Metformin is associated with a lower risk of active tuberculosis in patients with type 2 diabetes

BACKGROUND AND OBJECTIVE

Metformin is an oral anti-diabetic therapy (ADT) to manage type 2 diabetes mellitus (T2DM), and has been reported to have potential anti-tuberculosis (TB) effects. This study investigates the risk of active TB among persons with T2DM who were treated with various ADT and insulin therapies.

METHODS

We conducted a nationwide population-based cohort study using the Taiwan Longitudinal Health Insurance Database, including 49 028 T2DM patients who were metformin users (n = 44 002) or non-users (n = 5026). A total of 5026 propensity score-matched pairs of metformin users and non-users with T2DM were evaluated from 1998 to 2010. The data were analysed using Cox proportional hazard models.

RESULTS

Patients with T2DM had a significantly higher rate of incident TB than did the control subjects (adjusted hazard ratio: 2.01; 95% confidence interval (95% CI): 1.80-2.25). After adjusting for comorbidities, diabetes complications, ADT type and statin use, metformin use was an independent factor for predicting a reduced risk of active TB (adjusted relative risk (aRR): 0.24; 95% CI: 0.18-0.32). The association between metformin use and active TB risk was also consistent in most subgroup analyses, except for patients with metabolic disorders (aRR: 0.46; 95% CI: 0.11-1.87). This protective effect of metformin was dose-dependent but diminished gradually in the elderly population.

CONCLUSION

Among all types of ADT and insulin therapies, metformin is the only agent with a decreased risk of active TB in the T2DM population. However, this effect was diminished in the elderly population and was not observed in patients with metabolic disorders.

Dosing of U-100 insulin and associated outcomes among Medicare enrollees with type 1 or type 2 diabetes

Objective

To examine costs, resource utilization, adherence, and hypoglycemic events among various doses of U-100 insulin regimens among elderly patients (age ≥65 years) diagnosed with diabetes.

Methods

Truven Health Analytics Medicare databases from January 1, 2008 through December 31, 2011 were utilized. General linear models with a gamma distribution and log link were used to examine costs, while logistic and negative binomial regressions were used to examine resource utilization and hypoglycemic events. Analyses controlled for patient characteristics, pre-period comorbidities, general health, and use of antidiabetic medications as well as index dose of insulin.

Results

All-cause inpatient, emergency room, and outpatients costs, as well as diabetes-related inpatient costs, were highest among individuals who were treated with an index dose of 10–100 units/day followed by >300 units/day, while drug costs and total costs generally increased as index dosage increased. Resource utilization generally followed the same pattern as costs, with number of office visits increasing as the dose increased and the highest hospital length of stay, number of hospitalizations, number of emergency room visits, and number of diabetes-related hospitalizations were generally highest among those in the lowest and highest index dose cohorts. Compared to patients who initiated with an index dose of 10–100 units/day, all other patients were significantly less likely to achieve an adherence threshold of 80% based upon index dose range, and while those with an index dose of >100–150 units/day were significantly more likely to experience a hypoglycemic event.

Conclusion

These results suggest that, for elderly individuals with diabetes, there is a higher patient burden among those who receive the lowest and highest insulin doses.

Efficacy and safety of lixisenatide in elderly (≥65 years old) and very elderly (≥75 years old) patients with type 2 diabetes: an analysis from the GetGoal phase III programme

BACKGROUND

The objective of this article is to evaluate the pharmacokinetics, efficacy and safety of lixisenatide (subcutaneous injection) in elderly (≥65 years old) and very elderly (≥75 years old) patients with type 2 diabetes mellitus.

METHODS

We conducted a phase I, single-centre, open-label study to evaluate the safety and pharmacokinetics of a single lixisenatide 20 µg dose and a pooled analysis of six randomized, placebo-controlled, phase III studies (12-month or 24-month duration) that evaluated glycaemic parameters and safety in patients receiving lixisenatide 20 µg once daily or placebo.

