Comprehensive risk assessments of diabetic patients from seven Asian countries: The Joint Asia Diabetes Evaluation (JADE) program

Efficacy and Safety of Ertugliflozin Added to Metformin: A Pooled Population from Asia with Type 2 Diabetes and Overweight or Obesity

INTRODUCTION

The efficacy and safety of ertugliflozin have not been well characterized in Asian populations with type 2 diabetes (T2D) and overweight or obesity as defined by the Chinese Diabetes Society [body mass index (BMI) ≥ 24 kg/m²].

METHODS

These post hoc analyses of pooled data from two randomized, double-blind, 26-week studies assessed the efficacy and safety of ertugliflozin (5 mg or 15 mg) compared with placebo in participants from Asia with T2D and baseline BMI ≥ 24 kg/m², with inadequate glycemic control on metformin. Longitudinal analyses were used to calculate least squares (LS) mean [95% confidence interval (CI)] change from baseline in glycemic indices and body weight. The proportions of participants achieving efficacy targets and experiencing adverse events (AEs) were assessed.

RESULTS

The 445 participants had a mean age of 55.5 years, T2D duration 6.6 years, glycated hemoglobin (HbA1c) 8.1%, and BMI 27.6 kg/m². At week 26, placebo-adjusted LS mean (95% CI) changes from baseline for ertugliflozin 5 mg and 15 mg, respectively, were - 0.78% (- 0.95% to - 0.61%) and - 0.80% (- 0.98% to - 0.63%) for HbA1c, and - 1.74 kg (- 2.29 kg to - 1.19 kg) and - 2.04 kg (- 2.60 kg to - 1.48 kg) for body weight. A greater proportion of participants receiving ertugliflozin 5 mg and 15 mg versus placebo, respectively, achieved HbA1c < 7.0% (42.1% and 46.3% vs. 13.9%), body weight reduction ≥ 5% (35.5% and 38.3% vs. 11.1%), and systolic blood pressure < 130 mmHg (42.4% and 34.5% vs. 21.7%). The proportion of participants with AEs was 52.6% (ertugliflozin 5 mg), 52.3% (ertugliflozin 15 mg), and 55.6% (placebo).

CONCLUSIONS

In participants from Asia with T2D inadequately controlled by metformin monotherapy, and BMI ≥24 kg/m², ertugliflozin (5 mg or 15 mg) resulted in greater glycemic and body weight reductions compared with placebo and was generally well tolerated.

TRIAL REGISTRATION

Clinicaltrials.gov identifiers NCT02033889, NCT02630706.

Ten-Year Effectiveness of the Multidisciplinary Risk Assessment and Management Programme-Diabetes Mellitus (RAMP-DM) on Macrovascular and Microvascular Complications and All-Cause Mortality: A Population-Based Cohort Study

OBJECTIVE

The Risk Assessment and Management Programme-Diabetes Mellitus (RAMP-DM) is a protocol-driven, risk-stratified, and individualized management program offered by a multidisciplinary team in addition to usual care for primary care patients with diabetes. This study aimed to evaluate the effectiveness of RAMP-DM for preventing complications and mortality over 10 years.

RESEARCH DESIGN AND METHODS

A population-based, prospective cohort study of adult patients with type 2 diabetes managed in the Hong Kong public primary health care system between 2009 and 2010 was conducted. RAMP-DM participants and usual care patients were matched using one-to-one propensity score matching and followed for 10 years. Risks of macrovascular and microvascular complications and all-cause mortality were estimated by Cox proportional hazards regression.

RESULTS

A total of 36,746 patients (18,373 in each group) were included after propensity score matching, with a median follow-up of 9.5 years and 306,802 person-years. RAMP-DM participants had significantly lower risks of macrovascular (hazard ratio [HR] 0.52, 95% CI 0.50-0.54) and microvascular (HR 0.68, 95% CI 0.64-0.72) complications and all-cause mortality (HR 0.45, 95% CI 0.43-0.47) than patients who received usual care only. However, the effect of RAMP-DM on macrovascular and microvascular complications attenuated after the 9th and 8th year of follow-up, respectively. RAMP-DM participants also showed better control of hemoglobin A1c, blood pressure, triglycerides, and BMI and a slower decline in renal function.

