Cost-effective strategies in the prevention of diabetic nephropathy

Polysaccharide from Hemerocallis citrina Borani by subcritical water: Bioactivity, purification, characterization, and anti-diabetic effects in T2DM rats

Hemerocallis citrina Borani (daylily) has various health benefits. However, the structural characterization and hypoglycemic effects of its polysaccharide remain unclear. Here, we first report for the first time, the effects of subcritical water extraction temperature on bioactivity of Hemerocallis citrina Borani polysaccharide (HCBP). HCBP extracted at 160 °C had better scavenging ability of free-radical and pancreatic lipase inhibition. This study aimed to investigate the structural characterization and anti-diabetic effects of aforementioned HCBP. HCBP was separated into three fractions using a DEAE-Sepharose Fast Flow. HCBP-1 was the major component with lower molecular weight, HCBP-2 was the least abundant component, HCBP-3 was the component with higher uronic acid and molecular weight. HCBP treatment significantly decreased the concentrations of fasting blood glucose, insulin, total cholesterol, triglyceride, and low density lipoprotein, as well as improved glucose intolerance and insulin resistance in type 2 diabetes mellitus (T2DM) rats. HCBP also protected the kidneys and pancreatic organs by histopathology and immunohistochemical analyses in T2DM rats. In addition, HCBP significantly increased the antioxidant enzymes activities and decreased the level of malonaldehyde to alleviated the oxidative stress injury. The results indicate HCBP extracted by subcritical water is promising functional food ingredients and could be used in T2DM treatment.

Original article. Cost-effectiveness of annual microalbuminuria screening in Thai diabetics

Background: Diabetes is a leading cause of end stage renal disease (ESRD), which impacts on treatment costs and patients’ quality of life. Microalbuminuria screening in patients with diabetes as an early intervention is beneficial in slowing the progression of diabetic nephropathy.

Objectives: We aimed to assess the cost-effectiveness of annual microalbuminuria screening in type 2 diabetic patients.

Methods: We compared screening by urine dipsticks with a “do nothing” scenario. To replicate the natural history of diabetic nephropathy, a Markov model based on a simulated cohort of 10,000 45-year-old normotensive diabetic patients was utilized. We calculated the cost and quality of life gathered from a cross-sectional survey. The costs of dialysis were derived from The National Health Security Office (NHSO). We also calculated the incremental cost-effectiveness ratio (ICER) for lifetime with a future discount rate of 3%.

Results: The ICER was 3,035 THB per quality-adjusted life year (QALY) gained. One-way and probabilistic sensitivity analyses showed that all ICERs were less than the Thai Gross Domestic Product (GDP) per capita (150,000 THB in 2011) based on World Health Organization’s suggested criteria.

Conclusions: Annual microalbuminuria screening using urine dipsticks in type 2 diabetic patients is very costeffective in Thailand based on World Health Organization’s recommendations. This finding has corroborated the benefit of this screening in the public health benefit package.

Review: PROactive 03: Pioglitazone, type 2 diabetes and reducing macrovascular events — economic implications?

conomic value of medicines, medical devices and other technologies is an increasingly important consideration in healthcare management. Conducting high quality economic analyses alongside randomised controlled clinical trials (RCTs) is desirable since these offer timely information with high internal validity. The recent publication of the landmark PROactive study provides a relevant platform upon which to base a detailed economic evaluation of the possible additional benefit of pioglitazone over and above current best treatment in patients with type 2 diabetes with severe cardiovascular (CV) disease. Pioglitazone improved CV outcome and reduced the need to add insulin to existing therapy in individuals at high risk of further macrovascular events. The predefined economic analysis of this study using well-accepted methods will inform the cost effectiveness (CE) of pioglitazone confirming (or not) its value in the management of patients with type 2 diabetes with severe CV disease.