RESULTS

The pharmacokinetics study included 36 healthy subjects, including 18 elderly healthy subjects (≥65 years old) and 18 matched young healthy subjects (18-45 years old). The pooled analysis included 3188 patients, including 2565 patients <65 years old and 623 patients ≥65 years old (including 79 patients ≥75 years old). Mean exposure with lixisenatide 20 µg was ~30% higher in elderly than in young subjects, and the terminal half-life was prolonged by ~1.6 times. Maximum concentration (C(max)) and time to C(max) (t(max)) were comparable in both groups. Equal numbers of elderly and young subjects reported treatment-emergent adverse events, the majority of which were gastrointestinal disorders. In the pooled analysis, lixisenatide 20 µg once daily provided significant reductions in HbA1c versus placebo for all age groups. There was a similar incidence of treatment-emergent adverse events across all age groups (range: 69-73%). The incidence of symptomatic hypoglycaemia was generally comparable between lixisenatide-treated and placebo-treated patients.

CONCLUSION

These data suggest that lixisenatide is effective and well tolerated in elderly and very elderly patients with type 2 diabetes mellitus.

Therapeutic potency of saponin rich aqueous extract of Scoparia dulcis L. in alloxan induced diabetes in rats

Background:

Diabetes mellitus is major metabolic disorders of carbohydrate metabolism. This leads to alter the multiple organ system.

Aims:

To investigate the antidiabetic and antioxidant effects of the saponin rich aqueous extract of Scoparia dulcis (SRE-SD) using alloxan-induced hyperglycemic rat model.

Material and Methods:

The single dose of alloxan was injected for the induction of diabetes in rats. The SRE-SD and glibenclamide were administered for 15 consecutive days from the 3^rd day of alloxan administration. Quantity of food and water intake was measured at day 0, and 18. Further, body weight was recorded and blood samples were collected at different time intervals that is, day 0, 3, 8, 13, and 18. The oxidative biomarkers (i.e. thiobarbituric acid reactive substances (TBARS), reduced glutathione (GSH) and nitrite (NO²⁻) levels were also estimated in the serum sample.

Results:

The SRE-SD showed a remarkable dose and time-dependent changes in alloxan-induced rise in the level of food consumption and water intake, serum glucose level, TBARS, NO²⁻ and fall in the level of GSH. Further, significant attenuation was observed at 20 and 30 mg/kg of SRE-SD treated group.

Conclusions:

These findings demonstrate that SRE-SD has both antidiabetic and antioxidant effects on the experimental model of diabetes in rat.

Add-on treatment with teneligliptin ameliorates glucose fluctuations and improves glycemic control index in Japanese patients with type 2 diabetes on insulin therapy

BACKGROUND

This study investigated whether teneligliptin, a novel dipeptidyl peptidase-4 inhibitor, ameliorated glucose fluctuations in hospitalized Japanese patients with type 2 diabetes receiving insulin therapy, with or without other antidiabetes drugs, and using continuous glucose monitoring (CGM).

PATIENTS AND METHODS

Twenty-six patients with type 2 diabetes were admitted for glycemic control. After admission, patients continued to be treated with optimal dietary therapy plus insulin therapy, with or without other antidiabetes drugs, until they achieved stable glycemic control. CGM measurements were made for 7 consecutive days. On Days 1-3, patients received insulin with or without other antidiabetes drugs, and on Days 4-7, teneligliptin 20 mg once daily at breakfast was added to ongoing therapy. Doses of insulin were fixed during the study. Levels of serum glycated albumin (GA), 1,5-anhydro-d-glucitol (1,5-AG), and high-sensitivity C-reactive protein (hsCRP) were measured.

RESULTS

Add-on treatment with teneligliptin led to significant improvements in 24-h mean glucose levels, the proportion of time in normoglycemia, mean amplitude of glycemic excursions, and total area under the curve within 2 h after each meal. The proportion of time in hypoglycemia and hsCRP levels did not increase significantly compared with before teneligliptin. Values of 1,5-AG and GA were significantly improved by treatment with teneligliptin.

CONCLUSIONS

Addition of teneligliptin to insulin therapy led to a significant improvement in diurnal glycemic control and significant reductions in glucose fluctuations in 24-h periods without increasing hypoglycemia in Japanese patients with type 2 diabetes on insulin therapy, with or without other antidiabetes agents.

Use of basal insulin and the associated clinical outcomes among elderly nursing home residents with type 2 diabetes mellitus: a retrospective chart review study

BACKGROUND

The management of type 2 diabetes mellitus in long-term care (LTC) settings can be complex as a result of age-related complications. Despite guideline recommendations, sliding scale insulin remains commonplace in the LTC setting and data on basal insulin use are lacking.