CONCLUSIONS

Significant reductions in diabetes-related complications and all-cause mortality were observed among RAMP-DM participants over a 10-year follow-up, yet the effect of preventing complications attenuated after 8 years.

Indicators of optimal diabetes care and burden of diabetes complications in Africa: a systematic review and meta-analysis

OBJECTIVE

Contemporary data on the attainment of optimal diabetes treatment goals and the burden of diabetes complications in adult populations with type 2 diabetes in Africa are lacking. We aimed to document the current status of attainment of three key indicators of optimal diabetes care and the prevalence of five diabetes complications in adult African populations with type 2 diabetes.

METHODS

We systematically searched Embase, PubMed and the Cochrane library for published studies from January 2000 to December 2020. Included studies reported any information on the proportion of attainment of optimal glycated haemoglobin (HbA1c), blood pressure (BP) and low-density lipoprotein cholesterol (LDLC) goals and/or prevalence of five diabetes complications (diabetic peripheral neuropathy, retinopathy, nephropathy, foot ulcers and peripheral arterial disease). Random effect model meta-analysis was performed to determine the pooled proportion of attainment of the three treatment goals and the prevalence of five diabetes complications.

RESULTS

In total, 109 studies with a total of 63 890 participants (53.3% being females) were included in the meta-analysis. Most of the studies were conducted in Eastern African countries (n=44, 40.4%). The pooled proportion of attainment of an optimal HbA1c, BP and LDLC goal was 27% (95% CI 24 to 30, I²=94.7%), 38% (95% CI 30 to 46, I²=98.7%) and 42% (95% CI 32 to 52, I²=97.4%), respectively. The pooled prevalence of diabetic peripheral neuropathy, retinopathy, diabetic nephropathy, peripheral arterial disease and foot ulcers was 38% (95% CI 31 to 45, I²=98.2%), 32% (95% CI 28 to 36, I²=98%), 31% (95% CI 22 to 41, I²=99.3%), 19% (95% CI 12 to 25, I²=98.1%) and 11% (95% CI 9 to 14, I²=97.4%), respectively.

CONCLUSION

Attainment of optimal diabetes treatment goals, especially HbA1c, in adult patients with type 2 diabetes in Africa remains a challenge. Diabetes complications, especially diabetic peripheral neuropathy and retinopathy, are highly prevalent in adult populations with type 2 diabetes in Africa.

Quality of care and prescription patterns among patients with diabetic kidney disease-a large-scale cohort study from Taiwanese clinics

Aims

To investigate the quality of care and prescription patterns of patients with diabetic kidney disease (DKD) receiving primary care at local clinics in Taiwan.

Methods

A retrospective chart review was conducted in 43 primary care clinics in Taiwan. The patients' baseline characteristics, laboratory tests, presence of complications and antidiabetic agents prescribed were analyzed.

Results

7,200 patients with type 2 diabetes mellitus were enrolled. Percentage of HbA1c, blood pressure (BP), and low density lipoprotein cholesterol (LDL-C) goals reached were 52.5% in HbA1c < 7%, 40.9% in BP < 130/80 mmHg and 79.7% in LDL-C < 2.59 mmol/L. 18.3% achieved all three ABC goals. However, patients with DKD had a lower rate of ABC goal attainment and higher rate of complications. Among DKD patients with eGFR ≥ 30 ml/min/1.73 m² and on monotherapy, metformin was most frequently prescribed. As for dual therapy, the most common combinations were metformin with sulfonylurea and metformin with DPP-4 inhibitors.

Conclusions

Diabetes patients in Taiwan receiving primary diabetes care at local clinics had generally satisfactory management performance. However, more aggressive HbA1c, BP, and LDL-C management among DKD patients should be emphasized. Contrary to current recommendations, SGLT-2 inhibitors and GLP-1 receptor agonists as frontline therapy were under-prescribed.

Glycaemic control mediates the relationships of employment status and self-stigma with self-care behaviours in young adults with type 2 diabetes

AIMS AND OBJECTIVES

To investigate the relationships of sociodemographic factors, self-stigma, glycaemic control (measured by glycated haemoglobin (A1C)) and self-care behaviours in young adults with type 2 diabetes.

BACKGROUND

Young adults aged 25-44 years are in their most productive period. Once diagnosed with diabetes, this population tends to experience poor glycaemic control and perform poorly in self-care activities. Such patterns may raise perceptions of self-stigma and further decrease motivations to engage in self-care behaviours in patients with diabetes.