Accepting Medication Therapy Management Recommendations to Add ACEIs or ARBs in Diabetes Care

BACKGROUND

National guidelines and initiatives have promoted the use of angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs) for patients with diabetes. The University of Arizona Medication Management Center (UA-MMC) is contracted by Medicare health plans, pharmacy benefit managers (PBMs), and multiple commercial health insurance plans to provide medication therapy management (MTM) services for plan members. As part of the MTM program, recommendations have been made for those patients who may benefit from the addition of an ACEI/ARB. Although the intervention benefits and guidelines for using ACEIs/ARBs are clear, real-world evidence is needed to understand and potentially increase uptake of guideline interventions among eligible patients.

OBJECTIVES

To (a) identify patient characteristics that predict acceptance of guideline recommendations to add ACEI/ARB medications to diabetic treatment via MTM services and (b) examine how well different case characteristics (i.e., patient age and sex, type and number of recommendation attempts, type of health care plan) predict the odds of adding ACEI/ARB medications to diabetic regimens when recommended through an MTM call center.

METHODS

This was a retrospective analysis of secondary data provided by the UA-MMC. The de-identified national data included adult plan members with diabetes who the UA-MMC recommended adding an ACEI/ARB prescription based on 2012 national guidelines. The UA-MMC made recommendations by either patient letters, patient phone calls, physician faxes, or any combination thereof. We conducted a binary logistic regression analysis to assess the impact of case characteristics on the likelihood of accepting recommendations to add ACEI/ARB medications. The outcome variable was recommendation acceptance (yes/no), defined as new prescription claims for an ACEI/ARB within 120 days following the recommendation. Five predictor variables were assessed: (1) patient's age quartile; (2) method of communicating recommendations (letter, phone call, fax, or some combination thereof); (3) whether recommendations were made once or twice on separate dates; (4) patient's sex; and (5) type of health care plan.

RESULTS

Recommendations were made for 31,495 members of health plans or PBMs that contracted with the UA-MMC. Patients' ages ranged from 19-90 (Mean =72.01; SD =10.21), with females comprising 56% of the sample. The recommendation to add ACEI/ARB medications was accepted for 14.5% (4,559) of patients. In most cases (73%), recommendations occurred via a letter to patients together with a fax to their providers. The fitted model, containing 3 predictor variables (age quartile, type of contact to communicate the recommendations, and whether recommendation contacts were made twice), was statistically significant, χ(2) (10; N = 31,495) = 112.82 (P < 0.001), indicating that the model was able to distinguish between those who did and did not accept UA-MMC's recommendations to add ACEI/ARB medications. The likelihood of recommendation acceptance decreased as patient age increased compared with patients in the first age quartile (ages 19-67; P ≤ 0.005 at all levels). Compared with sending only a provider fax, patients who received all 3 types of contact (provider fax with patient phone call and letter) were estimated to be 1.34 times more likely (34% increase) to have recommendation acceptance ( P = 0.004; 95% CI = 1.10-1.63). Similarly, patients who received only letters were also 1.32 times more likely (32% increase) than provider faxes alone to result in recommendation acceptance ( P = 0.003; 95% CI = 1.10-1.59). Patients for whom recommendations were made twice were less likely to have recommendation acceptance than for those contacted once, controlling for all other predictor variables in the model ( P < 0.001; OR = 0.77; 95% CI = 0.69-0.86).

CONCLUSIONS

Recommendations to add an ACEI/ARB to diabetic regimens are more likely to be accepted for younger patients and those who receive recommendations through all 3 communication types (provider fax combined with patient phone call and letter) or just letters than provider faxes alone. Further research is needed to understand why prescribers are not accepting MTM recommendations.

Economic evaluations of angiotensin-converting enzyme inhibitors and angiotensin II receptor blockers in type 2 diabetic nephropathy: a systematic review

Background

Structured comparison of pharmacoeconomic analyses for ACEIs and ARBs in patients with type 2 diabetic nephropathy is still lacking. This review aims to systematically review the cost-effectiveness of both ACEIs and ARBs in type 2 diabetic patients with nephropathy.

Methods

A systematic literature search was performed in MEDLINE and EMBASE for the period from November 1, 1999 to Oct 31, 2011. Two reviewers independently assessed the quality of the articles included and extracted data. All cost-effectiveness results were converted to 2011 Euros.