METHODS

This retrospective study used medical chart data and the Minimum Data Set from elderly LTC facility patients who received basal insulin (insulin glargine, insulin detemir, or neutral protamine Hagedorn insulin) for the treatment of diabetes, to investigate the practice patterns and associated clinical outcomes.

RESULTS

A total of 2,096 elderly, insulin-treated patients in LTC were identified, with 59.5% of them (N=1,247) receiving basal insulin. Of these, more than 50% of patients received sliding scale insulin in co-administration with basal insulin. Despite its ease of use, insulin pen use was very low, at 14.6%. Significant differences were observed between the basal insulin groups for glycated hemoglobin level and dosing frequency. Hypoglycemia was uncommon -17.2% of patients experienced at least one event, and there was no significant difference in the prevalence of hypoglycemia between the groups.

CONCLUSION

These data suggest the underutilization of basal insulin in the LTC setting and worryingly high combinational use with sliding scale insulin. Differences in glycated hemoglobin and dosing frequencies between types of basal insulin warrant further comparative effectiveness studies.

Treating the elderly diabetic patient: special considerations

The prevalence of diabetes is rising in the >65 year-old group. The challenge of defining the goals of therapy arises from the heterogeneity of the aging process and the sparse clinical data in this patient population. In light of these challenges, the clinician should be aware of the pitfalls of caring for the older diabetic patient and prioritize an individualized treatment plan to ensure an optimal glycemic control, without placing the patient at unnecessary risk. We present a review of the current guidelines and literature that deal specifically with the treatment of the older diabetic patient in order to establish the principles of treatment in this age group and help the clinician make decisions regarding the care of these patients.

Association between different hemoglobin A1c levels and clinical outcomes among elderly nursing home residents with type 2 diabetes mellitus

OBJECTIVE

New guidelines recommend a target glycated hemoglobin (HbA1c) of 7.5% to 8.0% in elderly persons with type 2 diabetes mellitus (T2DM), but real-world data regarding outcomes associated with different HbA1c levels in the elderly are limited. This study assessed outcomes and their association with defined HbA1c thresholds and age ranges in insulin-treated, elderly, patients with T2DM in long-term care (LTC).

DESIGN

Retrospective analysis of medical charts and the Minimum Data Set (MDS) for the period September 2010 through September 2011.

SETTING

A total of 117 nursing homes in the United States.

PARTICIPANTS

Eligible patients had resided in LTC for 3 months or more, had at least 1 full MDS assessment, 2 or more records of insulin dispensing with no pump use, and 1 or more HbA1c measurements.

MEASUREMENTS

Outcomes that were measured included hypoglycemia, ketoacidosis, infections, falls, hospitalization, and emergency room (ER) visits.

RESULTS

A total of 583 patients were included (mean age 78.9 years, mean chart observation length 55 days). In all groups, hypoglycemia was lowest in patients with an HbA1c level higher than 9.0%. In patients 75 years or older, infection rates were highest when HbA1c levels were higher than 9.0%. Falls increased by HbA1c level in patients aged 65 to 74 years, but decreased by HbA1c levels in patients 85 years or older. Ketoacidosis, hospitalization, and ER visits were low in all groups.

CONCLUSION

These data suggest that better glycemic levels may not necessarily be associated with better clinical outcomes, and different age groups may exhibit different patterns, thereby supporting the call for individualized glycemic control among elderly patients.

Cost comparison of drug-drug and drug-condition interactions in patients with painful diabetic peripheral neuropathy treated with pregabalin versus duloxetine

PURPOSE

The frequency and financial impact of potential drug-drug interactions (DDIs) and drug-condition interactions (DCIs) in patients with painful diabetic peripheral neuropathy (DPN) treated with either pregabalin or duloxetine were compared.

METHODS

This retrospective cohort study was conducted using a large U.S. administrative claims database. Patients selected for study inclusion had a diagnosis of DPN and were newly initiated on either pregabalin or duloxetine between July 1, 2008, and October 1, 2010. Data on potential DDIs and DCIs were collected. Health care costs were measured as the sum of gross covered payments for all medical and prescription claims incurred during the six months after the index date.