DESIGN

A cross-sectional, correlational research design.

METHODS

The STROBE guidelines for cross-sectional studies were followed. A convenience sample of 115 participants was recruited from a medical centre in southern Taiwan. Instruments included the Self-Stigma Scale-Chinese version and the Diabetes Self-Care Behaviours Scale. Data were analysed using a three-step hierarchical regression analysis and the Sobel test.

RESULTS

The average age of the participants was 36.7 years. Marital status, employment status, self-stigma and A1C were significantly associated with self-care behaviours, and these four variables explained 43.6% of the variance in self-care behaviours. However, A1C (β = -.58, p < .001) was found to be the only determinant of self-care behaviours in the last regression model. The Sobel test showed that A1C had mediating effects on self-stigma and self-care behaviours as well as employment status and self-care behaviours.

CONCLUSION

This study supports the interactive relationship among self-stigma, employment status, glycaemic control and self-care behaviours in young adults with type 2 diabetes. Strategies aimed at optimising glycaemic control can help reduce the effects of self-stigma perceptions and employment status on the self-care behaviours of such patients.

RELEVANCE TO CLINICAL PRACTICE

More effective educational programmes should be designed to improve glycaemic control, lower the effects of employment and decrease perceptions of self-stigma to further motivate young adults to engage in better diabetes self-care behaviours.

Is therapeutic inertia present in hyperglycaemia, hypertension and hypercholesterolaemia management among adults with type 2 diabetes in three health clinics in Malaysia? a retrospective cohort study

BACKGROUND

Good-quality evidence has shown that early glycaemic, blood pressure and LDL-cholesterol control in people with type 2 diabetes (T2D) leads to better outcomes. In spite of that, diseases control have been inadequate globally, and therapeutic inertia could be one of the main cause. Evidence on therapeutic inertia has been lacking at primary care setting. This retrospective cohort study aimed to determine the proportions of therapeutic inertia when treatment targets of HbA1c, blood pressure and LDL-cholesterol were not achieved in adults with T2D at three public health clinics in Malaysia.

METHODS

The index prescriptions were those that when the annual blood tests were reviewed. Prescriptions of medication were verified, compared to the preceding prescriptions and classified as 1) no change, 2) stepping up and 3) stepping down. The treatment targets were HbA1c < 7.0% (53 mmol/mol), blood pressure (BP) < 140/90 mmHg and LDL-cholesterol < 2.6 mmol/L. Therapeutic inertia was defined as no change in the medication use in the present of not reaching the treatment targets. Descriptive, univariable, multivariable logistic regression and sensitive analyses were conducted.

RESULTS

A total of 552 cohorts were available for the assessment of therapeutic inertia (78.9% completion rate). The mean (SD) age and diabetes duration were 60.0 (9.9) years and 5.0 (6.0) years, respectively. High therapeutic inertia were observed in oral anti-diabetic (61-72%), anti-hypertensive (34-65%) and lipid-lowering therapies (56-77%), and lesser in insulin (34-52%). Insulin therapeutic inertia was more likely among those with shorter diabetes duration (adjusted OR 0.9, 95% CI 0.87, 0.98). Those who did not achieve treatment targets were less likely to experience therapeutic inertia: HbA1c ≥ 7.0%: adjusted OR 0.10 (0.04, 0.24); BP ≥ 140/90 mmHg: 0.28 (0.16, 0.50); LDL-cholesterol ≥ 2.6 mmol/L: 0.37 (0.22, 0.64).

CONCLUSIONS

Although therapeutic intensifications were more likely in the presence of non-achieved treatment targets but the proportions of therapeutic inertia were high. Possible causes of therapeutic inertia were less of the physician behaviours but might be more of patient-related non-adherence or non-availability of the oral medications. These observations require urgent identification and rectification to improve disease control, avoiding detrimental health implications and costly consequences.

TRIAL REGISTRATION

Number NCT02730754 , April 6, 2016.

