- Department of Pharmacy, Qurtaba University of Science and Technology, Peshawar 25000, Pakistan;
| | - Ramzi A. Mothana
- Department of Pharmacognosy, College of Pharmacy, King Saud University, Riyadh 11451, Saudi Arabia; (R.A.M.); (A.R.A.)
| | - Tahir Muhammad
- Molecular Neuropsychiatry & Development (MiND) Lab, Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, ON M6J 1H4, Canada;
- Institute of Medical Science, University of Toronto, Toronto, ON M5S 1A8, Canada
| | - Naveed Rahman
- Department of Pharmacy, University of Peshawar, Peshawar 25000, Pakistan;
| | - Abdullah R. Alanzi
- Department of Pharmacognosy, College of Pharmacy, King Saud University, Riyadh 11451, Saudi Arabia; (R.A.M.); (A.R.A.)
| | - Rani Akbar
- Department of Pharmacy, Abdul Wali Khan University, Mardan 23200, Pakistan;
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Kawahara T, Tsuji M, Tominaga N, Toyama N, Toda M. Frequency of adrenal insufficiency in patients with hypoglycemia in an emergency department: A cross-sectional study. J Endocr Soc 2022; 6:bvac119. [PMID: 36042975 PMCID: PMC9419498 DOI: 10.1210/jendso/bvac119] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Indexed: 11/19/2022] Open
Abstract
Abstract
Context
In most patients presenting with hypoglycemia in emergency departments, the etiology of hypoglycemia is identified. However, it cannot be determined in approximately 10% of cases.
Objective
We aimed to identify the causes of unknown hypoglycemia, especially adrenal insufficiency.
Methods
In this cross-sectional study, we evaluated the etiology of hypoglycemia among patients in our emergency department with hypoglycemia (plasma glucose level <70 mg/dL [3.9 mmol/L]) between April 1, 2016, and March 31, 2021, using a rapid adrenocorticotropic hormone (ACTH) test.
Results
There were 528 cases with hypoglycemia included (52.1% male; median age 62 years [range 19 to 92]). The majority (389 [73.7%]) of patients were using anti-diabetes drugs. Additionally, 33 (6.3%) consumed alcohol, 17 (3.2%) suffered from malnutrition, 13 (2.5%) liver dysfunction, 12 (2.3%) severe infectious disease, 11 (2.1%) malignancy, 9 (1.7%) heart failure, 4 (0.8%) insulin autoimmune syndrome, 3 (0.6%) insulinoma, 2 (0.4%) were using hypoglycemia-relevant drugs, and 1 (0.2%) suffered from non-islet cell tumor. Rapid ACTH tests revealed adrenal insufficiency in 32 (6.1%). In those patients, serum sodium levels were lower (132 vs. 139 mEq/L, P<0.01), eosinophil counts were higher (14 vs. 8%, P<0.01), and systolic blood pressure was lower (120 vs. 128 mmHg, P<0.05) at baseline than in patients with the other etiologies, respectively.
Conclusion
The frequency of adrenal insufficiency as a cause of hypoglycemia was much higher than what we anticipated. When protracted hypoglycemia of unknown etiology is recognized, we recommend that the patient is checked for adrenal function using a rapid ACTH test.
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Affiliation(s)
- Tetsuya Kawahara
- Department of Endocrinology and Diabetes, Shinkomonji Hospital , 8000057 Kitakyushu, Japan
| | - Maiko Tsuji
- Department of Emergency Medicine, Shinkomonji Hospital , 8000057 Kitakyushu, Japan
| | - Naoki Tominaga
- Department of Emergency Medicine, Shinkomonji Hospital , 8000057 Kitakyushu, Japan
| | - Nagahiro Toyama
- Department of Emergency Medicine, Shinkomonji Hospital , 8000057 Kitakyushu, Japan
| | - Mikio Toda
- Department of Internal Medicine, Shinkomonji Hospital , 8000057 Kitakyushu, Japan
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Kanazawa K, Suzuki S, Koga S, Kuwabara K. A comprehensive risk assessment for nocturnal hypoglycemia in geriatric patients with type 2 diabetes: A single-center case-control study. J Diabetes Complications 2022; 36:108239. [PMID: 35810146 DOI: 10.1016/j.jdiacomp.2022.108239] [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: 04/06/2022] [Revised: 06/15/2022] [Accepted: 06/23/2022] [Indexed: 11/16/2022]
Abstract
AIMS To evaluate the overall association between clinically significant nocturnal hypoglycemia (CsNH) and risk factors in geriatric patients with type 2 diabetes. METHODS Overall, 606 geriatric with type 2 diabetes were evaluated for CsNH using Freestyle Libre Pro® (Abbott Diabetes Care, Tokyo, Japan) during October 2018-February 2020. We defined CsNH as blood glucose level <54 mg/dL (3.0 mmol/L). We investigated clinical characteristics and efficacies of hypoglycemic agents and insulin and analyzed CsNH risk factors using univariate and multivariate logistic regression analyses. RESULTS We enrolled 152 patients each for the CsNH and non-nocturnal hypoglycemia groups. Insulin use (OR = 3.77 [95 % CI: 1.92-7.67]; P = 0.0002), age (OR = 1.06 [95 % CI: 1.01-1.12]; P = 0.0492), estimated glomerular filtration rate (OR = 0.97 [95 % CI: 0.95-0.98]; P = 0.0492), and fasting blood glucose level (OR = 0.94 [95 % CI: 0.91-0.94]; P < 0.0001) were independent CsNH risk factors. The combined results demonstrated a higher predictability of CsNH than each of the individual risk factors. CONCLUSIONS We identified risk factors that could help predict CsNH in geriatric patients with type 2 diabetes and demonstrated a comprehensive risk factor assessment.
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Affiliation(s)
- Ken Kanazawa
- Departments of Diabetes, Metabolism and Endocrinology, Japan Labour Health and Safety Organization, Tokyo Rosai Hospital, Tokyo, Japan.
| | - Shogo Suzuki
- Departments of Diabetes, Metabolism and Endocrinology, Japan Labour Health and Safety Organization, Tokyo Rosai Hospital, Tokyo, Japan
| | - Shinichiro Koga
- Departments of Diabetes, Metabolism and Endocrinology, Japan Labour Health and Safety Organization, Tokyo Rosai Hospital, Tokyo, Japan
| | - Koichiro Kuwabara
- Departments of Diabetes, Metabolism and Endocrinology, Japan Labour Health and Safety Organization, Tokyo Rosai Hospital, Tokyo, Japan
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Bae JP, Kadziola ZA, Liu D, Chinthammit C, Boye KS, Mather KJ. An Early Assessment of the Real-World Treatment Patterns of Type 2 Diabetes: A Comparison to the 2018 ADA/EASD Consensus Report Recommendations. Diabetes Ther 2022; 13:1499-1510. [PMID: 35764911 PMCID: PMC9309104 DOI: 10.1007/s13300-022-01289-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Accepted: 06/09/2022] [Indexed: 11/29/2022] Open
Abstract
INTRODUCTION Using the American Diabetes Association (ADA) Hyperglycemic Pharmacotherapy Guidelines for type 2 diabetes, we evaluated the medication use patterns in real-world patients with type 2 diabetes in the USA. METHODS Health care claims among patients with type 2 diabetes were analyzed (IBM® MarketScan® 2007 to 2019 Commercial and Medicare Databases). Diabetes treatment patterns were evaluated for the total patient sample of 580,741 during the year 2019. Prior years' claims data were used to construct patient history and determine clinical groups per the 2018 ADA/EASD consensus statement: atherosclerotic cardiovascular disease (ASCVD), chronic kidney disease (CKD), heart failure (HF), hypoglycemia (hypo), and obesity. The recommended therapy use rates (RTUR) were calculated for clinical groups. Univariate chi-square tests were performed to compare RTUR within and outside clinical groups. Multivariate logistic regression was used to identify variables associated with recommended therapy use. RESULTS A large proportion of patients belonged to multiple clinical groups; this was more common in the Medicare cohort. Each clinical group in the Commercial cohort had a substantially higher RTUR than in the Medicare cohort. However, no clinical group achieved > 40% RTUR. The RTUR was the highest in the CKD and obesity groups in the Commercial cohort and in the hypo and obesity groups in the Medicare cohort, but lowest in hypo and HF groups in the Commercial and Medicare cohorts, respectively. CONCLUSION Prevalence of guideline-aligned treatment use in 2019 was low, particularly since many patients fit into multiple risk groups with established treatment benefits.
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Affiliation(s)
- Jay P Bae
- Eli Lilly and Company, Lilly Corporate Center, Indianapolis, IN, 46285, USA.
| | | | - Dongju Liu
- Eli Lilly and Company, Lilly Corporate Center, Indianapolis, IN, 46285, USA
| | | | - Kristina S Boye
- Eli Lilly and Company, Lilly Corporate Center, Indianapolis, IN, 46285, USA
| | - Kieren J Mather
- Eli Lilly and Company, Lilly Corporate Center, Indianapolis, IN, 46285, USA
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Loganadan NK, Huri HZ, Vethakkan SR, Hussein Z. Pharmacogenetics of sulfonylurea-induced hypoglycemia in Type 2 diabetes patients: the SUCLINGEN study. Pharmacogenomics 2021; 22:1057-1068. [PMID: 34665019 DOI: 10.2217/pgs-2021-0059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Aim: This study investigated the incidence of sulfonylurea-induced hypoglycemia and its predictors in Type 2 diabetes (T2D) patients. Patients & methods: In this prospective, observational study, T2D patients on maximal sulfonylurea-metformin therapy >1 year were enrolled. Hypoglycemia was defined as having symptoms or a blood glucose level <3.9 mmol/l. Results: Of the 401 patients, 120 (29.9%) developed sulfonylurea-induced hypoglycemia during the 12-month follow-up. The ABCC8 rs757110, KCNJ11 rs5219, CDKAL1 rs7756992 and KCNQ1 rs2237892 gene polymorphisms were not associated with sulfonylurea-induced hypoglycemia (p > 0.05). Prior history of hypoglycemia admission (odds ratio = 16.44; 95% CI: 1.74-154.33, p = 0.014) independently predicted its risk. Conclusion: Sulfonylurea-treated T2D patients who experienced severe hypoglycemia are at increased risk of future hypoglycemia episodes.
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Affiliation(s)
- Navin Kumar Loganadan
- Department of Pharmacy, Putrajaya Hospital, Precinct 7, Putrajaya, 62250, Malaysia.,Faculty of Pharmacy, University of Malaya, Kuala Lumpur, 50603, Malaysia
| | - Hasniza Zaman Huri
- Faculty of Pharmacy, University of Malaya, Kuala Lumpur, 50603, Malaysia.,Clinical Investigation Centre, 5th Floor, East Tower, University of Malaya Medical Centre, Lembah Pantai, 59100, Kuala Lumpur, Malaysia
| | - Shireene Ratna Vethakkan
- Division of Endocrinology, Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, 50603, Malaysia
| | - Zanariah Hussein
- Department of Medicine, Putrajaya Hospital, Precinct 7, Putrajaya, 62250, Malaysia
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Yee J, Heo Y, Kim H, Yoon HY, Song G, Gwak HS. Association Between the CYP2C9 Genotype and Hypoglycemia Among Patients With Type 2 Diabetes Receiving Sulfonylurea Treatment: A Meta-analysis. Clin Ther 2021; 43:836-843.e4. [PMID: 33840516 DOI: 10.1016/j.clinthera.2021.03.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Revised: 02/25/2021] [Accepted: 03/12/2021] [Indexed: 12/21/2022]
Abstract
PURPOSE Two common variants, CYP2C9*2 (Arg144Cys, rs1799853) and CYP2C9*3 (Ile359Leu, rs1057910), are known to reduce the catalytic function of the CYP2C9 enzyme. Because impaired catalytic function is likely to affect sulfonylurea metabolism, it is predictable that CYP2C9 loss-of-function alleles may increase the risk of sulfonylurea-induced hypoglycemia. This systematic review and meta-analysis aimed to assess the association between CYP2C9 genotype and hypoglycemia among patients with type 2 diabetes mellitus (T2DM) receiving sulfonylurea. METHODS We searched for studies on the association between CYP2C9 genotype and sulfonylurea-induced hypoglycemia among patients with T2DM, published through August 7, 2020, using PubMed, Web of Science, and EMBASE. Odds ratios (ORs) and 95% CIs were calculated. FINDINGS Five cohort studies and 2 case-control studies were included, and the total number of patients analyzed in this meta-analysis was 2769. The CYP2C9 variant alleles were associated with an increase in sulfonylurea-induced hypoglycemia compared with wild-type homozygote (OR = 1.24; 95% CI, 1.03-1.48). Compared with CYP2C9 wild-type homozygotes, CYP2C9*2 allele was associated with increased incidence of hypoglycemia (OR = 1.85; 95% CI, 1.18-2.89), whereas the CYP2C9*3 allele failed to show the statistical significance (OR = 1.67; 95% CI, 0.40-6.86; P = 0.48). IMPLICATIONS On the basis of these results, CYP2C9 genotyping may be useful for predicting the risk of hypoglycemia during sulfonylurea treatment for T2DM.