RESULTS

The study sample comprised 2499 pregabalin users and 1354 duloxetine users. Among pregabalin users, 48 (1.8%) had at least one potential pregabalin DCI; none had potential pregabalin DDIs. Among duloxetine users, 966 (71%) had at least one potential duloxetine DDI or DCI. The frequencies of potential DDIs and DCIs differed significantly between pregabalin and duloxetine users (p < 0.001). Potential duloxetine DDIs and DCIs were associated with a significant increase in mean health care costs in duloxetine users (p = 0.002). Potential pregabalin DDIs and DCIs were not associated with additional health care costs in pregabalin users.

CONCLUSION

Among patients with painful DPN treated with either pregabalin or duloxetine, the frequency of potential duloxetine DDIs and DCIs was substantially higher than that of pregabalin. Potential DDIs and DCIs were associated with significantly increased health care costs in duloxetine users.

Linagliptin treatment in subjects with type 2 diabetes with and without mild-to-moderate renal impairment

AIMS

Renal disease is a frequent comorbidity of type 2 diabetes mellitus (T2DM) and an important factor complicating the choice of glucose-lowering drugs. The aim of this analysis was to evaluate the efficacy and safety of the dipeptidyl peptidase (DPP)-4 inhibitor linagliptin (5 mg/day) in mono, dual or triple oral glucose-lowering regimens in subjects with T2DM and mild or moderate renal impairment (RI).

METHODS

In this pooled analysis of three 24-week, placebo-controlled, phase 3 trials, subjects with mild (estimated glomerular filtration rate (eGFR) 60-<90 ml/min/1.73 m(2) , n = 838) or moderate RI (30-<60 ml/min/1.73 m(2), n = 93) were compared with subjects with normal renal function (≥90 ml/min/1.73 m(2), n = 1212).

RESULTS

Subjects with RI were older, had longer duration of diabetes, and increased prevalence of diabetes-related comorbidities. After 24 weeks, linagliptin achieved consistent placebo-corrected mean glycated haemoglobin (HbA1c) changes across the three renal function categories: normal (-0.63%; p < 0.0001), mild RI (-0.67%; p < 0.0001) and moderate RI (-0.53%; p < 0.01), with no inter-group difference (p = 0.74). Renal function with linagliptin remained stable across all categories. In linagliptin-treated subjects, overall adverse event (AE) rates and serious AE rates were similar to placebo. The incidence of hypoglycaemia with linagliptin and placebo was 11.1 versus 6.9%, 11.9 versus 9.0% and 15.9 versus 12.0% in the normal, mild RI and moderate RI categories, respectively.

CONCLUSIONS

This pooled analysis provides evidence that linagliptin is an effective, well-tolerated and convenient treatment in subjects with T2DM and mild or moderate RI.

Evaluation of the Prevalence of Chronic Kidney Disease and Rates of Oral Antidiabetic Prescribing in Accordance with Guidelines and Manufacturer Recommendations in Type 2 Diabetic Patients within a Long-Term Care Setting

This retrospective study assessed the prevalence of moderate to severe chronic kidney disease (CKD) among nursing home (NH) residents with type 2 diabetes. The pattern of oral antidiabetic drug (OAD) use and their concordance with the National Kidney Foundation (NKF) guideline and prescribing information (PI) was also assessed. About half (47%) of diabetic residents had moderate to severe CKD. A little over a quarter of the 186 residents using OADs received at least one NKF-discordant OAD prescription. Metformin was the most commonly misused OAD. PI nonconcordance was observed in 58.6% of residents and was highest in glipizide and metformin users. With the high prevalence of moderate to severe CKD in NH residents with diabetes, physicians should consider residents' renal function when choosing treatment plans and review treatments regularly to check compliance with the NKF guidelines or PIs.

Efficacy and safety of insulin lispro in geriatric patients with type 2 diabetes: a retrospective analysis of seven randomized controlled clinical trials

Background and Aims

Glycemic control in geriatric patients with type 2 diabetes (T2DM) remains clinically challenging. The objective of this study was to compare the safety and efficacy of insulin lispro in patients ≥65 years (geriatric) to those <65 years (non-geriatric), using a meta-analysis of randomized controlled clinical trials (RCT).

Methods

This is a retrospective analysis of predefined endpoints from an integrated database of seven RCTs of T2DM patients treated with insulin lispro. The primary efficacy measure tested the non-inferiority of insulin lispro (geriatric vs. non-geriatric; non-inferiority margin 0.4 %) in terms of hemoglobin A_1c (HbA_1c) change from baseline to Month 3 (N = 1,525), with change from baseline to Month 6 as a supportive analysis (N = 885). Changes in HbA_1c from baseline were evaluated with an analysis of covariance model. Secondary measures included incidence and rate of hypoglycemia, and incidence of cardiovascular events.