Use of SGLT-2 Inhibitors in Patients with Type 2 Diabetes Mellitus and Abdominal Obesity: An Asian Perspective and Expert Recommendations

The prevalence of obesity in Asia is of epidemic proportions, with an estimated 1 billion overweight/obese individuals in the region. The majority of patients with type 2 diabetes mellitus (T2DM) are overweight/obese, which increases the risk of cardiorenal outcomes in these patients; hence, sustained reductions in body weight and visceral adiposity are important management goals. However, most of the glucose-lowering therapies such as insulin, sulfonylureas, glinides, and thiazolidinediones induce weight gain, which makes the management of overweight/obese T2DM patients challenging. Sodium-glucose cotransporter-2 (SGLT-2) inhibitors are the only oral glucose-lowering agents that have been shown to reduce body weight and visceral adiposity. In addition, SGLT-2 inhibitors therapy reduces ectopic fat deposition and improves adipose tissue function and weight-related quality of life. In this article, we aim to consolidate the existing literature on the effects of SGLT-2 inhibitors in Asian patients with T2DM and to produce clinical recommendations on their use in overweight or obese patients with T2DM. Recommendations from international and regional guidelines, as well as published data from clinical trials in Asian populations and cardiovascular outcomes trials are reviewed. Based on the available data, SGLT-2 inhibitors represent an evidence-based therapeutic option for the management of overweight/obese patients with T2DM.

Sudomotor dysfunction independently predicts incident cardiovascular-renal events and all-cause death in type 2 diabetes: the Joint Asia Diabetes Evaluation register

BACKGROUND

Early detection and risk factor control prevent chronic kidney disease (CKD) progression. Evaluation of peripheral autonomic dysfunction may detect incident cardiovascular-renal events in type 2 diabetes (T2D).

METHODS

SUDOSCAN, a non-invasive tool, provides an age-adjusted electrochemical skin conductance (ESC) composite score incorporating hands/feet ESC measurements, with a score ≤53 indicating sudomotor dysfunction. A consecutive cohort of 2833 Chinese adults underwent structured diabetes assessment in 2012-13; 2028 participants without preexisting cardiovascular disease (CVD) and CKD were monitored for incident cardiovascular-renal events until 2015.

RESULTS

In this prospective cohort {mean age 57.0 [standard deviation (SD) 10.0] years; median T2D duration 7.0 [interquartile range (IQR) 3.0-13.0] years; 56.1% men; 72.5% never-smokers; baseline ESC composite score 60.7 (SD 14.5)}, 163 (8.0%) and 25 (1.2%) participants developed incident CKD and CVD, respectively, after 2.3 years of follow-up. The adjusted hazard ratios (aHRs) per 1-unit decrease in the ESC composite score for incident CKD, CVD and all-cause death were 1.02 [95% confidence interval (CI) 1.01-1.04], 1.04 (1.00-1.07) and 1.04 (1.00-1.08), respectively. Compared with participants with an ESC composite score >53, those with a score ≤53 had an aHR of 1.56 (95% CI 1.09-2.23) for CKD and 3.11 (95% CI 1.27-7.62) for CVD, independent of common risk markers. When added to clinical variables (sex and duration of diabetes), the ESC composite score improved discrimination of all outcomes with appropriate reclassification of CKD risk.

CONCLUSIONS

A low ESC composite score independently predicts incident cardiovascular-renal events and death in T2D, which may improve the screening strategy for early intervention.

Long-Term Effect of the Color Record Method in Self-Monitoring of Blood Glucose on Metabolic Parameters in Type 2 Diabetes: A 2-Year Follow-up of the Color IMPACT Study

INTRODUCTION

This article evaluates the potential long-term effect of two different color indication methods for self-monitoring of blood glucose (SMBG), the color record (CR) and color display (CD), on metabolic parameters in insulin-treated type 2 diabetes in a post-intervention period.

METHODS

101 participants with type 2 diabetes who completed the Color IMPACT study were enrolled in a 2-year comparison follow-up study. Participants continued SMBG with their usual diabetes care. The study outcomes were differences in change in HbA1c levels, blood pressure (BP), body weight and lipid profiles between the CR and non-CR arms and the CD and non-CD arms during a 1- and 2-year period of the study.

RESULTS

98 participants were analyzed. Reductions in HbA1c levels, systolic BP and low-density lipoprotein cholesterol levels were maintained in the CR arm by - 0.40% (95% CI: - 0.73 to - 0.06, p = 0.020), -1 3.2 mmHg (95% CI: - 24.1 to - 2.3, p = 0.019), - 11.4 mg/dl (95% CI: - 18.1 to - 4.6, p = 0.001), respectively, in a 1-year period. However, HbA1c and BP returned to the baseline levels during an additional 1-year period. In contrast, there were no significant changes in outcome in the CD arm during the study period.