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Affiliation(s)
- Jeong Yee
- College of Pharmacy and Graduate School of Pharmaceutical Sciences, Ewha Womans University, Seoul, Republic of Korea
| | - Yunhee Heo
- College of Pharmacy and Graduate School of Pharmaceutical Sciences, Ewha Womans University, Seoul, Republic of Korea
| | - Hamin Kim
- College of Pharmacy and Graduate School of Pharmaceutical Sciences, Ewha Womans University, Seoul, Republic of Korea
| | - Ha Young Yoon
- College of Pharmacy and Graduate School of Pharmaceutical Sciences, Ewha Womans University, Seoul, Republic of Korea
| | - Gonjin Song
- College of Pharmacy and Graduate School of Pharmaceutical Sciences, Ewha Womans University, Seoul, Republic of Korea
| | - Hye Sun Gwak
- College of Pharmacy and Graduate School of Pharmaceutical Sciences, Ewha Womans University, Seoul, Republic of Korea.
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7
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Kuroda N, Kusunoki Y, Osugi K, Ohigashi M, Azuma D, Ikeda H, Makino S, Otsuka A, Tamada D, Watanabe N, Washio K, Tsunoda T, Matsuo T, Konishi K, Katsuno T, Koyama H. Relationships between time in range, glycemic variability including hypoglycemia and types of diabetes therapy in Japanese patients with type 2 diabetes mellitus: Hyogo Diabetes Hypoglycemia Cognition Complications study. J Diabetes Investig 2021; 12:244-253. [PMID: 32594655 PMCID: PMC7858127 DOI: 10.1111/jdi.13336] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Revised: 06/10/2020] [Accepted: 06/19/2020] [Indexed: 12/20/2022] Open
Abstract
AIMS/INTRODUCTION Continuous glucose monitoring (CGM) metrics, such as times in range (TIR) and time below range, have been shown to be useful as clinical targets that complement glycated hemoglobin (HbA1c) for patients with type 2 diabetes mellitus. We investigated the relationships between TIR, glycemic variability and patient characteristics in patients with type 2 diabetes mellitus. MATERIALS AND METHODS We carried out continuous glucose monitoring in 281 outpatients with type 2 diabetes mellitus who participated in a multicenter cohort (Hyogo Diabetes Hypoglycemia Cognition Complications) study. RESULTS The results are shown as the median (interquartile range). The age, disease duration and HbA1c were 68 years (62-71 years), 13 years (7-23 years) and 6.9% (6.5-7.5%), respectively. TIR and standard deviation obtained by continuous glucose monitoring worsened significantly with increasing disease duration. Multiple regression analyses showed that disease duration (standard partial regression coefficient, β = -0.160, P = 0.003), diabetic peripheral neuropathy (β = -0.106, P = 0.033) and urinary albumin excretion (β = -0.100, P = 0.043) were useful explanatory factors for TIR. In contrast, HbA1c (β = -0.398, P < 0.001) and the use of antidiabetic drugs potentially associated with severe hypoglycemia (β = 0.180, P = 0.028), such as sulfonylureas, glinides and insulin, were useful explanatory factors for time below range in the elderly patients with type 2 diabetes mellitus. CONCLUSIONS The results of this study suggest that disease duration and diabetic complications are associated with TIR deterioration. In addition, low HbA1c levels and the use of antidiabetic drugs potentially associated with severe hypoglycemia might worsen the time below range in the elderly.
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Affiliation(s)
- Norihiro Kuroda
- Division of Diabetes, Endocrinology and Clinical ImmunologyDepartment of Internal MedicineHyogo College of MedicineNishinomiyaJapan
| | - Yoshiki Kusunoki
- Division of Diabetes, Endocrinology and Clinical ImmunologyDepartment of Internal MedicineHyogo College of MedicineNishinomiyaJapan
| | - Keiko Osugi
- Division of Diabetes, Endocrinology and Clinical ImmunologyDepartment of Internal MedicineHyogo College of MedicineNishinomiyaJapan
| | - Mana Ohigashi
- Division of Diabetes, Endocrinology and Clinical ImmunologyDepartment of Internal MedicineHyogo College of MedicineNishinomiyaJapan
| | | | | | | | | | | | | | - Kahori Washio
- Division of Diabetes, Endocrinology and Clinical ImmunologyDepartment of Internal MedicineHyogo College of MedicineNishinomiyaJapan
| | - Taku Tsunoda
- Division of Diabetes, Endocrinology and Clinical ImmunologyDepartment of Internal MedicineHyogo College of MedicineNishinomiyaJapan
| | - Toshihiro Matsuo
- Division of Diabetes, Endocrinology and Clinical ImmunologyDepartment of Internal MedicineHyogo College of MedicineNishinomiyaJapan
| | - Kosuke Konishi
- Division of Diabetes, Endocrinology and Clinical ImmunologyDepartment of Internal MedicineHyogo College of MedicineNishinomiyaJapan
| | - Tomoyuki Katsuno
- School of RehabilitationDepartment of Occupational TherapyHyogo University of Health SciencesKobeJapan
| | - Hidenori Koyama
- Division of Diabetes, Endocrinology and Clinical ImmunologyDepartment of Internal MedicineHyogo College of MedicineNishinomiyaJapan
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Hermann M, Heimro LS, Haugstvedt A, Hernar I, Sigurdardottir AK, Graue M. Hypoglycaemia in older home-dwelling people with diabetes- a scoping review. BMC Geriatr 2021; 21:20. [PMID: 33413148 PMCID: PMC7792330 DOI: 10.1186/s12877-020-01961-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Accepted: 12/14/2020] [Indexed: 12/21/2022] Open
Abstract
Background Hypoglycaemia is associated with cognitive and functional decline in older people with diabetes. Identification of individuals at risk and prevention of hypoglycaemia is therefore an important task in the management of diabetes in older home-dwelling individuals. The purpose of this scoping review was to map the literature on hypoglycaemia in home-dwelling older people with diabetes. Methods This scoping review included original research articles on hypoglycaemia in older (≥ 65 years) individuals with diabetes from developed countries. A broad search of the databases Cinahl, Embase and Medline was performed in July 2018. The report of the scoping review was conducted in accordance with the PRISMA Extension for Scoping Reviews. Results Our database search identified 577 articles of which 23 were eligible for inclusion. The identified literature was within four areas: 1) incidence of hypoglycaemia in older home-dwelling people with diabetes (11/23 articles), 2) risk factors of hypoglycaemia (9/23), 3) diabetes knowledge and self-management (6/23) and 4) consequences of hypoglycaemia for health care use (6/23). The majority of the literature focused on severe hypoglycaemia and the emergency situation. The literature on diabetes knowledge and management related to preventing adverse events relevant to older home-dwellers, was limited. We found no literature on long-term consequences of hypoglycaemia for the use of home health care services and the older persons’ ability to remain home-dwelling. Conclusions We identified a lack of studies on prevention and management of hypoglycaemia in the older individuals’ homes. Such knowledge is of utmost importance in the current situation where most western countries’ governmental policies aim to treat and manage complex health conditions in the patient’s home. Future studies addressing hypoglycaemia in older individuals with diabetes are needed in order to tailor interventions aiming to enable them to remain home-dwelling as long as possible. Supplementary Information The online version contains supplementary material available at 10.1186/s12877-020-01961-6.
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Affiliation(s)
- Monica Hermann
- Faculty of Health and Social Sciences, Institute of Health and Caring Sciences, Western Norway University of Applied Sciences, Stord, Norway.
| | - Lovise S Heimro
- Faculty of Health and Social Sciences, Institute of Health and Caring Sciences, Western Norway University of Applied Sciences, Stord, Norway
| | - Anne Haugstvedt
- Faculty of Health and Social Sciences, Institute of Health and Caring Sciences, Western Norway University of Applied Sciences, Bergen, Norway
| | - Ingvild Hernar
- Faculty of Health and Social Sciences, Institute of Health and Caring Sciences, Western Norway University of Applied Sciences, Bergen, Norway
| | - Arun K Sigurdardottir
- School of Health Sciences, University of Akureyri, Akureyri, Iceland.,Akureyri Hospital, Akureyri, Iceland
| | - Marit Graue
- Faculty of Health and Social Sciences, Institute of Health and Caring Sciences, Western Norway University of Applied Sciences, Bergen, Norway
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9
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Jitschin A, Schleser-Mohr S, Stierling A, Meier JJ, Nauck MA. Risk of hypoglycaemia associated with professional, recreational, and traffic-related activities in patients with type 2 diabetes: a cross-sectional study by questionnaire. Acta Diabetol 2020; 57:965-972. [PMID: 32166401 DOI: 10.1007/s00592-020-01502-y] [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: 12/20/2019] [Accepted: 02/11/2020] [Indexed: 11/30/2022]
Abstract
AIMS We aimed to quantify the exposure to physical exercise associated with professional, recreational, or traffic-related activities in patients with type 2 diabetes, which may provoke or aggravate hypoglycaemic episodes, and to assess whether such risks determine the choice of medications minimizing the risk of hypoglycaemia. METHODS In total, 203 patients with type 2 diabetes (98 women, 105 men, age 65 [56;72; median, inter-quartile range] years, diabetes duration 10 [5;15] years) were recruited from a German diabetes practice. A questionnaire assessed their engagement in professional, recreational, or traffic-related activities. The prescription insulin or sulphonylureas was quantified in relation to the number of such activities. RESULTS 63.5% of the patients were treated with insulin, 7.4% with sulphonylureas, and 70.9% with either. Sixty-six patients (22.7%) were professionally active: 36 (54.4%) of those were professionally exposed to risky behaviour (14 [31.8%] patients with exposure to multiple risks and 20 (30.3%) who experienced hypoglycaemic episodes in the past year). In total, 194 (95.6%) patients were exposed to risky behaviour during recreational activities, 129 (63.6%) to multiple ones. All patients were exposed to traffic-related activities, 144 (70.9%) were exposed to more than being pedestrian, and 24 (11.8%) experienced hypoglycaemic episodes while in traffic. CONCLUSIONS Patients with type 2 diabetes are exposed to risks associated with professional, recreational, and traffic-related activities. We recommend a careful assessment of such risks before glucose-lowering medications with a potential for provoking hypoglycaemic episodes are prescribed.
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Affiliation(s)
- Anne Jitschin
- Diabeteszentrum Bad Lauterberg, Bad Lauterberg im Harz, Germany
| | | | - Almut Stierling
- Diabetes-Schwerpunktpraxis am Gauss-Wall, Göttingen, Germany
| | - Juris J Meier
- Diabetes Division, Katholisches Klinikum Bochum, St. Josef-Hospital (Ruhr-University Bochum), Gudrunstr. 56, 44791, Bochum, Germany
| | - Michael A Nauck
- Diabeteszentrum Bad Lauterberg, Bad Lauterberg im Harz, Germany.
- Diabetes Division, Katholisches Klinikum Bochum, St. Josef-Hospital (Ruhr-University Bochum), Gudrunstr. 56, 44791, Bochum, Germany.
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10
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Singh AK, Patel PK, Choudhary K, Joshi J, Yadav D, Jin JO. Quercetin and Coumarin Inhibit Dipeptidyl Peptidase-IV and Exhibits Antioxidant Properties: In Silico, In Vitro, Ex Vivo. Biomolecules 2020; 10:biom10020207. [PMID: 32023875 PMCID: PMC7072504 DOI: 10.3390/biom10020207] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2019] [Revised: 01/28/2020] [Accepted: 01/29/2020] [Indexed: 02/02/2023] Open
Abstract
Quercetin and coumarin, two naturally occurring phytochemicals of plant origin, are known to regulate hyperglycemia and oxidative stress. The present study was designed to evaluate the inhibitory activity of quercetin and coumarin on dipeptidyl peptidase-IV (DPP-IV) and their antioxidant potential. DPP-IV inhibition assays were performed, and evaluated IC50 values of diprotin A, quercetin, coumarin, and sitagliptin were found to be 0.653, 4.02, 54.83, and 5.49 nmol/mL, respectively. Furthermore, in silico studies such as the drug-likeliness and docking efficiency of quercetin and coumarin to the DPP-IV protein were performed; the ex vivo antiperoxidative potential of quercetin and coumarin were also evaluated. The results of the present study showed that the DPP-IV inhibitory potential of quercetin was slightly higher than that of sitagliptin. Virtual docking revealed the tight binding of quercetin with DPP-IV protein. Quercetin and coumarin reduced oxidative stress in vitro and ex vivo systems. We report for the first time that both compounds inhibited the DPP-IV along with antioxidant activity and thus may be use as function food ingredients in the prevention of diabetes.
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Affiliation(s)
- Anand-Krishna Singh
- Institute of Life Science, Shri Vaishnav Vidyapeeth Vishwavidyalaya, Indore 452111, India
- School of Life Sciences, Devi Ahilya University, Indore, Madhya Pradesh 452001, India; (P.K.P.); (K.C.)
- Correspondence: (A.-K.S.); (D.Y.); (J.-O.J.); Tel.: +91-9713850334 (A.-K.S.); +82-1022021191 (D.Y.); +82-53-810-3033 (J.-O.J.)
| | - Pankaj Kumar Patel
- School of Life Sciences, Devi Ahilya University, Indore, Madhya Pradesh 452001, India; (P.K.P.); (K.C.)
| | - Komal Choudhary
- School of Life Sciences, Devi Ahilya University, Indore, Madhya Pradesh 452001, India; (P.K.P.); (K.C.)
| | - Jaya Joshi
- Oral Pathology and Microbiology, Government Dental College, Indore, Madhya Pradesh 452001, India;
| | - Dhananjay Yadav
- Department of Medical Biotechnology, Yeungnam University, Gyeongsan 712-749, Korea
- Correspondence: (A.-K.S.); (D.Y.); (J.-O.J.); Tel.: +91-9713850334 (A.-K.S.); +82-1022021191 (D.Y.); +82-53-810-3033 (J.-O.J.)
| | - Jun-O Jin
- Department of Medical Biotechnology, Yeungnam University, Gyeongsan 712-749, Korea
- Correspondence: (A.-K.S.); (D.Y.); (J.-O.J.); Tel.: +91-9713850334 (A.-K.S.); +82-1022021191 (D.Y.); +82-53-810-3033 (J.-O.J.)