Results

Mean change in HbA_1c from baseline to Month 3 was similar for geriatric (−0.97 %) and non-geriatric patients (−1.05 %); least-square (LS) mean difference (95 % CI) was 0.02 % (−0.11, 0.15 %; p = 0.756). Similar results were observed in patients treated up to Month 6; LS mean difference (95 % CI) was 0.07 % (−0.12, 0.26 %; p = 0.490). Decrease in HbA_1c from baseline to Months 3 and 6 was non-inferior in geriatric compared with non-geriatric patients. There were no significant differences in the incidence and the rate of hypoglycemia, incidence of cardiovascular events, or other serious adverse events including malignancy, post-baseline between the two cohorts.

Conclusion

Key measures of efficacy and safety in geriatric patients with T2DM were not significantly different from non-geriatric patients when utilizing insulin lispro. Insulin lispro may be considered a safe and efficacious therapeutic option for the management of T2DM in geriatric patients.

Does Device Make Any Difference? A Real-world Retrospective Study of Insulin Treatment Among Elderly Patients With Type 2 Diabetes

We compared real-world clinical and economic outcomes for insulin glargine treatment administered by disposable pen and traditional vial-and-syringe injections among elderly patients with type 2 diabetes mellitus (T2DM). Using a large database of US retirees, this retrospective longitudinal study examined 1-year follow-up outcomes in patients with T2DM aged 65 years or older who were either insulin naïve and initiated insulin glargine via disposable pen (pen initiators [PI]) or vial (vial initiators [VI]) or were already insulin glargine users but either continued with a vial (vial continuers [VC]) or switched to a disposable pen (pen switchers [PS]). There were 7856 propensity-score-matched patients, including 2930 each in the PI and VI cohorts, and 998 each in the VC and PS cohorts. Compared with vial-and-syringe users, the disposable pen users had significantly greater treatment persistence (P < .0001 for both comparisons), duration of persistence (P < .0001 for both), and adherence (P < .01 for both) and lower insulin daily average consumption (P < .05 for both). Compared with the VI cohort, the PI cohort had significantly fewer hypoglycemia-related events (P = .0164). Total health care costs were comparable for the respective matched cohorts. In elderly patients with T2DM receiving insulin glargine therapy, initiating or switching to a disposable pen was associated with better treatment persistence and adherence than initiating or continuing with vial-and-syringe, without increased total health care costs. Among insulin-naïve patients, initiating insulin glargine by disposable pen was also associated with significantly reduced risk of hypoglycemia compared with vial-and-syringe patients.

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

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.

Clinical utility of the dipeptidyl peptidase-4 inhibitor linagliptin

INTRODUCTION

Dipeptidyl peptidase-4 (DPP-4) inhibitors have emerged as new options in the management of type 2 diabetes mellitus, demonstrating meaningful antihyperglycemic effects and good tolerability profiles. Glycemic control is improved by preventing the DPP-4-mediated degradation of incretin hormones, with a resulting increase in insulin secretion and inhibition of glucagon secretion.

PURPOSE

This article provides a discussion of the clinical utility of linagliptin.

RESULTS AND CONCLUSION

Linagliptin is a xanthine-based, oral DPP-4 inhibitor that has been approved in the United States and Europe. It has been evaluated extensively in clinical trials, and results in improved glycemic control when used as monotherapy, initial combination therapy with metformin or pioglitazone, add-on therapy to metformin and/or a sulfonylurea, or add-on therapy to basal insulin (with or without oral antidiabetic drugs). Consistent with other members of its class, the benefits of linagliptin also include a low risk of hypoglycemia and weight gain. However, linagliptin is the first DPP-4 inhibitor to be approved as a once-daily, 5-mg dose and, due to its primarily non-renal route of excretion, no dosage adjustment is required for patients with renal or hepatic impairment. The pharmacokinetics and pharmacodynamics of linagliptin are not affected to a clinically meaningful degree by race or ethnicity and linagliptin has very low potential for drug-drug interactions.

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)

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.