CONCLUSION

Intervention promoting self-action such as the color record method in SMBG sustains a beneficial effect on metabolic parameters after the intervention. This long-term effect is helpful for people with type 2 diabetes to manage their diabetes ABCs (HbA1c, BP, cholesterol) and to prevent diabetic complications.

TRIAL REGISTRATION

UMIN clinical trials registry identifier, UMIN000006865.

A seven-year study on an integrated hospital-community diabetes management program in Chinese patients with diabetes

AIMS

To assess whether an integrated hospital-community diabetes management program could improve major cardiovascular risk factor control among patients with diabetes in real-world clinical settings.

METHODS

985 adults with diabetes in the Shanghai Taopu community health service center were enrolled at baseline and 907 subjects completed the follow-up. The follow-up levels of the metabolic profiles were assessed by their averages during the follow up period.

RESULTS

After a mean 7-year follow-up period, heamoglobin A1c, systolic and diastolic blood pressure levels decreased by 0.6%, 5.7mmHg, and 1.5mmHg, respectively (all P<0.001). There was a non-significant difference in low-density lipoprotein cholesterol, while high-density lipoprotein cholesterol increased 1.9mg/dL and triglycerides decreased 28.3mg/dL, respectively (all P<0.001). The percentage of patients with diabetes who met any one of three Chinese Diabetes Society goals (heamoglobin A1c <7.0%, blood pressure <140/80mmHg, and low-density lipoprotein cholesterol <100mg/dL) increased from 58.2% to 70.1%. The chronic diabetes complication screening rates (diabetic retinopathy, diabetic neuropathy, diabetic nephropathy) have significantly increased, from almost zero to 12-78%.

CONCLUSIONS

This long-term program has increased the proportions of attaining major cardiovascular risk factors control goals and diabetic chronic complication screening rates among patients with diabetes.

Cross-sectional survey of biosimilar insulin utilization in Asia: The Joint Asia Diabetes Evaluation Program

Aims/Introduction

Biosimilar insulin can reduce treatment costs, although the extent of its use is largely unknown. We examined biosimilar insulin use and its associations with the quality of glycemic control using the Joint Asia Diabetes Evaluation register.

Materials and Methods

We carried out a cross‐sectional analysis in 81,531 patients with type 1 and type 2 diabetes enrolled into the Joint Asia Diabetes Evaluation Program from 2007 to 2014. All insulin related terms are extracted from the Joint Asia Diabetes Evaluation portal, and compared clinical profiles between biosimilar and originator insulin users. Multivariate analysis was performed to assess the association of biosimilar insulin compared with originator insulin with dosage, glycated hemoglobin and hypoglycemia events.

Results

Amongst 81,531 patients, 20.5% (n = 16,738) were insulin‐treated. In four countries with high use of biosimilar insulin, 4.7% (n = 719) of insulin users (n = 10,197) were treated with biosimilar insulin (India n = 507, 70.3%; the Philippines n = 90, 12.5%; China n = 62, 8.6%; Vietnam n = 60, 8.3%). Biosimilar insulin users were younger and had higher body mass index, glycated hemoglobin, insulin dosage and more frequent hypoglycemia than originator insulin users. These associations were non‐significant after adjustment for confounders. Only age, college education, diabetes education, lipid control, physical activity and history of cardiovascular complications were independently associated with these quality measures.

Conclusions

Biosimilar insulin use is not uncommon in Asia. Data exclusion due to incomplete capturing of brand names suggests possibly higher use. The multiple determinants of the quality of glycemic control call for establishment of prospective cohorts and diabetes registers to monitor the safety and efficacy of different brands of biosimilar insulin and their impacts on clinical outcomes.

Five-Year Cost-effectiveness of the Multidisciplinary Risk Assessment and Management Programme-Diabetes Mellitus (RAMP-DM)

OBJECTIVE

To estimate the cost-effectiveness of the multidisciplinary Risk Assessment and Management Programme-Diabetes Mellitus (RAMP-DM) in primary care patients with type 2 diabetes in comparison with usual primary care in a cohort with 5 years' follow-up.