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11
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Hendriks AM, Schrijnders D, Kleefstra N, de Vries EGE, Bilo HJG, Jalving M, Landman GWD. Sulfonylurea derivatives and cancer, friend or foe? Eur J Pharmacol 2019; 861:172598. [PMID: 31408647 DOI: 10.1016/j.ejphar.2019.172598] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2019] [Revised: 08/07/2019] [Accepted: 08/08/2019] [Indexed: 02/07/2023]
Abstract
Type 2 diabetes mellitus (T2DM) is associated with a higher risk of cancer and cancer-related mortality. Increased blood glucose and insulin levels in T2DM patients may be, at least in part, responsible for this effect. Indeed, lowering glucose and/or insulin levels pharmacologically appears to reduce cancer risk and progression, as has been demonstrated for the biguanide metformin in observational studies. Studies investigating the influence of sulfonylurea derivatives (SUs) on cancer risk have provided conflicting results, partly due to comparisons with metformin. Furthermore, little attention has been paid to within-class differences in systemic and off-target effects of the SUs. The aim of this systematic review is to discuss the available preclinical and clinical evidence on how the different SUs influence cancer development and risk. Databases including PubMed, Cochrane, Database of Abstracts on Reviews and Effectiveness, and trial registries were systematically searched for available clinical and preclinical evidence on within-class differences of SUs and cancer risk. The overall preclinical and clinical evidence suggest that the influence of SUs on cancer risk in T2DM patients differs between the various SUs. Potential mechanisms include differing affinities for the sulfonylurea receptors and thus differential systemic insulin exposure and off-target anti-cancer effects mediated for example through potassium transporters and drug export pumps. Preclinical evidence supports potential anti-cancer effects of SUs, which are of interest for further studies and potentially repurposing of SUs. At this time, the evidence on differences in cancer risk between SUs is not strong enough to guide clinical decision making.
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Affiliation(s)
- Anne M Hendriks
- Department of Medical Oncology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Dennis Schrijnders
- Langerhans Medical Research Group, Zwolle, the Netherlands; Diabetes Center, Isala Hospital, Zwolle, the Netherlands
| | | | - Elisabeth G E de Vries
- Department of Medical Oncology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Henk J G Bilo
- Diabetes Center, Isala Hospital, Zwolle, the Netherlands; Department of Internal Medicine, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Mathilde Jalving
- Department of Medical Oncology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands.
| | - Gijs W D Landman
- Langerhans Medical Research Group, Zwolle, the Netherlands; Department of Internal Medicine, Gelre Hospital, Apeldoorn, the Netherlands
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12
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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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13
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Khalil V, Sajan C, Tsai T, Ma D. Antidiabetics' usage in type 2 diabetes mellitus: Are prescribing guidelines adhered to? A single centre study. Diabetes Metab Syndr 2018; 12:635-641. [PMID: 29666033 DOI: 10.1016/j.dsx.2018.04.005] [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: 02/25/2018] [Accepted: 04/09/2018] [Indexed: 11/26/2022]
Abstract
AIM The primary aim of this study was to examine the prescribing patterns of antidiabetic agents (AA) in this hospital according to current prescribing contraindications (PCI). The secondary aims are to assess factors affecting the prescribing of AA and to evaluate the pharmacist impact on their prescribing. METHOD A retrospective cross sectional study was performed to review all prescribed AA over a 3 month period. Data extracted from medical records included: patients' demographics, management and pharmacists' interventions. Appropriateness of prescribing was determined according to the AA prescribing information of the Medical Index of Medical Specialities (MIMS). RESULTS A total of 314 AA were examined, of which 74(23%) orders were prescribed despite contraindications. Metformin was the AA to have the most PCI in dosage adjustments in renal impairment (RI). Logistic regression analysis showed patients with severe RI were less likely to be prescribed metformin (OR = 0.115 95%CI(0.048-0.274) P < 0.01), instead insulin was preferred (OR = 2.210 95%CI (1.028-4.751) P < 0.05). Insulin was also more likely to be prescribed in patients with hypertension and hyperglycaemia (OR=2.005 95%CI(1.005-4.001) P < 0.05, OR = 3.535 95%CI(1.756-7.113) P < 0.01) respectively. Sulphonylureas were less likely to be prescribed in patients with cardiovascular disease (OR = 0.339 95%CI(0.163-0.708), P < 0.01. There was low PCI in the other AA. Pharmacists reviewed 89% of AA. PCI was lower in this group compared to those with no pharmacist input (23% vs 28%). CONCLUSION The audit showed good adherence to PCI. Pharmacist involvement has a positive impact on AP. Prescriber education is required in relation to dosage adjustments of AA in RI.
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Affiliation(s)
- Viviane Khalil
- Peninsula Health, 2 Hastings Rd, Frankston Vic, 3199, Australia; Monash University, Department of Postgraduate studies and professional Development Parkville, Vic, 3052, Australia.
| | - Christy Sajan
- Peninsula Health, 2 Hastings Rd, Frankston Vic, 3199, Australia.
| | - Tiffany Tsai
- Peninsula Health, 2 Hastings Rd, Frankston Vic, 3199, Australia.
| | - David Ma
- Peninsula Health, 2 Hastings Rd, Frankston Vic, 3199, Australia.
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14
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Dissanayake HA, Keerthisena GSP, Gamage KKK, Liyanage JH, Ihalagama IRHS, Wijetunga WMUA, Tillekaratne TAD, Katulanda GW, Katulanda P. Hypoglycaemia in diabetes: do we think enough of the cause? An observational study on prevalence and causes of hypoglycaemia among patients with type 2 diabetes in an out-patient setting in Sri Lanka. BMC Endocr Disord 2018; 18:35. [PMID: 29884151 PMCID: PMC5994038 DOI: 10.1186/s12902-018-0264-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2017] [Accepted: 06/01/2018] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Hypoglycaemia is a feared experience for people with diabetes. We aimed to study the prevalence and causes of hypoglycaemia among Sri Lankans with diabetes. METHODS One thousand patients with diabetes attending a private sector diabetic clinic were interviewed using a structured questionnaire. Hypoglycaemic episodes within the preceding month were inquired and severity was graded according to clinical features and/or capillary blood glucose levels. RESULTS Mean age 55.0 years (± 12.5), 58.6% were males, mean diabetes duration 10.6 years (± 8.1), mean FPG 7.48 mmol/l (± 2.79) and mean HbA1c 7.82% (± 1.71) (62 mmol/mol). Of them, 26.1%. (mild 20.7%, moderate 3.9%, and severe 1.5%) experienced symptomatic hypoglycaemia. Sudden change diet (46.7%), unaccustomed exercise (15.7%) and increase in antihyperglycaemic therapy dosage (14.9%) were the recognized causes. Cause was not recognized by 16.3%. Non-prescribed native food items accounted for hypoglycaemia in 16.9% of patients (Momordica charantia 54.5%, Costus speciosus 52.3%, Salacia prinoides 11.4%, Coccinia grandis 6.8%, Adenanthera pavonina 4.5%). Severity of hypoglycaemia was positively correlated to age and duration of diabetes but not to HbA1C. CONCLUSION Hypoglycaemia is common among patients with diabetes. Patients need advice on regular diet and exercise. Consumption of non-prescribed native foods should be considered as a possible cause.
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Affiliation(s)
- H. A. Dissanayake
- Diabetes Research Unit, Department of Clinical Medicine, Faculty of Medicine, University of Colombo, Colombo, Sri Lanka
- University Medical Unit, National Hospital of Sri Lanka, Colombo 10, Sri Lanka
| | - G. S. P. Keerthisena
- Diabetes Research Unit, Department of Clinical Medicine, Faculty of Medicine, University of Colombo, Colombo, Sri Lanka
| | - K. K. K. Gamage
- Diabetes Research Unit, Department of Clinical Medicine, Faculty of Medicine, University of Colombo, Colombo, Sri Lanka
| | - J. H. Liyanage
- Diabetes Research Unit, Department of Clinical Medicine, Faculty of Medicine, University of Colombo, Colombo, Sri Lanka
| | - I. R. H. S. Ihalagama
- Diabetes Research Unit, Department of Clinical Medicine, Faculty of Medicine, University of Colombo, Colombo, Sri Lanka
| | - W. M. U. A. Wijetunga
- Diabetes Research Unit, Department of Clinical Medicine, Faculty of Medicine, University of Colombo, Colombo, Sri Lanka
| | - T. A. D. Tillekaratne
- Diabetes Research Unit, Department of Clinical Medicine, Faculty of Medicine, University of Colombo, Colombo, Sri Lanka
| | | | - P. Katulanda
- Diabetes Research Unit, Department of Clinical Medicine, Faculty of Medicine, University of Colombo, Colombo, Sri Lanka
- Oxford Centre for Diabetes, Endocrinology and Metabolism, University of Oxford, Oxford, UK
- Cruddas Link Fellow, Harris Manchester University, University of Oxford, Oxford, UK
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15
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[Essence and Perspective of the JGS/JDS Clinical Practice Guideline for the Treatment of Diabetes in the Elderly]. Nihon Ronen Igakkai Zasshi 2018; 55:1-12. [PMID: 29503351 DOI: 10.3143/geriatrics.55.1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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16
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Namba M, Iwakura T, Nishimura R, Akazawa K, Matsuhisa M, Atsumi Y, Satoh J, Yamauchi T. The current status of treatment-related severe hypoglycemia in Japanese patients with diabetes mellitus: A report from the committee on a survey of severe hypoglycemia in the Japan Diabetes Society. J Diabetes Investig 2018; 9:642-656. [PMID: 29498232 PMCID: PMC5934273 DOI: 10.1111/jdi.12790] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2017] [Accepted: 12/14/2017] [Indexed: 01/17/2023] Open
Abstract
Despite great strides in pharmacotherapy for diabetes, there is increasing concern over the risk of hypoglycemia in patients with diabetes receiving pharmacotherapy as they become increasingly older. This has prompted the Japan Diabetes Society (JDS) to initiate a survey on the current status of severe hypoglycemia in clinical settings. In July 2015, following approval from the JDS Scientific Survey/Research Ethics Committee, the JDS extended an invitation to executive educators, who represented a total of 631 healthcare facilities accredited by the JDS for diabetes education, to participate in the proposed survey. Of these, those who expressed their willingness to participate in the survey were sent an application form required for obtaining ethical approval at these healthcare facilities and were then asked, following approval, to enter relevant clinical data on an unlinked, anonymous basis in a web-based registry. The current survey was fully funded by the JDS Scientific Survey/Research Committee. A case registry (clinical case database) was launched after facility-specific information (healthcare facility database) was collected from all participating facilities and after informed consent was obtained from all participating patients. With severe hypoglycemia defined as the "presence of hypoglycemic symptoms requiring assistance from another person to treat and preferably venous plasma glucose levels at onset/diagnosis of disease or at presentation clearly less than 60 mg/dL (capillary whole blood glucose, less than 50 mg/dL)", the current survey was conducted between April 1, 2014 and March 31, 2015, during which facility-specific information was collected from a total of 193 facilities with a total of 798 case reports collected from 113 facilities. Of the 193 respondent facilities, 149 reported having an emergency department as well, with the median number of patients who required emergency transportation services to reach these facilities totaling 4,962 annually, of which those with severe hypoglycemia accounted for 0.34% (17). The respondent facilities accommodated a total of 2,237 patients with severe hypoglycemia annually, with the number of patients thus accommodated being 6.5 patients per site. A total of 1,171 patients were admitted for severe hypoglycemia, with the number of patients thus admitted being 4.0 per site, who accounted for 52.3% of all patients visiting annually for severe hypoglycemia. A review of the 798 case reports collected during the survey revealed that 240, 480 and 78 patients had type 1 diabetes, type 2 diabetes, and other types of diabetes, respectively; those with type 2 diabetes were shown to be significantly older (median [interquartile range], 77.0 [68.0-83.0]) than those with type 1 diabetes (54.0 [41.0-67.0]) (P < 0.001); and the BMI was shown to be significantly higher for those with type 2 diabetes (22.0 [19.5-24.8] kg/m2 ) than for those with type 1 diabetes (21.3 [18.9-24.0] kg/m2 ) (P = 0.003). It was also found that the median estimated glomerular filtration rate (eGFR) was significantly lower among those with type 2 diabetes (50.6 mL [31.8-71.1]/min/1.73 m2 ) than among those with type 1 diabetes (73.3 [53.5-91.1] mL/min/1.73 m2 ) (P < 0.001). Again, the median HbA1c value at onset of severe hypoglycemia was shown to be 7.0 (6.3-8.1)% among all patients examined, 7.5 (6.9-8.6)% among those with type 1 diabetes, and 6.8 (6.1-7.6)% among those with type 2 diabetes, with the HbA1c value at onset of hypoglycemia being significantly lower among those with type 2 diabetes (P < 0.001). Antecedent symptoms of severe hypoglycemia were shown to be present, absent and unknown in 35.5, 35.6, and 28.9% of all patients, respectively, with the incidence of symptomatic hypoglycemia being significantly lower among those with type 1 diabetes (41.0%) than among those with type 2 diabetes (56.9%). The antidiabetic agents used in those with type 2 diabetes were insulin preparations (292 patients including 29 receiving concomitant sulfonylureas [SUs]) (60.8%), SUs (159 insulin-naïve patients) (33.1%), and no insulin preparations or SUs (29 patients) (6.0%). Of the 798 patients surveyed, 296 patients (37.2%) were shown to have required emergency transportation services for severe hypoglycemia before. Thus, the survey revealed, for the first time, the current status of treatment-related severe hypoglycemia in Japan and clearly highlights the acute need for implementing preventive measures against hypoglycemia not only through education on hypoglycemia but through optimization of antidiabetic therapy for those at high risk of severe hypoglycemia or those with a history of severe hypoglycemia.