Results

Up to October 2011, 434 articles were identified. After full-text checking and quality assessment, 30 articles were finally included in this review involving 39 study settings. All 6 ACEIs studies were literature-based evaluations which synthesized data from different sources. Other 33 studies were directed at ARBs and were designed based on specific trials. The Markov model was the most common decision analytic method used in the evaluations. From the cost-effectiveness results, 37 out of 39 studies indicated either ACEIs or ARBs were cost-saving comparing with placebo/conventional treatment, such as amlodipine. A lack of evidence was assessed for valid direct comparison of cost-effectiveness between ACEIs and ARBs.

Conclusion

There is a lack of direct comparisons of ACEIs and ARBs in existing economic evaluations. Considering the current evidence, both ACEIs and ARBs are likely cost-saving comparing with conventional therapy, excluding such RAAS inhibitors.

Prevalence and risk factors of microalbuminuria in Thai nondiabetic hypertensive patients

PURPOSE

To assess the prevalence and risk factors of microalbuminuria in nondiabetic hypertensive patients in Thailand.

PATIENTS AND METHODS

A cross-sectional study was performed during January to December 2007 at outpatients departments of Bhumibol Adulyadej hospital. Nondiabetic hypertensive patients without a history of pre-existing kidney diseases participated in this study. A questionnaire was used for collecting information on demographics, lifestyle, and family history of cardiovascular and kidney disease. Spot morning urine samples were collected for albuminuria estimation. Albuminuria thresholds were evaluated and defined using albumin-creatinine ratio (ACR).

RESULTS

A total of 559 hypertensive patients (283 males, 276 females), aged 58.0 +/- 11.6 years were enrolled in this study. Microalbuminuria (ACR 17 to 299 mg/g in males and 25 to 299 mg/g in females) was found in 93 cases (16.6%) [15.0%-18.2%]. The independent determinants of elevated urinary albumin excretion in a multiple logistic regression model were; body mass index > or =30 (odds ratio (OR) = 2.24, 95% confidence intervals (CI): 1.33-3.76) and dihydropyridine calcium channel blockers (DCCB) use (OR = 1.92, 95% CI: 1.22-3.02).

CONCLUSION

In Thai nondiabetic hypertensive patients, microalbuminuria was not uncommon. Obesity and use of dihydropyridine calcium channel blocker were found to be the important predictors. Prognostic value of the occurrence of microalbuminuria in this population remains to be determined in prospective cohort studies.

Prevalence of increased albumin excretion rate in young saudi adults

INTRODUCTION

Albuminuria is an important risk predictor of chronic kidney disease and cardiovascular disease. In this study, we aim to evaluate the prevalence of increased urinary albumin excretion (UAE) rate amongst a subgroup of young Saudi army/navy recruits.

METHODS

2,000 Saudi military recruits were tested for microalbuminuria by dipstick and 24-hour urine collection for quantitative evaluation.

RESULTS

In the whole group studied, the rate of microalbuminuria-positive dipstick testing was 10.3% (n = 206), but decreased on quantitative evaluation of 24-hour urine collection to 6.2% (n = 124). Increased UAE was independently associated with diabetes mellitus (DM), hypertension (HT), obesity, male gender and hypercholesterolemia. 55 of the 124 (44.4%) were diabetics while 14 (11.3%) were hypertensives. Around 21% of individuals with albuminuria were obese; body mass index for the whole group with albuminuria = 31.15 +/- 5.8 kg/m(2) and showed no gender difference. Increased risk of albuminuria was noted with DM (OR = 5.07 [3.5-7.4], p < 0.0001), obesity (OR = 1.59 [1.0-2.5], p = 0.042) and HT (OR = 1.8 [1.0-3.2], p = 0.046). An estimated glomerular filtration rate of approximately 77 ml/min/1.73 m(2) was present in the whole group with a significantly lower level in macroalbuminuric subjects compared to those with microalbuminuria (p = 0.03). Also, age was higher in the macroalbuminuric group (p = 0.004) with comparable prevalence of DM (47.4 vs. 45.2%, p = NS).