No evidence of hypoglycemia or hypotension in older adults during 6 months of flax lignan supplementation in a randomized controlled trial: a safety evaluation

CONTEXT

The natural health product, BeneFlax, is a standardized flaxseed [Linum usitatissimum L. (Linaceae)] lignan enriched product with evidence of product quality and known quantity of the bioactive component, lignan. The acceptance of this natural health product for its various health benefits requires greater evidence of its safety in the general population.

OBJECTIVE

We determined whether flaxseed lignan causes clinical hypoglycemia or hypotension in healthy older adults as an important aspect of safety.

MATERIALS AND METHODS

Participants aged 49-87 years were randomized in a double-blind trial to receive flaxseed lignan (543 mg/day in BeneFlax) or placebo while completing a 6-month walking program. The 94 participants who completed the study were stratified by age (<65 years versus ≥65 years) and treatment category to determine whether older adults were more susceptible to adverse effects.

RESULTS

After 6 months of treatment, average plasma glucose level (5.4 ± 0.6 mmol/L), systolic blood pressure (127 ± 14 mm Hg), and diastolic blood pressure (80 ± 9 mm Hg) were within normal clinical range. Controlling for sex and body mass index covariates resulted in no observed differences between plasma glucose or blood pressure measurements between treatment or age groups (p > 0.05). No incidents of hypoglycemia or hypotension were observed during BeneFlax treatment, suggesting that 543 mg falls at or below the no observable adverse effect level (NOAEL).

DISCUSSION AND CONCLUSION

These data suggest the flaxseed lignan product BeneFlax does not pose a risk of hypoglycemia or hypotension in healthy adults aged 49-87 years.

Efficacy and safety of insulin glargine compared to other interventions in younger and older adults: a pooled analysis of nine open-label, randomized controlled trials in patients with type 2 diabetes

OBJECTIVE

Elderly patients with type 2 diabetes mellitus (T2DM) present therapeutic challenges related to co-morbidities, treatment adherence, and safety. This study examines the efficacy and safety of insulin glargine compared to other glucose-lowering interventions in younger and older adults.

METHODS

In this pooled analysis of 24-week data from nine prospective open-label, multicenter, phase 3/4, two-arm, parallel-group, randomized controlled trials, patients with T2DM aged 18-80 years received insulin glargine (used as a basal insulin regimen) or comparators (including rosiglitazone, pioglitazone, insulin lispro, insulin lispro 75/25, NPH insulin, NPH insulin 30/70, and lifestyle/dietary measures). Endpoints included change from baseline to week 24 in: glycated hemoglobin; fasting plasma glucose; body weight; body mass index; insulin dose; incidence of nocturnal, daytime, or any hypoglycemia. Results were stratified by age (<65, ≥65, 65-74, and ≥75 years) and treatment (insulin glargine or comparator).

RESULTS

A total of 2,938 patients were included (2,263 aged <65 years, 675 aged ≥65 years). Similar levels of glycemic control were achieved in both younger (<65 years) and older (≥65 years) patients with T2DM. Insulin glargine was associated with better glycemic control and a reduced incidence of daytime and any hypoglycemia versus comparator interventions in both younger and older T2DM patients.

CONCLUSION

This analysis suggests that insulin glargine may represent a safe option to improve glycemic control in older patients with T2DM.

The impact of diabetes counseling and education: clinical and cost outcomes from a large population of US managed care patients with type 2 diabetes

PURPOSE

The purpose of this study is to examine outcomes in adult patients with type 2 diabetes mellitus who received diabetes counseling and education (C/E) services compared with those who did not.

METHODS

A matched, retrospective cohort study of 17 483 C/E recipients and 17 470 non-C/E controls was followed for up to 12 months. Outcomes included glycemic control (glycosylated hemoglobin A1C levels <7.0%), hypoglycemic events, and health care utilization and costs.

RESULTS

Compared with the non-C/E group, patients in the C/E group had significantly lower A1C (7.7% vs 7.2%) and were more likely to achieve glycemic control at 6 months' follow-up; they were also more likely to have a hypoglycemic event. During the 1-year period following the index date, C/E recipients had more inpatient visits (0.21 vs 0.20 visits per patient) and ambulatory visits (21.5 vs 18.6 visits per patient) compared with non-C/E controls. The increased use of health care services in the C/E groups was associated with $2388 higher annual overall costs and $827 higher diabetes-related costs.

CONCLUSIONS

Diabetes C/E is associated with improved glycemic control, albeit with a slight increase in the risk of hypoglycemia. C/E was associated with higher health care costs across 12 months. Further analyses are needed to evaluate long-term cost-effectiveness of diabetes counseling and education.