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Affiliation(s)
| | - Toshio Iwakura
- Diabetes and EndocrinologyKobe City Medical Center General HospitalKobeJapan
| | - Rimei Nishimura
- Department of Diabetes, Metabolism and EndocrinologyJikei University School of MedicineTokyoJapan
| | - Kohei Akazawa
- Department of Medical InformaticsNiigata University Medical & Dental HospitalNiigataJapan
| | - Munehide Matsuhisa
- Diabetes Therapeutics and Research CenterInstitute of Advanced Medical SciencesTokushima UniversityTokushimaJapan
| | | | - Jo Satoh
- Tohoku Medical and Pharmaceutical University Wakabayashi HospitalSendaiJapan
| | - Toshimasa Yamauchi
- Department of Diabetes and Metabolic DiseasesGraduate School of MedicineUniversity of TokyoTokyoJapan
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The current status of treatment-related severe hypoglycemia in Japanese patients with diabetes mellitus: a report from the committee on a survey of severe hypoglycemia in the Japan Diabetes Society. Diabetol Int 2018; 9:84-99. [PMID: 30603355 DOI: 10.1007/s13340-018-0346-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2018] [Indexed: 01/21/2023]
Abstract
Despite great strides in pharmacotherapy for diabetes, there is increasing concern over the risk of hypoglycemia in patients with diabetes receiving pharmacotherapy as they become increasingly older. This has prompted the Japan Diabetes Society (JDS) to initiate a survey on the current status of severe hypoglycemia in clinical settings. In July 2015, following approval from the JDS Scientific Survey/Research Ethics Committee, the JDS extended an invitation to executive educators, who represented a total of 631 health-care facilities accredited by the JDS for diabetes education, to participate in the proposed survey. Of these, those who expressed their willingness to participate in the survey were sent an application form required for obtaining ethical approval at these health-care facilities and were then asked, following approval, to enter relevant clinical data on an unlinked, anonymous basis in a Web-based registry. The current survey was fully funded by the JDS Scientific Survey/Research Committee. A case registry (clinical case database) was launched after facility-specific information (healthcare facility database) was collected from all participating facilities and after informed consent was obtained from all participating patients. With severe hypoglycemia defined as the "presence of hypoglycemic symptoms requiring assistance from another person to treat and preferably venous plasma glucose levels at onset/diagnosis of disease or at presentation clearly less than 60 mg/dL (capillary whole blood glucose, less than 50 mg/dL)", the current survey was conducted between April 1, 2014 and March 31, 2015, during which facility-specific information was collected from a total of 193 facilities with a total of 798 case reports collected from 113 facilities. Of the 193 respondent facilities, 149 reported having an emergency department as well, with the median number of patients who required emergency transportation services to reach these facilities totaling 4962 annually, of which those with severe hypoglycemia accounted for 0.34% (17). The respondent facilities accommodated a total of 2237 patients with severe hypoglycemia annually, with the number of patients thus accommodated being 6.5 patients per site. A total of 1171 patients were admitted for severe hypoglycemia, with the number of patients thus admitted being 4.0 per site, who accounted for 52.3% of all patients visiting annually for severe hypoglycemia. A review of the 798 case reports collected during the survey revealed that 240, 480, and 78 patients had type 1 diabetes, type 2 diabetes, and other types of diabetes, respectively; those with type 2 diabetes were shown to be significantly older [median (interquartile range), 77.0 (68.0-83.0)] than those with type 1 diabetes [54.0 (41.0-67.0)] (P < 0.001); and the BMI was shown to be significantly higher for those with type 2 diabetes [22.0 (19.5-24.8) kg/m2] than for those with type 1 diabetes [21.3 (18.9-24.0) kg/m2] (P = 0.003). It was also found that the median estimated glomerular filtration rate (eGFR) was significantly lower among those with type 2 diabetes [50.6 mL (31.8-71.1)/min/1.73 m2] than among those with type 1 diabetes [73.3 (53.5-91.1) mL/min/1.73 m2] (P < 0.001). Again, the median HbA1c value at onset of severe hypoglycemia was shown to be 7.0 (6.3-8.1)% among all patients examined, 7.5 (6.9-8.6)% among those with type 1 diabetes, and 6.8 (6.1-7.6)% among those with type 2 diabetes, with the HbA1c value at onset of hypoglycemia being significantly lower among those with type 2 diabetes (P < 0.001). Antecedent symptoms of severe hypoglycemia were shown to be present, absent, and unknown in 35.5, 35.6, and 28.9% of all patients, respectively, with the incidence of symptomatic hypoglycemia being significantly lower among those with type 1 diabetes (41.0%) than among those with type 2 diabetes (56.9%). The antidiabetic agents used in those with type 2 diabetes were insulin preparations (292 patients including 29 receiving concomitant sulfonylureas [SUs]) (60.8%), SUs (159 insulin-naïve patients) (33.1%), and no insulin preparations or SUs (29 patients) (6.0%). Of the 798 patients surveyed, 296 patients (37.2%) were shown to have required emergency transportation services for severe hypoglycemia before. Thus, the survey revealed, for the first time, the current status of treatment-related severe hypoglycemia in Japan and clearly highlights the acute need for implementing preventive measures against hypoglycemia, not only through education on hypoglycemia but also through optimization of antidiabetic therapy for those at high risk of severe hypoglycemia or those with a history of severe hypoglycemia.
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18
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Yakaryılmaz FD, Öztürk ZA. Treatment of type 2 diabetes mellitus in the elderly. World J Diabetes 2017; 8:278-285. [PMID: 28694928 PMCID: PMC5483426 DOI: 10.4239/wjd.v8.i6.278] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2017] [Revised: 05/05/2017] [Accepted: 05/19/2017] [Indexed: 02/05/2023] Open
Abstract
The prevalence of type 2 diabetes is expected to increase gradually with the prolongation of population aging and life expectancy. In addition to macrovascular and microvascular complications of elderly patients of diabetes mellitus, geriatric syndromes such as cognitive impairment, depression, urinary incontinence, falling and polypharmacy are also accompanied by aging. Individual functional status in the elderly shows heterogeneity so that in these patients, there are many unanswered questions about the management of diabetes treatment. The goals of diabetes treatment in elderly patients include hyperglycemia and risk factors, as in younger patients. comorbid diseases and functional limitations of individuals should be taken into consideration when setting treatment targets. Thus, treatment should be individualized. In the treatment of diabetes in vulnerable elderly patients, hypoglycemia, hypotension, and drug interactions due to multiple drug use should be avoided. Since it also affects the ability to self-care in these patients, management of other concurrent medical conditions is also important.
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19
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Pratley RE, Heller SR, Miller MA. Treatment of type 2 diabetes mellitus in the older adult: a review. Endocr Pract 2016; 20:722-36. [PMID: 24518176 DOI: 10.4158/ep13192.ra] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
OBJECTIVE This review summarizes the particular challenges of diabetes in older individuals and the evidence base guiding the selection of treatment targets and strategies in this population. METHODS An in-depth literature search was conducted to identify the evidence base from randomized, controlled, and population-based epidemiological studies, as well as guidelines derived from expert opinion. RESULTS Older patients are a highly heterogeneous population with respect to the pathogenesis and course of diabetes and, as a group, manifest significant comorbidities that impact treatment goals and strategies. There is a lack of consensus regarding "optimal" glucose targets in older patients with diabetes. Hypoglycemia is more common in the older patient, contributes to increased morbidity and reduced quality of life, and limits treatment in many cases. Duration of diabetes, comorbidities, life expectancy, and functional status are other important factors to consider when identifying appropriate glycemic goals and choosing an antihyperglycemic agent for older patients with type 2 diabetes mellitus (T2DM). CONCLUSION Current, limited treatment recommendations in older patients with T2DM are based on expert opinion due to the general lack of evidence from randomized controlled trials. This underscores the importance of individualizing pharmacologic therapy in these patients with a focus on the risk-to-benefit ratio. Additional trials in older patients are needed to assess drug safety, efficacy, and dosing.
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Affiliation(s)
- Richard E Pratley
- Florida Hospital Diabetes and Translational Research Institutes, Sanford Burnham Medical Research Institute, Orlando, Florida
| | - Simon R Heller
- Sheffield Teaching Hospitals Foundation Trust, University of Sheffield, Sheffield, United Kingdom
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20
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van Dalem J, Brouwers MCGJ, Stehouwer CDA, Krings A, Leufkens HGM, Driessen JHM, de Vries F, Burden AM. Risk of hypoglycaemia in users of sulphonylureas compared with metformin in relation to renal function and sulphonylurea metabolite group: population based cohort study. BMJ 2016; 354:i3625. [PMID: 27413017 PMCID: PMC4948031 DOI: 10.1136/bmj.i3625] [Citation(s) in RCA: 52] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
OBJECTIVE To determine the association between use of sulphonylureas and risk of hypoglycaemia in relation to renal function and sulphonylurea metabolic group compared with use of metformin. DESIGN Population based cohort study using routinely collected data from general practices in England. SETTING Clinical Practice Research Datalink (CPRD) database, 2004-12. PARTICIPANTS 120 803 new users of a non-insulin antidiabetic agent with at least one prescription and aged 18 years or more. The first prescription defined start of follow-up. Patients were followed until the end of data collection, a record for hypoglycaemia, or a blood glucose level of less than 3.0 mmol/L. MAIN OUTCOME MEASURES Associations between sulphonylurea dose, renal impairment, type of sulphonylurea used, and risk of hypoglycaemia, were determined using Cox proportional hazard models. Adjustments were made for age, sex, lifestyle, comorbidity, and drug use. RESULTS The risk of hypoglycaemia in current users of sulphonylureas only was significantly increased compared with current users of metformin only (adjusted hazard ratio 2.50, 95% confidence interval 2.23 to 2.82). The higher risk in current users of sulphonylureas only was further increased in patients with an estimated glomerular filtration rate of less than 30 mL/min/1.73 m(2) (4.96, 3.76 to 6.55). The risk of hypoglycaemia was also significantly higher in patients with a high sulphonylurea dose (3.12, 2.68 to 3.62) and in current users of glibenclamide (7.48, 4.89 to 11.44). Gliclazide, the sulphonylurea of first choice, showed a similar risk of hypoglycaemia compared with other sulphonylureas. CONCLUSIONS Sulphonylurea treatment in patients with a renal function of less than 30 mL/min/1.73 m(2) should be considered with caution. Moreover, an increased risk of hypoglycaemic events was observed among all users of sulphonylureas. This contrasts with several guidelines that recommend gliclazide as first choice sulphonylurea, and therefore requires further investigation.
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Affiliation(s)
- Judith van Dalem
- Department of Clinical Pharmacy, Maastricht University Medical Centre, Maastricht, Netherlands Department of Clinical Pharmacy, Zuyderland MC, Heerlen, Netherlands Care and Public Health Research Institute (CAPHRI), Maastricht, Netherlands
| | - Martijn C G J Brouwers
- Department of Internal Medicine, Division of Endocrinology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre, Maastricht, Netherlands
| | - Coen D A Stehouwer
- Department of Internal Medicine, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre, Maastricht, Netherlands
| | - André Krings
- Department of Clinical Pharmacy, Zuyderland MC, Heerlen, Netherlands
| | - Hubert G M Leufkens
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences Utrecht University, PO Box 80082, 3508 TB Utrecht, Netherlands
| | - Johanna H M Driessen
- Department of Clinical Pharmacy, Maastricht University Medical Centre, Maastricht, Netherlands Care and Public Health Research Institute (CAPHRI), Maastricht, Netherlands Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences Utrecht University, PO Box 80082, 3508 TB Utrecht, Netherlands
| | - Frank de Vries
- Department of Clinical Pharmacy, Maastricht University Medical Centre, Maastricht, Netherlands Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences Utrecht University, PO Box 80082, 3508 TB Utrecht, Netherlands
| | - Andrea M Burden
- Department of Clinical Pharmacy, Maastricht University Medical Centre, Maastricht, Netherlands Care and Public Health Research Institute (CAPHRI), Maastricht, Netherlands Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences Utrecht University, PO Box 80082, 3508 TB Utrecht, Netherlands
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21
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Schloot NC, Haupt A, Schütt M, Badenhoop K, Laimer M, Nicolay C, Reaney M, Fink K, Holl RW. Risk of severe hypoglycemia in sulfonylurea-treated patients from diabetes centers in Germany/Austria: How big is the problem? Which patients are at risk? Diabetes Metab Res Rev 2016; 32:316-24. [PMID: 26409039 DOI: 10.1002/dmrr.2722] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2015] [Revised: 08/18/2015] [Accepted: 08/31/2015] [Indexed: 12/21/2022]
Abstract
BACKGROUND We investigated the rate of severe hypoglycemic events and confounding factors in patients with type 2 diabetes treated with sulfonylurea at specialized diabetes centers, documented in the German/Austrian DPV-Wiss database. METHODS Data from 29 485 sulfonylurea-treated patients were analyzed (median[IQR] age 70.8[62.2-77.8] years, diabetes duration 8.2[4.3-12.8] years). The primary objective was to estimate the event rate of severe hypoglycemia (requiring external help, causing unconsciousness/coma/convulsion and/or emergency hospitalization). Secondary objectives included exploration of confounding risk factors through group comparison and Poisson regression. RESULTS Severe hypoglycemic events were reported in 826(2.8%) of all patients during their most recent year of sulfonylurea treatment. Of these, n = 531(1.8%) had coma, n = 501(1.7%) were hospitalized at least once. The adjusted event rate of severe hypoglycemia [95%CI] was 3.9[3.7-4.2] events/100 patient-years (coma: 1.9[1.8-2.1]; hospitalization: 1.6[1.5-1.8]). Adjusted event rates by diabetes treatment were 6.7 (sulfonylurea + insulin), 4.9 (sulfonylurea + insulin + other OAD), 3.1 (sulfonylurea + other OAD) and 3.8 (sulfonylurea only). Patients with ≥1 severe event were older (p < 0.001) and had longer diabetes duration (p = 0.020) than patients without severe events. Participation in educational diabetes-programs and indirect measures of insulin-resistance (increased BMI, plasma-triglycerides) were associated with fewer events (all p < 0.001). Impaired renal function was common (n = 3113 eGFR; ≤30 mL/min) and associated with an increased rate of severe events (≤30 mL/min: 7.7; 30-60 mL/min: 4.8; >60 mL/min: 3.9). CONCLUSIONS These real-life data showed a rate of severe hypoglycemia of 3.9/100 patient-years in sulfonylurea-treated patients from specialized diabetes centers. Higher risk was associated with known risk factors including lack of diabetes education, older age and decreased eGFR but also with lower BMI and lower triglyceride levels, suggesting that sulfonylurea treatment in those patients should be considered with caution.