RESEARCH DESIGN AND METHODS

We conducted a prospective cohort study among 17,140 propensity score-matched participants in RAMP-DM and those under usual primary care. The effectiveness measures were cumulative incidences of complications and all-cause mortality over 5 years. In a bottom-up approach, we estimated the program costs of RAMP-DM and health service utilization from the public health service provider's perspective. The RAMP-DM program costs included the setup costs, ongoing intervention costs, and central administrative costs. We calculated the incremental cost-effectiveness ratio by dividing the incremental costs by the incremental effectiveness of the RAMP-DM group compared with those of the usual-care group.

RESULTS

There were significantly lower cumulative incidences of individual on any complications (15.34% vs. 28.65%, P < 0.001) and all-cause mortality (7.96% vs. 21.35%, P < 0.001) in the RAMP-DM group compared with the usual-care group. The mean program cost of RAMP-DM was 157 U.S. dollars (range 66-209) per participant over 5 years. The costs of health service utilization among participants in RAMP-DM group was 7,451 USD less than that of the usual-care group, resulting in a net savings of 7,294 USD per individual.

CONCLUSIONS

RAMP-DM added to usual primary care was a cost-saving intervention in managing diabetes in patients over 5 years. These findings support the integration of RAMP-DM as part of routine primary care for all patients with diabetes.

Meeting American Diabetes Association diabetes management targets: trends in Mauritius

AIMS

To examine the proportion of people with diabetes in the multi-ethnic country of Mauritius meeting American Diabetes Association targets in 2009 and 2015.

METHODS

Data from independent population-based samples of 858 and 656 adults with diagnosed diabetes in 2009 and 2015, respectively, were analysed with regard to recommended American Diabetes Association targets for HbA_1c , blood pressure and LDL cholesterol.

RESULTS

In 2015 compared with 2009, the proportion of people achieving American Diabetes Association targets for glycaemic control in Mauritius was higher in women (P≤0.01) and in those with only a primary education level (P=0.07), but not in men or people with a higher level of education. Achievement of blood pressure <140/90 mmHg was higher in 2015 compared with 2009 (60% vs 42%) in people of South Asian ethnicity (P<0.001), but not in those of African ethnicity (P=0.16). The percentages of people with LDL cholesterol <2.59 mmol/l were 42.1% and 50.4%, in 2009 and 2015, respectively (P=0.27). Better control of HbA_1c and blood pressure was observed in groups in which that control was poorest in 2009. The use of glucose-, blood pressure- and LDL cholesterol-lowering medication was higher in 2015 than in 2009.

CONCLUSIONS

In certain subgroups, namely women, those with poorer education and those of South Asian ethnicity, whose target achievement was the poorest in 2009, control of glycaemia and blood pressure was better in 2015 as compared with 2009. While these findings are encouraging, further work is required to improve outcomes.

Optimizing Glycemic Control Through Titration of Insulin Glargine 100 U/mL: A Review of Current and Future Approaches with a Focus on Asian Populations

Various data have demonstrated inadequate glycemic control amongst Asians with type 2 diabetes mellitus (T2DM), possibly on account of suboptimal titration of basal insulin-an issue which needs to be further examined. Here we review the available global and Asia-specific data on titration of basal insulin, with a focus on the use of insulin glargine 100 U/mL (Gla-100). We also discuss clinical evidence on the efficacy and safety of titrating Gla-100, different approaches to titration, including some of the latest technological advancements, and guidance on the titration of basal insulin from international and local Asian guidelines. The authors also provide their recommendations for the initiation and titration of basal insulin for Asian populations. Discussion of the data included in this review and in relation to the authors' clinical experience with treating T2DM in Asian patients is also included. Briefly, clinical studies demonstrate the achievement of adequate glycemic control in adults with T2DM through titration of Gla-100. However, studies investigating approaches to titration, specifically in Asian populations, are lacking and need to be conducted. Given that the management of insulin therapy is a multidisciplinary team effort involving endocrinologists, primary care physicians, nurse educators, and patients, greater resources and education targeted at these groups are needed regarding the optimal titration of basal insulin. Technological advancements in the form of mobile or web-based applications for automated dose adjustment can aid different stakeholders in optimizing the dose of basal insulin, enabling a larger number of patients in Asia to reach their target glycemic goals with improved outcomes.