Efficacy and safety of sitagliptin as add-on therapy on glycemic control and blood glucose fluctuation in Japanese type 2 diabetes subjects ongoing with multiple daily insulin injections therapy

To assess the efficacy and safety of adding sitagliptin, an oral dipeptidyl peptidase-4 inhibitor, in subjects with type 2 diabetes inadequately controlled with multiple daily insulin injections therapy (MDI). HbA1c, 1,5-anhydroglucitol (1,5-AG), body mass index (BMI), insulin doses, six-point self-measured plasma glucose (SMPG) profiles were assessed before, after 12 weeks, and after 24 weeks of MDI with 50 mg/day of sitagliptin in 40 subjects with type 2 diabetes. Safety endpoints included hypoglycemia and any adverse events. HbA1c significantly decreased during the first 12 weeks ( -0.64±0.60%), and was sustained over 24 weeks ( -0.69±0.85%). 1,5-AG increased significantly from 7.5±4.5 μg/mL at baseline to 9.6±5.5 μg/mL after 24 weeks. The bolus insulin dose at 12 weeks was decreased, and the mean plasma glucose, the SD of daily glucose, M-value, and the mean amplitude of glycemic excursions (MAGE) also decreased significantly as compared with baseline values. BMI and frequency of hypoglycemia were not changed significantly. Univariate linear regression analyses revealed that % change in HbA1c was significantly associated with BMI, and % changes in the indexes of glycemic instability (SD of daily glucose and MAGE) were significantly associated with age. In conclusion, adding sitagliptin to MDI significantly improved glycemic control and decreased the daily glucose fluctuation in subjects with type 2 diabetes inadequately controlled with MDI, without weight gain or an increase in the incidence of hypoglycemia. This trial was registered with UMIN (no. UMIN000010157).

Comparison between sitagliptin as add-on therapy to insulin and insulin dose-increase therapy in uncontrolled Korean type 2 diabetes: CSI study

AIM

Individuals requiring insulin therapy for type 2 diabetes often require escalation of their regimen to achieve glycaemic control. Optimal management strategies for uncontrolled type 2 diabetes would improve glycaemic control without hypoglycaemia and weight gain. This study compared the efficacy and tolerability of adding sitagliptin, an oral dipeptidyl peptidase-4 inhibitor, and an up to 20% increase in insulin dose in patients with uncontrolled type 2 diabetes on insulin therapy.

METHODS

We conducted a 24-week, randomized, active-competitor, parallel-group study in subjects with uncontrolled type 2 diabetes [haemoglobin A1c (HbA1c) = 7.5-11%] currently using insulin therapy. Subjects were randomly assigned to either the sitagliptin adding (100 mg daily, n = 70) or an insulin-increasing arm (≥ 10% at week 12 and ≥ 10% at week 24, n = 70) while continuing other medications.

RESULTS

Average baseline HbA1c was 9.2% in both groups. HbA1c decreased more at 24 weeks in the sitagliptin adding than the insulin-increasing arm (-0.6 ± 0.1% vs. -0.2 ± 0.1%, p < 0.01). Insulin was increased by 25% at 24 weeks in the insulin-increasing group. Hypoglycaemic events were less common and less severe in sitagliptin adding arm than insulin-increasing arm (7.0 vs. 14.3 events per patient-year, p < 0.05). Weight was stable in the sitagliptin adding subjects (68.6 ± 11.6 vs. 68.1 ± 11.4 kg) but increased in the insulin-increasing subjects (66.2 ± 10.6 vs. 67.4 ± 9.7 kg, p < 0.05). Other adverse events occurred at similar rates in both arms.

CONCLUSIONS

Compared to a 25% increase in insulin dose, adding sitagliptin to an insulin-based regimen was more effective at lowering HbA1c and associated with less hypoglycaemia and weight gain over 24 weeks.

CLINICAL TRIAL NUMBER

NCT01100125.