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Affiliation(s)
- Nanette C Schloot
- Medical BU Diabetes, Lilly Deutschland GmbH, Bad Homburg, Bad Homburg, Germany
- Institute for Clinical Diabetology, German Diabetes Center, Heinrich Heine University, Düsseldorf, Germany
| | - Axel Haupt
- Medical BU Diabetes, Lilly Deutschland GmbH, Bad Homburg, Bad Homburg, Germany
| | - Morten Schütt
- Department of Internal Medicine I, University of Lübeck, Lübeck, Germany
| | - Klaus Badenhoop
- Department of Internal Medicine I, Division of Endocrinology and Metabolism, Goethe University Hospital, Frankfurt am Main, Germany
| | - Markus Laimer
- Department of Internal Medicine I, Medical University of Innsbruck, Innsbruck, Austria
- Division of Endocrinology, Diabetes & Clinical Nutrition, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Claudia Nicolay
- European Statistics, Diabetes (HTA/Medical Affairs), Lilly Deutschland GmbH, Bad Homburg, Bad Homburg, Germany
| | - Matthew Reaney
- eResearchTechnology Limited (ERT), Peterborough, United Kingdom
| | - Katharina Fink
- Institute for Epidemiology and Medical Biometry (ZIBMT), German Center for Diabetes Research (DZD), University Ulm, Ulm, Germany
| | - Reinhard W Holl
- Institute for Epidemiology and Medical Biometry (ZIBMT), German Center for Diabetes Research (DZD), University Ulm, Ulm, Germany
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22
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Jafari B, Britton ME. Hypoglycaemia in elderly patients with type 2 diabetes mellitus: a review of risk factors, consequences and prevention. JOURNAL OF PHARMACY PRACTICE AND RESEARCH 2015. [DOI: 10.1002/jppr.1163] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Affiliation(s)
- Badieh Jafari
- Department of General Medicine and Aged Care; Hervey Bay Hospital; Queensland Australia
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23
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Salutini E, Bianchi C, Santini M, Dardano A, Daniele G, Penno G, Miccoli R, Del Prato S. Access to emergency room for hypoglycaemia in people with diabetes. Diabetes Metab Res Rev 2015; 31:745-51. [PMID: 26044573 DOI: 10.1002/dmrr.2667] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2015] [Revised: 05/08/2015] [Accepted: 05/10/2015] [Indexed: 11/12/2022]
Abstract
BACKGROUND Hypoglycaemia is a major burden of the pharmacological therapy of diabetes and is associated with increased morbidity, mortality and treatment costs. METHODS We screened all admissions to the emergency room of the Pisa University Hospital from 1 January 2009 to 31 December 2013, selecting individuals with a discharge diagnosis of hypoglycaemia. We retrieved 500 admissions involving adult diabetic patients: age 71 ± 16 years; M/F 50.2/49.8%; 70.2% type 2 diabetes (T2DM). RESULTS Among T2DM, 42.2% were on insulin, 10.8% on insulin plus oral anti-diabetes drugs and 38.2% on oral anti-diabetes drugs alone (92% sulphonylureas/glinides ± insulin-sensitizers). Glibenclamide was the most frequently used sulphonylurea (69%). Individuals treated with oral anti-diabetes drugs were older than those on insulin (79 ± 11 versus 74 ± 12 years; p < 0.0001). Among patients taking sulphonylurea, 47% had estimated glomerular filtration rate <60 mL/min/1.73 m(2) and 13.5% had <30 mL/min/1.73 m(2) . In-hospital admission occurred in 20% of cases. Hospitalized patients with T2DM were older than those discharged (80 ± 10 versus 76 ± 12 years, p < 0.01) and were on oral antidiabetic drugs in 54.8% of the cases, whereas 35.7% were on insulin (χ(2) , p < 0.0001) and 8.3% on combined therapy. Notably, 93.5% of those on oral anti-diabetic drugs were taking a secretagogue. Insulin-treated subjects were younger than those treated with oral anti-diabetic drugs alone (77 ± 12 versus 82 ± 7 years; p < 0.02). The mean in-hospital annual mortality rate was 85 deaths per 1000 patients-year. CONCLUSIONS Our results support the recommendation that the risk associated with insulin and insulin-secretagogues should be carefully assessed, particularly when prescribed in vulnerable patients with T2DM.
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Affiliation(s)
- Elisabetta Salutini
- Department of Clinical and Experimental Medicine - Section of Diabetes and Metabolic Diseases, University of Pisa, Pisa, Italy
| | - Cristina Bianchi
- Department of Clinical and Experimental Medicine - Section of Diabetes and Metabolic Diseases, University of Pisa, Pisa, Italy
| | - Massimo Santini
- Department of Emergency - Emergency Medicine Section, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
| | - Angela Dardano
- Department of Clinical and Experimental Medicine - Section of Diabetes and Metabolic Diseases, University of Pisa, Pisa, Italy
| | - Giuseppe Daniele
- Department of Clinical and Experimental Medicine - Section of Diabetes and Metabolic Diseases, University of Pisa, Pisa, Italy
| | - Giuseppe Penno
- Department of Clinical and Experimental Medicine - Section of Diabetes and Metabolic Diseases, University of Pisa, Pisa, Italy
| | - Roberto Miccoli
- Department of Clinical and Experimental Medicine - Section of Diabetes and Metabolic Diseases, University of Pisa, Pisa, Italy
| | - Stefano Del Prato
- Department of Clinical and Experimental Medicine - Section of Diabetes and Metabolic Diseases, University of Pisa, Pisa, Italy
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Weir MR, Gravens-Muller L, Costa N, Ivanova A, Manitpisitkul W, Bostom AG, Diamantidis CJ. Safety events in kidney transplant recipients: results from the folic Acid for vascular outcome reduction in transplant trial. Transplantation 2015; 99:1003-8. [PMID: 25393158 DOI: 10.1097/tp.0000000000000454] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Kidney transplant recipients are at increased risk for adverse safety events related to their reduced renal function and many medications. METHODS We determined the incidence of adverse safety events based on previously defined Agency for Healthcare and Research Quality (AHRQ) International Classification of Diseases-9 (ICD-9) code-derived patient safety indicators (PSI) in the Folic Acid for Vascular Outcome Reduction in Transplant trial participants who had a hospitalization stratified by tertiles of estimated glomerular filtration rate (GFR). We also examined the frequency of Micromedex defined two precautionary drug-drug interactions, and two medications whose use may be contraindicated because of reduced GFR from the Folic Acid for Vascular Outcome Reduction in Transplant trial medication thesaurus at baseline, and annually among 4,110 participants. Logistic regression was used to examine the relationship between patient safety events and baseline demographic and clinical variables at a participant level. Event rates were estimated at participant and visit levels. RESULTS Of the 2,514 patients with a hospitalization, 978 (38.9%) experienced an AHRQ PSI. Factors which were associated with more common AHRQ PSI included: U.S. location, history of cardiovascular disease or diabetes, and lower tertile of estimated GFR. At a participant level, 2,524 of the 4,110 participants (61.4%) were taking calcineurin inhibitor and statin, 378 (9.2%) were taking azathioprine and an angiotensin-converting enzyme inhibitor, 171 (12.9%) were taking a sulfonylurea), 45 (3.4%) were taking metformin despite a baseline GFR below 40 mL per min per 1.73 m. CONCLUSION We conclude that patient safety events are not uncommon in kidney transplant recipients. Careful monitoring is necessary to prevent adverse outcomes.
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Affiliation(s)
- Matthew R Weir
- 1 Division of Nephrology, Department of Medicine, University of Maryland School of Medicine, Baltimore, MD. 2 Department of Biostatistics, University of North Carolina, Chapel Hill, NC. 3 Department of Pharmacy, University of Maryland Medical Center, Baltimore, MD. 4 Rhode Island Hospital, Brown University School of Medicine, Providence, RI
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25
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Lapane KL, Jesdale BM, Dubé CE, Pimentel CB, Rajpathak SN. Sulfonylureas and risk of falls and fractures among nursing home residents with type 2 diabetes mellitus. Diabetes Res Clin Pract 2015; 109:411-9. [PMID: 26008723 DOI: 10.1016/j.diabres.2015.05.009] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2014] [Revised: 02/11/2015] [Accepted: 05/02/2015] [Indexed: 11/28/2022]
Abstract
AIMS Although sulfonylureas increase the risk of hypoglycemia which may lead to fall-associated fractures, studies quantifying the association between sulfonylureas and falls and/or fractures are sparse and existing studies have yielded inconsistent results. Our objective is to evaluate the extent to which sulfonylurea use was associated with fractures and falls among nursing home residents with type 2 diabetes mellitus. METHODS We performed a propensity-matched retrospective new user cohort study of 12,327 Medicare Parts A/B/D eligible long-stay NH residents. Medicare Part D data provided information on sulfonylurea and biguanide use initiated as monotherapy (nsulfonylurea=5807 and nbiguanide=6151) after NH entry. Medicare hospitalizations were used to identify hypoglycemic events (ICD-9-CM codes 250.8, 251.1, 251.2) and fall-associated fractures (ICD-9-CM codes 800, 804, 812-817, 820, 823, 824). Minimum Data Set 2.0 (2008-2010) provided information on falls and potential confounders. Cox models conducted on propensity-matched samples provided adjusted hazard ratio (aHR) estimates and 95% confidence intervals (CI). RESULTS Falls were common (37.4 per 100 person-years). Fractures were not associated with initiation of sulfonylureas. Sulfonylurea initiation was associated with an excess risk of falls among residents with moderate activities of daily living limitations (aHR: 1.13; 95% CI: 1.00-1.26), but not among those with minimal limitations or dependence in activities of daily living. CONCLUSIONS Nursing home residents with moderate limitations in activities of daily living are at increased risk of falls upon initiation of sulfonylureas. Initiating sulfonylurea use in NH residents must be done with caution.
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Affiliation(s)
- Kate L Lapane
- Department of Quantitative Health Sciences, University of Massachusetts Medical School, 368 Plantation Street, Worcester, MA 01605, USA.
| | - Bill M Jesdale
- Department of Quantitative Health Sciences, University of Massachusetts Medical School, 368 Plantation Street, Worcester, MA 01605, USA
| | - Catherine E Dubé
- Department of Quantitative Health Sciences, University of Massachusetts Medical School, 368 Plantation Street, Worcester, MA 01605, USA
| | - Camilla B Pimentel
- Clinical and Population Health Research Program, Graduate School of Biomedical Sciences, University of Massachusetts Medical School, 368 Plantation Street, Worcester, MA 01605, USA
| | - Swapnil N Rajpathak
- US Outcomes Research, Merck & Co., Inc., 1 Merck Drive, Whitehouse Station, NJ 08889, USA
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26
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Gomha SM, Eldebss TMA, Badrey MG, Abdulla MM, Mayhoub AS. Novel 4-heteroaryl-antipyrines as DPP-IV inhibitors. Chem Biol Drug Des 2015; 86:1292-303. [PMID: 26032047 DOI: 10.1111/cbdd.12593] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2015] [Revised: 05/06/2015] [Accepted: 05/22/2015] [Indexed: 01/24/2023]
Abstract
Type 2 diabetes mellitus is a vast growing progressive disease that almost affects one person among every twelve globally. Regardless the availability of wide variety of oral hypoglycemics, only one-third of patients achieves proper glycemic control. With the advantage of the low risk of hypoglycemia, DPP-IV attracted the attention of medicinal chemists as a new target for oral hypoglycemics. In this report, a lead compound 1, with antipyrine scaffold, was obtained, and its binding mode was calculated. Several derivatives with bridged nitrogenous heterocycles have been synthesized via multicomponent reaction under controlled microwave heating conditions. The antidiabetic activity versus DPP-IV protein was evaluated and compared with sitagliptin. Compounds with smaller- or medium-sized nitrogenous bridges were comparable with sitagliptin in terms of DPP-IV inhibitory activity, potentially via targeting Glu203 and Glu204. The oral hypoglycemic activities of compounds with submicromolar IC50 values were further evaluated using diabetic mouse model.