CONCLUSIONS

This is the first description of increased UAE in a small percentage of young adult Arab subjects from Saudi Arabia detected through a selective screening process carried out on potential army recruits. It highlights the association of albuminuria in the general population with predisposing conditions such as DM, HT and obesity.

Comparison of Commonly Used Assays for the Detection of Microalbuminuria

There are a variety of methods for assessing urinary albumin excretion, extending from the very low-range microalbuminuria to higher ranges extending into macroalbuminuria or proteinuria. The recommendation for the initial screening of a new patient is to use a urine dipstick to assess for microalbuminuria. If positive, a spot urine for albumin:creatinine should be measured and reassessed annually. All patients with kidney disease, diabetes, or hypertension and metabolic syndrome should be screened for albuminuria. New methodologies using high-performance liquid chromatography are much more sensitive and specific when compared with older methods of detection and may prove very useful for earlier identification of high-risk patients. This is important since studies have shown that albuminuria levels below the microalbuminuria range, determined by conventional methodologies in uncomplicated essential hypertensive men, are associated with an adverse cardiovascular and metabolic risk profile. High performance liquid chromatography methodology, in contrast to older studies, detects all intact albumin and enables clinicians to assess disease severity and monitor therapeutic effectiveness with confidence in the accuracy of the microalbuminuria data reported to them.

Microalbuminuria: what is it? Why is it important? What should be done about it? An update

Microalbuminuria (MA) is defined as a persistent elevation of albumin in the urine of >30 to <300 mg/d (>20 to <200 microg/min). Use of the morning spot urine test for albumin-to-creatinine measurement (mg/g) is recommended as the preferred screening strategy for all patients with diabetes and with the metabolic syndrome and hypertension. MA should be assessed annually in all patients and every 6 months within the first year of treatment to monitor the impact of antihypertensive therapy. It is an established risk marker for the presence of cardiovascular disease and predicts progression of nephropathy when it increases to frank microalbuminuria>300 mg/d. Data support the concept that the presence of MA is the kidney's warning that there is a problem with the vasculature. The presence of MA is a marker of endothelial dysfunction and a predictor of increased cardiovascular risk. MA can be reduced, and progression to overt proteinuria prevented, by aggressive blood pressure reduction, especially with a regimen based on medications that block the renin-angiotensin-aldosterone system, and control of diabetes. The National Kidney Foundation recommends that blood pressure levels be maintained at or below 130/80 mm Hg in anyone with diabetes or kidney disease.

Microalbuminuria and cardiovascular disease

To reduce the burden of cardiovascular disease (CVD), management strategies are increasingly focusing on preventive measures following early detection of markers of atherosclerosis. This review focuses on microalbuminuria, which is gaining recognition as a simple marker of an atherogenic milieu. Prospective and epidemiologic studies have found that microalbuminuria is predictive, independently of traditional risk factors, of all-cause and cardiovascular mortality and CVD events within groups of patients with diabetes or hypertension, and in the general population. The pathophysiologic mechanism underlying the association between albumin excretion and CVD is not fully defined. One hypothesis is that microalbuminuria may be a marker of CVD risk because it reflects subclinical vascular damage in the kidneys and other vascular beds. It may also signify systemic endothelial dysfunction that predisposes to future cardiovascular events. Based on this theory, periodic screening for microalbuminuria could allow early identification of vascular disease and help stratify overall cardiovascular risk, especially in patients with risk factors such as hypertension or diabetes. A positive test for urinary albumin excretion could signify the need for an intensive multifactorial intervention strategy, including behavior modification and targeted pharmacotherapy, aimed at preventing further renal deterioration and improving the overall CVD risk factor profile. Data from intervention studies suggest that treatment with angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers, statins, and/or strict glycemic control (in diabetics) offer significant reductions in cardiovascular and/or renal morbidity in patients with albuminuria. Use of this (old) marker may allow improved use of medications and strategies for secondary prevention.