Insulin use in elderly adults: risk of hypoglycemia and strategies for care

Hypoglycemia is a significant problem in elderly adults with diabetes mellitus. Elderly individuals with diabetes mellitus are at greater risk than younger adults for hypoglycemic events. Several factors contribute to this risk, including the high prevalence of comorbidities, polypharmacy, cognitive impairment, and concomitant use of agents that interfere with glucose metabolism. To minimize the risk of hypoglycemia and maximize the benefits of glycemic control, guidelines typically recommend individualizing glycosylated hemoglobin (HbA1c) targets based on life expectancy, functional status, and individual goals. Although many individuals with type 2 diabetes mellitus will ultimately require insulin therapy to achieve and maintain glycemic control, earlier insulin initiation in elderly individuals may be warranted, particularly in those with renal, cardiovascular, or hepatic concerns that could interfere with the use of oral agents. There are few data on the use of insulin-or other glucose-lowering agents-in elderly adults, but limited evidence suggests that the use of insulin, especially insulin analogs, may be appropriate in this population. Insulin analogs offer a better pharmacokinetic profile, greater convenience, and less variable glycemic control than human insulin. Because of the high prevalence of cognitive impairment and other geriatric syndromes in elderly adults, clinicians should perform a comprehensive assessment of patients' ability to administer and monitor insulin therapy and recognize and treat hypoglycemia.

Pharmacokinetics and pharmacodynamic changes associated with aging and implications for drug therapy

The population of older adults continues to increase, and polypharmacy in this population is more the rule than the exception. Physiologic changes that occur with aging result in multiple alterations to the pharmacokinetics and pharmacodynamics of drugs, which, in turn, increase the risk of adverse drug reactions. Consideration of initial dose adjustment, along with frequent medication reconciliation and analysis of the medication list, are keys to providing optimal pharmaceutical care for elderly patients.

Polypharmacy and food-drug interactions among older persons: a review

Polypharmacy is generally defined as the use of 5 or more prescription medications on a regular basis. The average number of prescribed and over-the-counter medications used by community-dwelling older adults per day in the United States is 6 medications, and the number used by institutionalized older persons is 9 medications. Almost all medications affect nutriture, either directly or indirectly, and nutriture affects drug disposition and effect. This review will highlight the issues surrounding polypharmacy, food-drug interactions, and the consequences of these interactions for the older adult.

Noninsulin treatment of type 2 diabetes mellitus in geriatric patients: a review

BACKGROUND

Currently, 42% of the US population with diabetes is aged ≥65 years.

OBJECTIVE

The aim of this review was to discuss the efficacy and tolerability of noninsulin therapies for type 2 diabetes mellitus (T2DM), with an emphasis on patients aged ≥65 years.

METHODS

PubMed and EMBASE (1977-2010) were searched using the terms geriatric, elderly patients, type 2 diabetes mellitus, metformin, secretagogues, thiazolidinediones (TZDs), alpha-glucosidase inhibitors, dipeptidyl peptidase-4 (DPP-4) inhibitors, and glucagon-like peptide-1 (GLP-1) receptor agonists. Articles were included if they were clinical trials, reviews, or meta-analyses.

RESULTS

More than 10 classes of noninsulin treatments are available for T2DM. However, most treatments have been evaluated only in trials in patients aged <65 years, and trials in older populations are scarce. Therefore, health care providers should consider the overall benefit to risk, with a focus on risk factors in older patients. A1C reductions range from 0.6% to 2%, with similar decreases observed for metformin, TZDs, sulfonylureas (SUs), glinides, and GLP-1 receptor agonists Treatment-associated adverse events vary. The prevalence of hypoglycemia is high with the secretagogues, SUs, and glinides (20% with glibenclamide or glipizide, 16% with repaglinide). The TZDs have been associated with an increased risk for heart failure (adjusted ratio = 1.60; 95% CI, 1.21-2.10; P < 0.001) compared with the other oral therapies. Gastrointestinal adverse events have been commonly reported with metformin (38% of patients), which is contraindicated in cases of renal insufficiency. Use of the GLP-1 RAs liraglutide and exenatide have been associated with comparable weight reductions of ∼3 kg and with a low risk for hypoglycemia (prevalence, 4% with exenatide 10 μg; ∼5% with liraglutide 1.2 or 1.8 mg). Treatment with the GLP-1 RAs has been associated with transient gastrointestinal reactions, mainly nausea.

CONCLUSIONS

The selection of noninsulin treatments in older patients with T2DM should be individualized based on patient assessment and on careful evaluation of the potential benefits (glycemic and extraglycemic) and risks (ie, hypoglycemia, weight gain, cardiovascular risks). More clinical trials in older patients, especially those aged ≥65 years, with T2DM are needed.