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Affiliation(s)
- Sobhi M Gomha
- Department of Chemistry, Faculty of Science, Cairo University, Giza, 12613, Egypt
| | - Taha M A Eldebss
- Department of Chemistry, Faculty of Science, Cairo University, Giza, 12613, Egypt
| | - Mohamed G Badrey
- Chemistry Department, Faculty of Science, Fayoum University, El-Fayoum, 63514, Egypt
| | | | - Abdelrahman S Mayhoub
- Department of Organic Chemistry, Faculty of Pharmacy, Al-Azhar University, Cairo, 11884, Egypt.,Al-Andalous for Pharmaceutical Industries, 6th of October City, Egypt
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27
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Shankar RR, Xu L, Golm GT, O'Neill EA, Goldstein BJ, Kaufman KD, Engel SS. A comparison of glycaemic effects of sitagliptin and sulfonylureas in elderly patients with type 2 diabetes mellitus. Int J Clin Pract 2015; 69:626-31. [PMID: 25652751 DOI: 10.1111/ijcp.12607] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
Abstract
INTRODUCTION In the USA, 45% of patients with type 2 diabetes mellitus (T2DM) are elderly (≥ 65 years old). In general, use of sulfonylurea increases with patient age as does the associated risk for hypoglycaemia, and the consequences of hypoglycaemia can be more pronounced in elderly patients. Sitagliptin, a DPP-4 inhibitor, improves glycaemic control in adult patients of all ages with T2DM, with a low risk of hypoglycaemia when used alone or in combination with other antidiabetic agents that are not generally associated with hypoglycaemia when used independently. METHODS In a post hoc analysis, pooled data from elderly patients who participated in one of three double-blind studies comparing the effects of therapy with sitagliptin (100 mg/day) vs. sulfonylurea (in titrated doses) were analysed for changes from baseline in HbA1c, fasting plasma glucose (FPG), and body weight and for the incidence of reported symptomatic hypoglycaemia. In these studies, patients on diet alone or metformin were randomised to sitagliptin or glipizide for 104 weeks (studies 1 and 2) or glimepiride for 30 weeks (study 3). The analysis included 372 elderly patients who completed a trial through 25 or 30 weeks. RESULTS Both HbA1c and FPG decreased from baseline with each treatment, with no statistically significant differences between treatments. A significantly lower incidence of reported hypoglycaemia was observed with sitagliptin compared with sulfonylurea (6.2% vs. 27.8%; p < 0.001). Body weight decreased significantly with sitagliptin but not with sulfonylurea. Significantly more patients on sitagliptin than on sulfonylureas achieved a composite end-point of >0.5% HbA1c reduction with no reported hypoglycaemia or increase in body weight (44.1% vs. 16.0%; p < 0.001). CONCLUSION In this analysis of elderly patients with T2DM, compared with sulfonylurea, sitagliptin provided similar glycaemic efficacy with less hypoglycaemia and with body weight loss.
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Affiliation(s)
- R R Shankar
- Merck & Co., Inc., Whitehouse Station, NJ, USA
| | - L Xu
- Merck & Co., Inc., Whitehouse Station, NJ, USA
| | - G T Golm
- Merck & Co., Inc., Whitehouse Station, NJ, USA
| | - E A O'Neill
- Merck & Co., Inc., Whitehouse Station, NJ, USA
| | | | - K D Kaufman
- Merck & Co., Inc., Whitehouse Station, NJ, USA
| | - S S Engel
- Merck & Co., Inc., Whitehouse Station, NJ, USA
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28
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Douros A, Ebert N, Jakob O, Martus P, Kreutz R, Schaeffner E. Estimating kidney function and use of oral antidiabetic drugs in elderly. Fundam Clin Pharmacol 2015; 29:321-8. [DOI: 10.1111/fcp.12118] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2014] [Revised: 03/16/2015] [Accepted: 03/24/2015] [Indexed: 12/20/2022]
Affiliation(s)
- Antonios Douros
- Department of Clinical Pharmacology and Toxicology; Charité-Universitätsmedizin Berlin; Charitéplatz 1 10117 Berlin Germany
- Department of Clinical Epidemiology; Leibniz Institute for Prevention Research and Epidemiology - BIPS GmbH; Bremen Germany
| | - Natalie Ebert
- Department of Nephrology and Intensive Care Medicine; Charité-Universitätsmedizin Berlin; Augustenburgerplatz 1 13353 Berlin Germany
| | - Olga Jakob
- Institute for Biostatistics and Clinical Epidemiology; Charité-Universitätsmedizin Berlin; Hindenburgdamm 30 12203 Berlin Germany
| | - Peter Martus
- Institute for Biostatistics and Clinical Epidemiology; Charité-Universitätsmedizin Berlin; Hindenburgdamm 30 12203 Berlin Germany
| | - Reinhold Kreutz
- Department of Clinical Pharmacology and Toxicology; Charité-Universitätsmedizin Berlin; Charitéplatz 1 10117 Berlin Germany
| | - Elke Schaeffner
- Department of Nephrology and Intensive Care Medicine; Charité-Universitätsmedizin Berlin; Augustenburgerplatz 1 13353 Berlin Germany
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Doody HK, Peterson GM, Watson D, Castelino RL. Retrospective evaluation of potentially inappropriate prescribing in hospitalized patients with renal impairment. Curr Med Res Opin 2015; 31:525-35. [PMID: 25629794 DOI: 10.1185/03007995.2015.1010036] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND/AIMS Patients with chronic kidney disease require appropriate adjustment of nephrotoxic and renally cleared medications to ensure safe and effective pharmacotherapy. It is currently unclear how often appropriate medication selection and dosage adjustment occurs in practice. Therefore, this study aimed to evaluate the extent of potentially inappropriate prescribing (PIP) (the use of a contraindicated medication or inappropriately high dose according to the renal function) in patients with renal impairment from admission through to discharge from the Royal Hobart Hospital (RHH), Tasmania, Australia; to evaluate the medications most commonly implicated in PIP; and the factors associated with PIP in renal impairment. METHODS Medical records of 251 patients consecutively admitted to the RHH aged 40 years and above, with a creatinine clearance of ≤60 mL/min, and hypertension and/or diabetes mellitus in their medical history, were reviewed. PIP was assessed using the Australian Medicines Handbook and/or product information. RESULTS Of the 251 patients, 81 (32.3%) were receiving a total of 116 potentially inappropriate medications (PIMs) at the time of admission. The number of patients receiving PIMs (81 vs. 44, p<0.001 chi-square test) as well as the total number of PIMs (116 vs. 63, p<0.001 Wilcoxon signed rank test) were significantly decreased at discharge. Metformin was the most common PIM at admission. However, PIP of metformin was reduced by approximately 50% by discharge. Logistic regression analysis revealed two significant independent risk factors for PIP: a higher number of medications at admission increased risk of PIP (OR 1.1, 95% CI 1.02-1.18, p=0.010), and higher initial estimated glomerular filtration rate (eGFR) decreased the risk of PIP (OR 0.9, 95% CI 0.96-0.99, p=0.011). CONCLUSIONS Despite the limitations of lack of body weight documentation and lack of clear guidelines for dosage adjustment based on the eGFR, PIP in patients with renal impairment is common and admission to the hospital was associated with a significant reduction in PIP. More recognition of chronic kidney disease in the community and strategies to alert clinicians of the need for dosage adjustment in renal impairment are warranted.
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Penfornis A, Fiquet B, Blicklé JF, Dejager S. Potential glycemic overtreatment in patients ≥75 years with type 2 diabetes mellitus and renal disease: experience from the observational OREDIA study. Diabetes Metab Syndr Obes 2015; 8:303-13. [PMID: 26170705 PMCID: PMC4498726 DOI: 10.2147/dmso.s83897] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Few data exist examining the management of elderly patients with type 2 diabetes mellitus and renal impairment (RI). This observational study assessed the therapeutic management of this fragile population. METHODS Cross-sectional study: data from 980 diabetic patients ≥75 years with renal disease are presented. RESULTS Patients had a mean age of 81 years (range 75-101) with long-standing diabetes (15.4 years) often complicated (half with macrovascular disease). Mean estimated glomerular filtration rate was 43 mL/min/1.73 m(2) and 20% had severe RI. Mean hemoglobin A1c was 7.4%. Anti-diabetic therapy was oral based for 51% of patients (60% ≥2 oral anti-diabetic drugs [OAD]) and insulin based for 49% (combined with OAD in 59%). OAD included metformin (47%), sulfonylureas (26%), glinides (19%), and DPP-4 inhibitors (31%). Treatments were adjusted to increasing RI, with less use of metformin, sulfonylureas, and DPP-4 inhibitors, and more glinides and insulin in severe RI. In all, 579 (60%) of these elderly patients with comorbidities had hemoglobin A1c <7.5% (mean 6.7%) while being intensively treated: 69% under insulin-secretagogues and/or insulin, putting them at high risk for severe hypoglycemia. Only one-fourth were under oral monotherapy. CONCLUSION In clinical practice, a substantial proportion of elderly patients may be overtreated. RI is insufficiently taken into account when prescribing OAD.
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Affiliation(s)
- Alfred Penfornis
- Department of Endocrinology and Diabetology, Centre Hospitalier Sud Francilien, Corbeil-Essonnes Cedex, France
| | - Béatrice Fiquet
- Clinical Affairs, Novartis Pharma SAS, Rueil-Malmaison, France
| | - Jean Frédéric Blicklé
- Department of Internal Medicine and Diabetology, Strasbourg University Hospital, Strasbourg, France
| | - Sylvie Dejager
- Clinical Affairs, Novartis Pharma SAS, Rueil-Malmaison, France
- Department of Diabetology, Metabolism and Endocrinology, Pitié-Salpétrière Hospital, Paris, France
- Correspondence: Sylvie Dejager, Clinical Affairs, Novartis Pharma SAS, 10 rue Lionel Terray, 92506 Rueil-Malmaison, France, Tel +33 1 5547 6339, Fax +33 1 5547 6593, Email
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Barnett AH. Linagliptin for the treatment of type 2 diabetes mellitus: a drug safety evaluation. Expert Opin Drug Saf 2014; 14:149-59. [PMID: 25351273 DOI: 10.1517/14740338.2014.971008] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
INTRODUCTION Established treatments for type 2 diabetes mellitus (T2DM) have side effects that limit their use in specific populations. New therapies with improved safety profiles are needed, especially because of the chronic and progressive nature of T2DM. AREAS COVERED This review describes the overall safety and tolerability of linagliptin--a dipeptidyl peptidase-4 inhibitor that improves glycemic control without increasing risk for hypoglycemia and without weight gain. Specifically, the safety of linagliptin is evaluated in difficult-to-treat patients with T2DM, in relation to risk of cardiovascular (CV) events and acute pancreatitis, and in comparison with other antihyperglycemic drugs. EXPERT OPINION Linagliptin is generally well tolerated in a broad range of patient populations. It can be used in patients with renal impairment without dose titration and may be a rational alternative treatment in this vulnerable population. Ongoing long-term trials are fully evaluating the CV and renal safety profile of linagliptin.
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Affiliation(s)
- Anthony H Barnett
- Heart of England NHS Foundation Trust and University of Birmingham, Diabetes Centre , Birmingham , UK
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Bruderer SG, Bodmer M, Jick SS, Bader G, Schlienger RG, Meier CR. Incidence of and risk factors for severe hypoglycaemia in treated type 2 diabetes mellitus patients in the UK--a nested case-control analysis. Diabetes Obes Metab 2014; 16:801-11. [PMID: 24612200 DOI: 10.1111/dom.12282] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2013] [Revised: 12/02/2013] [Accepted: 02/18/2014] [Indexed: 12/23/2022]
Abstract
AIMS To assess incidence rates (IRs) of and identify risk factors for incident severe hypoglycaemia in patients with type 2 diabetes newly treated with antidiabetic drugs. METHODS Using the UK-based General Practice Research Database, we performed a retrospective cohort study between 1994 and 2011 and a nested case-control analysis. Ten controls from the population at risk were matched to each case with a recorded severe hypoglycaemia during follow-up on general practice, years of history in the database and calendar time. Using multivariate conditional logistic regression analyses, we adjusted for potential confounders. RESULTS Of 130,761 patients with newly treated type 2 diabetes (mean age 61.7 ± 13.0 years), 690 (0.5%) had an incident episode of severe hypoglycaemia recorded [estimated IR 11.97 (95% confidence interval, CI, 11.11-12.90) per 10,000 person-years (PYs)]. The IR was markedly higher in insulin users [49.64 (95% CI, 44.08-55.89) per 10,000 PYs] than in patients not using insulin [8.03 (95% CI, 7.30-8.84) per 10,000 PYs]. Based on results of the nested case-control analysis increasing age [≥ 75 vs. 20-59 years; adjusted odds ratio (OR), 2.27; 95% CI, 1.65-3.12], cognitive impairment/dementia (adjusted OR, 2.00; 95% CI, 1.37-2.91), renal failure (adjusted OR, 1.34; 95% CI, 1.04-1.71), current use of sulphonylureas (adjusted OR, 4.45; 95% CI, 3.53-5.60) and current insulin use (adjusted OR, 11.83; 95% CI, 9.00-15.54) were all associated with an increased risk of severe hypoglycaemia. CONCLUSIONS Severe hypoglycaemia was recorded in 12 cases per 10,000 PYs. Risk factors for severe hypoglycaemia included increasing age, renal failure, cognitive impairment/dementia, and current use of insulin or sulphonylureas.