Screening, Monitoring, and Treatment of Albuminuria: Public Health Perspectives

Microalbuminuria is an early sign of progressive cardiovascular and renal disease in individuals with and without diabetes. Despite compelling data, at present only a minority of patients with diabetes and rarely individuals without diabetes are screened for albuminuria in a systematic way. All of the criteria to implement systematic albuminuria screening are fulfilled in diabetes, and most are nearly fulfilled for microalbuminuria screening in individuals without diabetes. Because of the growing evidence that treatment of microalbuminuria in individuals without diabetes may offer a cost-effective benefit to prevent cardiovascular disease, nephrologists and other health care providers should pay more attention to the early detection and subsequent treatment of individuals with microalbuminuria.

Improving Antihypertensive Therapy in Patients with Diabetic Nephropathy

Nearly all patients with diabetic nephropathy have comorbid hypertension, which greatly elevates the risk for cardiovascular events. As patients are surviving longer, their risk of progressing to end-stage renal disease is increasing, particularly in patients with type 2 diabetes. Prevention of cardiovascular and renal events in this population requires diligent efforts to control blood pressure, serum glucose, and serum lipids. Improving antihypertensive therapy in patients with diabetic nephropathy relies on the following unified strategies: reducing blood pressure to <130/80 mm Hg, prescribing an agent that blocks the renin-angiotensin system, and designing an antihypertensive regimen that both reduces albuminuria and provides cardiovascular protection. A majority of patients will require three or more antihypertensive agents to achieve these objectives. Appropriate antihypertensive therapy in patients with diabetic nephropathy delays progression of renal disease and leads to substantial cost savings.

Pharmacoeconomics of angiotensin II antagonists in type 2 diabetic patients with nephropathy: implications for decision making

Angiotensin II receptor antagonists (angiotensin II receptor blockers; ARBs) are a class of antihypertensive drugs that are generally considered comparable to ACE inhibitors in the prevention of heart and kidney failure. However, these two classes of agents do interfere in different stages of the renin-angiotensin system. In patients with type 2 diabetes mellitus, advantages for ARBs over conventional (non-ACE inhibitor) therapy on progression from micro- to macroalbuminuria and overt nephropathy and end-stage renal disease have been shown in clinical trials. In patients with type 2 diabetes and end-stage renal disease, the need for dialysis and/or transplantation results in the use of major healthcare resources. This paper reviews the available economic evidence on treatment with ARBs in type 2 diabetic patients with advanced renal disease.Within-trial analytic and Markov model economic evaluations of the RENAAL (Reduction of Endpoint in Non-insulin dependent diabetes mellitus with Angiotensin II Antagonist Losartan), IDNT (Irbesartan Diabetic Nephropathy Trial) and IRMA (IRbesartan in type 2 diabetes with MicroAlbuminuria)-2 studies suggest that treatment with ARBs in patients with type 2 diabetes with overt or incipient nephropathy confers health gains and net cost savings compared with conventional (non-ACE inhibitor) therapy. For reimbursement and reference pricing decisions, there is a need for a head-to-head comparison of an ACE inhibitor with ARBs to model all possible costs and effects of ACE inhibitors and ARBs. This will result in a proper pharmacoeconomic outcome, where both types of drugs can be compared for healthcare decisions.

Demographic and epidemiologic transition in the developing world: Role of albuminuria in the early diagnosis and prevention of renal and cardiovascular disease

The developing world is facing a real pandemic of renal and cardiovascular disease. With the decrease of infectious disease morbidity and mortality, and the exposure to more westernized life style, signs of increasing renal and cardiovascular disease is particularly shown in the tremendous rise in type 2 diabetes and its sequelae. A group of doctors and scientists from all over the world have convened in Bellagio to halt this dramatic disease change and burden to the developing countries. They came to the conclusion that screening and treatment should clearly focus on cost-beneficial strategies, among which blood pressure and urinary albumin measurement, as well as effective and affordable treatment strategies to lower blood pressure and albuminuria, are essential.