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Affiliation(s)
- S G Bruderer
- Basel Pharmacoepidemiology Unit, Division of Clinical Pharmacy and Epidemiology, Department of Pharmaceutical Sciences, University of Basel, Basel, Switzerland; Hospital Pharmacy, University Hospital Basel, Basel, Switzerland
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Andreassen LM, Sandberg S, Kristensen GBB, Sølvik UØ, Kjome RLS. Nursing home patients with diabetes: prevalence, drug treatment and glycemic control. Diabetes Res Clin Pract 2014; 105:102-9. [PMID: 24853809 DOI: 10.1016/j.diabres.2014.04.012] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2013] [Revised: 02/26/2014] [Accepted: 04/19/2014] [Indexed: 01/21/2023]
Abstract
AIMS Determine prevalence of diabetes, and describe use of blood glucose lowering (BGL) drugs and glycemic control in Norwegian nursing homes. METHODS In this cross-sectional study we collected details of BGL drugs, capillary blood glucose measurements (CBGM) in the last four weeks and HbA1c measurements in the last 12 months from the medical records of patients with diabetes, within a population of 742 long-term care patients from 19 randomly selected nursing homes in Western Norway. Descriptive statistics were applied, and Pearson's chi-squared (P≤0.05) or non-overlapping 95% confidence intervals were interpreted as significant effects. RESULTS 116 patients (16%) had diabetes, 100 of these gave informed consent and medical data were available. BGL treatment was as follows: (1) insulin only (32%), (2) insulin and oral antidiabetics (OADs) (15%), (3) OADs only (27%) and (4) no drugs (26%). Patients with cognitive impairment were less likely to receive medical treatment (P=0.04). CBGM and HbA1c measurements were performed for 73% and 77% of patients, respectively. Mean HbA1c was 7.3% (57 mmol/mol), 46% of patients had an HbA1c <7.0% (53 mmol/mol), and CBGM consistent with risk of hypoglycemia was found for 60% of these patients. CONCLUSIONS Prevalence of diabetes and BGL treatment in Norwegian nursing homes is comparable to other European countries. Although special care seems to be taken when choosing treatment for patients with cognitive impairment, there are signs of overtreatment in the population as a whole. The strict glycemic control unveiled may negatively affect these frail patients' quality of life and increase the risk of early death.
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Affiliation(s)
- Lillan Mo Andreassen
- Research group in Social Pharmacy, Department of Global Public Health and Primary Care, and Centre for Pharmacy, University of Bergen, Norway.
| | - Sverre Sandberg
- Research group in General Practice, Department of Global Public Health and Primary Care, University of Bergen, Norway; Noklus, Norwegian Quality Improvement of Primary Care Laboratories, Bergen, Norway
| | | | - Una Ørvim Sølvik
- Research group in General Practice, Department of Global Public Health and Primary Care, University of Bergen, Norway; Noklus, Norwegian Quality Improvement of Primary Care Laboratories, Bergen, Norway
| | - Reidun Lisbet Skeide Kjome
- Research group in Social Pharmacy, Department of Global Public Health and Primary Care, and Centre for Pharmacy, University of Bergen, Norway
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Maffioli P, Derosa G. Hypoglycemia, its implications in clinical practice, and possible ways to prevent it. Curr Med Res Opin 2014; 30:771-3. [PMID: 24479383 DOI: 10.1185/03007995.2014.890096] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- Pamela Maffioli
- Department of Internal Medicine and Therapeutics, University of Pavia and Fondazione IRCCS Policlinico S. Matteo , Pavia , Italy
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Yehuda AB, Zinger A, Durso S. The older patient with diabetes: a practical approach. Diabetes Metab Res Rev 2014; 30:88-95. [PMID: 24123811 DOI: 10.1002/dmrr.2485] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2013] [Revised: 07/07/2013] [Accepted: 07/10/2013] [Indexed: 12/13/2022]
Abstract
Type 2 diabetes mellitus is very prevalent among persons aged 60-80 years old. This population is expected to increase in number and is characterized by the presence of comorbidities, long standing diabetes, frailty, high rate of cognitive impairment and limited life expectancy. These characteristics have a significant impact on diabetes and treatment among the elderly, much as diabetes predisposes to these conditions. In this article we will describe mechanisms that may lead to insulin resistance and diabetes among the elderly and also how these conditions contribute to the development of frailty and cognitive impairment. Hypoglycemia and it's consequences are important considerations when planning the treatment of diabetes. Treatment options in light of new goals and the danger of hypoglycemia will be detailed.
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Affiliation(s)
- Arie Ben Yehuda
- Division of Medicine C, Department of Medicine, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
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CYP2C9, KCNJ11 and ABCC8 polymorphisms and the response to sulphonylurea treatment in type 2 diabetes patients. Eur J Clin Pharmacol 2014; 70:421-8. [PMID: 24442125 DOI: 10.1007/s00228-014-1641-x] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2013] [Accepted: 01/01/2014] [Indexed: 01/11/2023]
Abstract
PURPOSE Sulphonylureas (SU) are widely used in the management of type 2 diabetes. We investigated the influence of CYP2C9, KCNJ11 and ABCC8 polymorphisms on the response to SU currently used in everyday clinical practice. METHODS Patients treated for type 2 diabetes with sulphonylurea in monotherapy (n = 21) or in combination with metformin (n = 135) were provided with glucose-monitoring devices and instructed to measure fasting blood glucose levels once per week and additionally at any signs and symptoms suggesting low blood glucose for a period of three months. All patients were genotyped for CYP2C9 rs1799853 and rs1057910 (*2 and *3 allele, respectively), KCNJ11 rs5219 and rs5215, and ABCC8 rs757110. RESULTS The average duration of diabetes in the study group was 10.6 ± 7.1 years. Most of the patients achieved relatively good blood glucose control (HbA1c 7.0 ± 0.9). In total, 76 hypoglycemia events were observed (mean 0.48 ± 1.3). No severe hypoglycemia was reported; the lowest blood glucose was 2.1 mmol/l. Although 124 (79.5 %) patients never experienced hypoglycemia, 32 (20.5 %) patients experienced from one to eight events. None of the investigated polymorphisms influenced HbA1c levels or risk for hypoglycemia episodes in the whole group of patients. CYP2C9 genotype significantly influenced the occurrence of hypoglycemia events among the elderly patients (aged 60 years and over; n = 103). Among them, carriers of two wild-type alleles suffered 0.36 ± 0.98 events, while patients with one or two polymorphic alleles had 0.79 ± 1.7 or 2.67 ± 4.6 events, respectively (p = 0.014). CONCLUSIONS Our results indicate that the CYP2C9 genotype may influence the risk for hypoglycemia events in elderly patients, but not in the overall population of type 2 diabetes patients.
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Anderson M, Powell J, Campbell KM, Taylor JR. Optimal management of type 2 diabetes in patients with increased risk of hypoglycemia. Diabetes Metab Syndr Obes 2014; 7:85-94. [PMID: 24623984 PMCID: PMC3949696 DOI: 10.2147/dmso.s48896] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
With the number of individuals diagnosed with type 2 diabetes on the rise, it has become more important to ensure these patients are effectively treated. The Centers for Disease Control and Prevention estimated that 8.3% of all Americans were diagnosed with diabetes in 2011 and this number will likely continue to rise. With lifestyle interventions, such as proper diet and exercise, continuing to be an essential component of diabetes treatment, more patients are requiring medication therapy to help them reach their therapeutic goals. It is important for the clinician, when determining the treatment strategy for these individuals, to find a balance between reaching treatment goals and limiting the adverse effects of the treatments themselves. Of all the adverse events associated with treatment of diabetes, the risk of hypoglycemia is one that most therapies have in common. This risk is often a limiting factor when attempting to aggressively treat diabetic patients. This manuscript will review how hypoglycemia is defined and categorized, as well as discuss the prevalence of hypoglycemia among the many different treatment options.
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Affiliation(s)
- Morgan Anderson
- North Florida/South Georgia Veterans Health System, Malcom Randall VAMC, Gainesville, FL, USA
| | - Jason Powell
- University of Florida, College of Pharmacy, Gainesville, FL, USA
| | - Kendall M Campbell
- The Center for Underrepresented Minorities in Academic Medicine, The Florida State University College of Medicine Tallahassee, FL, USA
| | - James R Taylor
- University of Florida, College of Pharmacy, Gainesville, FL, USA
- Correspondence: James R Taylor, University of Florida, College of Pharmacy, 1225 Center Drive HPNP Bulding, Room 3309 Gainesville, FL 32610, USA, Tel +1 352 273 6239, Fax +1 352 273 6242, Email
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Vora J, Caputo S, Damci T, Orozco-Beltran D, Pan C, Svendsen AL, Sølje KS, Khunti K. Effect of once-daily insulin detemir on oral antidiabetic drug (OAD) use in patients with type 2 diabetes. J Clin Pharm Ther 2013; 39:136-43. [PMID: 24329524 DOI: 10.1111/jcpt.12116] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2013] [Accepted: 11/05/2013] [Indexed: 11/30/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVE There are acknowledged benefits to continuing metformin when initiating insulin, but there appears to be growing concern over the role of sulphonylureas and thiazolidinediones when used in combination with insulin. This analysis investigates the effects of continuing or discontinuing oral antidiabetic drugs (OADs) following the initiation of once-daily insulin detemir. METHODS SOLVE is a 24-week, multinational observational study of insulin detemir initiation in patients with type 2 diabetes mellitus treated with one or more OADs. RESULTS In the total cohort (n = 17 374), there were significant improvements in HbA1c (-1·3%, 95% CI -1·34; -1·27%) and weight (-0·6 kg, 95% CI -0·65; -0·47 kg), with an increase in the incidence rate of minor hypoglycaemia (+0·256 events ppy, P < 0·001), but not severe hypoglycaemia (-0·038 events ppy, P < 0·001). Study participants had information on OAD use either prior to (n = 17 086) or during insulin initiation (n = 16 346). HbA1c reductions were significantly greater in patients continuing treatment with metformin (-1·3% vs. -1·1%, P < 0·01), thiazolidinediones (-1·3% vs. -1·0%, P < 0·01) and DPP-IV inhibitors (-1·3% vs. -0·9%, P < 0·001). Final insulin doses were significantly greater in patients discontinuing treatment with sulphonylureas (0·29 vs. 0·26 IU/kg, P < 0·001), glinides (0·28 vs. 0·26 IU/kg, P < 0·01), thiazolidinediones (0·31 vs. 0·26 IU/kg, P < 0·001) and DPP-IV inhibitors (0·35 vs. 0·29 IU/kg, P < 0·001) compared with patients continuing these respective agents. All patient subgroups had a mean weight loss irrespective of OAD continuation, apart from those continuing thiazolidinediones (+0·2 kg). The largest improvements in weight were seen following the withdrawal of sulphonylureas and thiazolidinediones (-1·1 and -1·1 kg, respectively). WHAT IS NEW AND CONCLUSION Discontinuation (or switching) of OADs at the time of insulin initiation appears to be governed principally by concerns about hypoglycaemia and weight. HbA1c improvements were smaller in patients discontinuing OADs at the time of insulin initiation and may be associated with insufficient insulin titration.
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Affiliation(s)
- J Vora
- Department of Diabetes and Endocrinology, Royal Liverpool University Hospital, Liverpool, UK
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Barnett AH, Huisman H, Jones R, von Eynatten M, Patel S, Woerle HJ. Linagliptin for patients aged 70 years or older with type 2 diabetes inadequately controlled with common antidiabetes treatments: a randomised, double-blind, placebo-controlled trial. Lancet 2013; 382:1413-23. [PMID: 23948125 DOI: 10.1016/s0140-6736(13)61500-7] [Citation(s) in RCA: 136] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND A substantial proportion of patients with type 2 diabetes are elderly (≥65 years) but this group has been largely excluded from clinical studies of glucose-lowering drugs. We aimed to assess the effectiveness of linagliptin, a dipeptidyl peptidase-4 inhibitor, in elderly patients with type 2 diabetes. METHODS In this randomised, double-blind, parallel-group, multinational phase 3 study, patients aged 70 years or older with type 2 diabetes, glycated haemoglobin A1c (HbA1c) of 7·0% or more, receiving metformin, sulfonylureas, or basal insulin, or combinations of these drugs, were randomised (by computer-generated randomisation sequence, concealed with a voice-response system, stratified by HbA1c level [<8·5% vs ≥8·5%] and insulin use [yes vs no], block size four) in a 2:1 ratio to once-daily oral treatment with linagliptin 5 mg or matching placebo for 24 weeks. Investigators and participants were masked to assignment throughout the study. The primary endpoint was change in HbA1c from baseline to week 24. This trial is registered with ClinicalTrials.gov, number NCT01084005. FINDINGS 241 community-living outpatients were randomised (162 linagliptin, 79 placebo). Mean age was 74·9 years (SD 4·3). Mean HbA1c was 7·8% (SD 0·8). At week 24, placebo-adjusted mean change in HbA1c with linagliptin was -0·64% (95% CI -0·81 to -0·48, p<0·0001). Overall safety and tolerability were much the same between the linagliptin and placebo groups; 75·9% of patients in both groups had an adverse event (linagliptin n=123, placebo n=60). No deaths occurred. Serious adverse events occurred in 8·6% (14) of patients in the linagliptin group and 6·3% (five) patients in the placebo group; none were deemed related to study drug. Hypoglycaemia was the most common adverse event in both groups, but did not differ between groups (24·1% [39] in the linagliptin group, 16·5% [13] in the placebo group; odds ratio 1·58, 95% CI 0·78-3·78, p=0·2083). INTERPRETATION In elderly patients with type 2 diabetes linagliptin was efficacious in lowering glucose with a safety profile similar to placebo. These findings could inform treatment decisions for achieving individualised glycaemic goals with minimal risk in this important population of patients. FUNDING Boehringer Ingelheim.
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Affiliation(s)
- Anthony H Barnett
- Diabetes Centre, Heart of England NHS Foundation Trust, Birmingham, UK; University of Birmingham, Birmingham, UK.
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He F, Li Y, Zeng C, Xia C, Xiong Y, Zhang H, Huang S, Liu M. Contribution of cytochrome P450 isoforms to gliquidone metabolism in rats and human. Xenobiotica 2013; 44:229-34. [DOI: 10.3109/00498254.2013.831957] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Karnieli E, Baeres FMM, Dzida G, Ji Q, Ligthelm R, Ross S, Svendsen AL, Yale JF. Observational study of once-daily insulin detemir in people with type 2 diabetes aged 75 years or older: a sub-analysis of data from the Study of Once daily LeVEmir (SOLVE). Drugs Aging 2013; 30:167-75. [PMID: 23371395 PMCID: PMC3574560 DOI: 10.1007/s40266-013-0054-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
OBJECTIVES Older patients are particularly vulnerable to hypoglycaemia. The aim of this study was to evaluate the response to initiation of once-daily insulin detemir in patients aged ≥75 years with type 2 diabetes mellitus (T2DM) treated with one or more oral antidiabetic drugs (OADs). METHODS A sub-analysis was conducted using data from SOLVE (Study of Once daily LeVEmir), a 24-week observational study involving 3,219 investigators and 2,817 project sites from ten countries. Routine clinical practice was followed; there were no study-prescribed procedures. The total cohort comprised 17,374 participants, of whom 2,398 (14 %) were aged ≥75 years. The physicians collected information from patient recall, the patients' medical records and their self-monitored blood glucose diaries (if kept). RESULTS Pre-insulin glycated haemoglobin (HbA(1c)) was similar between participants aged ≥75 years and those aged <75 years (HbA(1c) 8.8 ± 1.5 % vs. 8.9 ± 1.6 % [mean ± SD], respectively). After 24 weeks of treatment, similar reductions in HbA(1c) were observed in the two subgroups: 7.6 ± 1.1 % and 7.5 ± 1.2 % in participants aged ≥75 years and those aged <75 years, respectively. The incidence of severe hypoglycaemia (episodes per patient-year) decreased during the study in both age groups (from 0.057 to 0.007 in patients aged ≥75 years; from 0.042 to 0.005 in patients aged <75 years), while minor hypoglycaemia increased from 1.1 to 2.0 and from 1.7 to 1.8 episodes per patient-year in the older and younger age groups, respectively. Average weight reduction was similar in both groups: -0.5 kg (≥75 years) and -0.6 kg (<75 years). CONCLUSION In both the older and younger age groups, the addition of once-daily insulin detemir to existing OAD regimens was effective and safe. In older patients, an improvement in HbA(1c) of 1.2 % was not associated with an increased risk of severe hypoglycaemia or weight gain.
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Affiliation(s)
- Eddy Karnieli
- Endocrinology, Diabetes and Metabolism, Rambam Medical Center and Rappaport Faculty of Medicine, Technion, 12 Halia St, Samy Ofer Tower, Fl #8, Haifa, 31096, Israel.
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Holstein A, Beil W, Kovacs P. CYP2C metabolism of oral antidiabetic drugs--impact on pharmacokinetics, drug interactions and pharmacogenetic aspects. Expert Opin Drug Metab Toxicol 2013; 8:1549-63. [PMID: 23153186 DOI: 10.1517/17425255.2012.722619] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
INTRODUCTION The cytochrome P4502C enzymes account for the metabolism of approximately 20% of therapeutic drugs including certain oral antidiabetic drugs (OADs). AREAS COVERED This review focuses on the effect of CYP2C enzymes on metabolism of sulphonylureas (SUs), meglitinides, and thiazolidinediones (TZDs) discussing their impact on pharmacokinetics, drug interactions and toxicological profiles. Pharmacogenetic aspects reflecting individual gene variants and variable drug effects are also considered. EXPERT OPINION Genetic polymorphisms of CYP2C9 enzymes (*2/*2, *2/*3, *3/*3) influence the glycaemic response to SUs and impair their substrate metabolism. Restricted data from small-sized studies with heterogenous definitions of hypoglycaemia revealed no clear association between CYP2C9 genotypes and the risk of hypoglycaemia. Functional polymorphisms of CYP2C8- and CYP2C9 drug metabolizing genes affect markedly pharmacokinetics of meglitinides. Compared to wild-type carriers, patients treated with TZDs and carrying the common CYP2C8*3 and *4 variants showed a reduced glycaemic control. The strong CYP2C8 and OATP1B1 inhibitor gemfibrozil increases substantially the plasma concentrations of repaglinide and TZDs. Numerous metabolic drug interactions exist between SUs and commonly prescribed drugs, especially anti-infectives. The complex pharmacokinetic and pharmacogenetic properties and the unfavourable short and long term risk profile of glibenclamide and glimepiride raise the question whether their use can be justified any longer.
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Affiliation(s)
- Andreas Holstein
- Lippe-Detmold Hospital, First Department of Medicine, Röntgenstr. 18, Detmold, 32756, Germany.
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Ahrén B. Avoiding hypoglycemia: a key to success for glucose-lowering therapy in type 2 diabetes. Vasc Health Risk Manag 2013; 9:155-63. [PMID: 23637538 PMCID: PMC3639216 DOI: 10.2147/vhrm.s33934] [Citation(s) in RCA: 121] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Type 2 diabetes carries a risk for hypoglycemia, particularly in patients on an intensive glucose control plan as a glucose-lowering strategy, where hypoglycemia may be a limitation for the therapy and also a factor underlying clinical inertia. Glucose-lowering medications that increase circulating insulin in a glucose-independent manner, such as insulin and sulfonylurea therapy, are the most common cause of hypoglycemia. However, other factors such as a delayed or missed meal, physical exercise, or drug or alcohol consumption may also contribute. Specific risk factors for development of hypoglycemia are old age, long duration of diabetes, some concomitant medication, renal dysfunction, hypoglycemia unawareness, and cognitive dysfunction. Hypoglycemia is associated with acute short-term symptoms related to either counterregulation, such as tachycardia and sweating, or to neuroglycopenia, such as irritability, confusion, and in severe cases stupor, coma, and even death. However, there are also long-term consequences of hypoglycemia such as reduced working capacity, weight gain, loss of self-confidence with reduced quality of life, and increased risk for cardiovascular diseases. For both the patients, the health care system, and the society at large, hypoglycemia carries a high cost. Strategies to mitigate the risk of hypoglycemia include awareness of the condition; education of patients, relatives, and health care providers; and selecting appropriate glucose-lowering medication that also judges the risk for hypoglycemia to prevent this complication. This article summarizes the current knowledge of hypoglycemia and its consequences with a special emphasis on its consequences for the choice of glucose-lowering therapy.
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Affiliation(s)
- Bo Ahrén
- Department of Clinical Sciences, Lund, Faculty of Medicine, Lund University, Lund, Sweden.
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Scheen AJ. Pharmacokinetic considerations for the treatment of diabetes in patients with chronic kidney disease. Expert Opin Drug Metab Toxicol 2013; 9:529-50. [PMID: 23461781 DOI: 10.1517/17425255.2013.777428] [Citation(s) in RCA: 68] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
INTRODUCTION People with chronic kidney disease (CKD) of stages 3 - 5 (creatinine clearance < 60 ml/min) represent ≈ 25% of patients with type 2 diabetes mellitus (T2DM), but the problem is underrecognized or neglected in clinical practice. However, most oral antidiabetic agents have limitations in case of renal impairment (RI), either because they require a dose adjustment or because they are contraindicated for safety reasons. AREAS COVERED The author performed an extensive literature search to analyze the influence of RI on the pharmacokinetics (PK) of glucose-lowering agents and the potential consequences for clinical practice. EXPERT OPINION As a result of PK interferences and for safety reasons, the daily dose should be reduced according to glomerular filtration rate (GFR) or even the drug is contraindicated in presence of severe CKD. This is the case for metformin (risk of lactic acidosis) and for many sulfonylureas (risk of hypoglycemia). At present, however, the exact GFR cutoff for metformin use is controversial. New antidiabetic agents are better tolerated in case of CKD, although clinical experience remains quite limited for most of them. The dose of DPP-4 inhibitors should be reduced (except for linagliptin), whereas both the efficacy and safety of SGLT2 inhibitors are questionable in presence of CKD.
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Affiliation(s)
- André J Scheen
- University of Liège, Division of Diabetes, Nutrition and Metabolic Disorders, Division of Clinical Pharmacology, Department of Medicine, CHU Sart Tilman (B35), Liège, Belgium.
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Baldwin D, Apel J. Management of hyperglycemia in hospitalized patients with renal insufficiency or steroid-induced diabetes. Curr Diab Rep 2013; 13:114-20. [PMID: 23090580 DOI: 10.1007/s11892-012-0339-7] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Pharmacologic doses of glucocorticoids and chronic renal failure are challenging comorbidities and complications for safe and effective dosing of insulin for the management of hospitalized patients with diabetes. Glucocorticoids are used widely in hospitalized patients and will commonly provoke new-onset hyperglycemia in patients without a prior history of diabetes or will provoke severely uncontrolled hyperglycemia in patients with known diabetes. Insulin therapy is invariably necessary for the treatment of glucocorticoid-induced hyperglycemia and must be tailored to the pharmacodynamics of the glucocorticoid being given. Renal failure causes a decrease in the clearance of insulin, especially exogenous injected insulin. Dosing algorithms for hospitalized patients should be adjusted for patients with renal failure in order to minimize hypoglycemia. Many patients with type 2 diabetes will need little or no therapy after the development of end-stage renal failure. Care must be taken to avoid the overtreatment of hyperglycemia.
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Affiliation(s)
- David Baldwin
- Section of Endocrinology, Rush University Medical Center, 1725 W. Harrison St. suite 250, Chicago, IL 60612, USA.
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Bramlage P, Gitt AK, Binz C, Krekler M, Deeg E, Tschöpe D. Oral antidiabetic treatment in type-2 diabetes in the elderly: balancing the need for glucose control and the risk of hypoglycemia. Cardiovasc Diabetol 2012; 11:122. [PMID: 23039216 PMCID: PMC3508810 DOI: 10.1186/1475-2840-11-122] [Citation(s) in RCA: 87] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2012] [Accepted: 10/04/2012] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND We aimed at identifying variables predicting hypoglycemia in elderly type 2 diabetic patients and the relation to HbA1c values achieved. DESIGN Prospective, observational registry in 3810 patients in primary care. Comparison of patients in different age tertiles: with an age < 60 (young, n=1,253), age 60 to < 70 (middle aged, n=1,184) to those ≥ 70 years (elderly, n=1,373). Odds Ratios (OR) with 95% confidence intervals (CI) were determined from univariable and multivariable regression analyses. RESULTS Elderly patients had a later diabetes diagnosis, a longer diabetes duration, better glucose control and more frequent co-morbid disease conditions. Overall 10.7% of patients experienced any severity hypoglycemia within the last 12 months prior to inclusion. Higher rates of hypoglycemia were observed in the elderly than in the young after adjusting for differences in HbA1c, fasting and post-prandial blood glucose (OR 1.68; 95%CI 1.16-2.45). This was particularly true for hypoglycemic episodes without specific symptoms (OR 1.74; 95%CI 1.05-2.89). In a multivariate model stroke / transitory ischemic attack, the presence of heart failure, clinically relevant depression, sulfonylurea use and blood glucose self-measurement were associated with hypoglycemic events. CONCLUSION Elderly patients are at an increased risk of hypoglycemia even at comparable glycemic control. Therefore identified variables associated with hypoglycemia in the elderly such as heart failure, clinically relevant depression, the use of sulfonylurea help to optimize the balance between glucose control and low levels of hypoglycemia. Asymptomatic hypoglycemia should not be disregarded as irrelevant but considered as a sign of possible hypoglycemia associated autonomic failure.
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Affiliation(s)
- Peter Bramlage
- Institut für Pharmakologie und präventive Medizin, Menzelstrasse 21, 15831 Mahlow, Germany.
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Morley JE. Diabetes Mellitus: “The Times They Are A-Changin”. J Am Med Dir Assoc 2012; 13:574-5. [DOI: 10.1016/j.jamda.2012.06.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2012] [Accepted: 06/08/2012] [Indexed: 12/27/2022]
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Abstract
The mechanisms for hyperglycemia-mediated harm in the hospitalized cardiac patient are poorly understood. Potential obstacles in the inpatient management of hyperglycemia in cardiac patients include rapidly changing clinical status, frequent procedures and interruptions in carbohydrate exposure, and short hospital length of stay. A patient's preadmission regimen is rarely suitable for inpatient glycemic control. Instead, an approach to a flexible, physiologic insulin regimen is described, which is intended to minimize glycemic excursions. When diabetes or hyperglycemia is addressed early and consistently, the hospital stay can serve as a potential window of opportunity for reinforcing self-care behaviors that reduce long-term complications.
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Affiliation(s)
- Jared Moore
- Department of Internal Medicine, The Ohio State University, 2050 Kenny Road, Columbus, OH 43221-3502, USA
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[Hypoglycemia: each patient's individual risk has to be evaluated]. MMW Fortschr Med 2012; 154:62-6; quiz 67-8. [PMID: 22693761 DOI: 10.1007/s15006-012-0524-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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