Pharmacotherapy of 'treatment resistant' type 2 diabetes

INTRODUCTION

Despite type 2 diabetes (T2D) management offers a variety of pharmacological interventions targeting different defects, numerous patients remain with persistent hyperglycaemia responsible for severe complications. Unlike resistant hypertension, treatment resistant T2D is not a classical concept although it is a rather common observation in clinical practice. Areas covered: This article proposes a definition for 'treatment resistant diabetes', analyses the causes of poor glucose control despite standard therapy, briefly considers the alternative approaches to glucose-lowering pharmacotherapy and finally describes how to overcome poor glycaemic control, using innovative oral or injectable combination therapies. Expert opinion: Before considering intensifying the pharmacotherapy of a patient with poorly controlled T2D, it is important to verify treatment adherence, target obesity and consider various non pharmacological improvement quality interventions. If treatment resistant diabetes is defined as not achieving glycated haemoglobin target despite oral triple therapy with a third glucose-lowering agent added to metformin-sulfonylurea dual treatment, the combination of a dipeptidyl peptidase-4 (DPP-4) inhibitor and a sodium glucose cotransporter type 2 (SGLT2) inhibitor may offer new opportunities before considering injectable therapies. Insulin basal therapy (± metformin) may be optimized by the addition of a SGLT2 inhibitor or a glucagon-like peptide-1 (GLP-1) receptor agonist.

Efficacy and safety of empagliflozin in patients with type 2 diabetes from Asian countries: pooled data from four phase III trials

We investigated the efficacy and safety of empagliflozin over 24 weeks in Asian patients with type 2 diabetes (T2DM) using pooled data from four phase III trials. In these trials, patients were randomized to receive empagliflozin 10 mg, empagliflozin 25 mg or placebo as monotherapy or add-on to metformin, metformin plus sulphonylurea or pioglitazone ± metformin. In total, 1326 patients from Asia received ≥1 dose of study drug. At week 24, adjusted mean differences versus placebo in change from baseline in glycated haemoglobin (HbA1c) were -0.66% [95% confidence interval (CI) -0.76, -0.56] and -0.73% (95% CI -0.83, -0.64) and in weight were -1.6 kg (95% CI -1.9, -1.3) and -1.8 kg (95% CI -2.1, -1.5) with empagliflozin 10 and 25 mg, respectively (all p < 0.001). Empagliflozin significantly reduced systolic and diastolic blood pressure. The proportion of patients reporting ≥1 adverse event was similar across treatment groups, but events consistent with genital infection were more common in patients treated with empagliflozin 10 mg (3.4%) or 25 mg (2.3%) than placebo (0.9%). Thus in Asian patients with T2DM, empagliflozin reduced HbA1c, weight and blood pressure, and was well tolerated.

Hba1c, Blood Pressure, and Lipid Control in People with Diabetes: Japan Epidemiology Collaboration on Occupational Health Study

Aims

The control of blood glucose levels, blood pressure (BP), and low-density lipoprotein cholesterol (LDL-C) levels reduces the risk of diabetes complications; however, data are scarce on control status of these factors among workers with diabetes. The present study aimed to estimate the prevalence of participants with diabetes who meet glycated hemoglobin (HbA1c), BP, and LDL-C recommendations, and to investigate correlates of poor glycemic control in a large working population in Japan.

Methods

The Japan Epidemiology Collaboration on Occupational Health (J-ECOH) Study is an ongoing cohort investigation, consisting mainly of employees in large manufacturing companies. We conducted a cross-sectional analysis of 3,070 employees with diabetes (2,854 men and 216 women) aged 20–69 years who attended periodic health examinations. BP was measured and recorded using different company protocols. Risk factor targets were defined using both American Diabetes Association (ADA) guidelines (HbA1c < 7.0%, BP < 140/90 mmHg, and LDL-C < 100 mg/dL) and Japan Diabetes Society (JDS) guidelines (HbA1c < 7.0%, BP < 130/80 mmHg, and LDL-C < 120 mg/dL). Logistic regression models were used to explore correlates of poor glycemic control (defined as HbA1c ≥ 8.0%).

Results

The percentages of participants who met ADA (and JDS) targets were 44.9% (44.9%) for HbA1c, 76.6% (36.3%) for BP, 27.1% (56.2%) for LDL-C, and 11.2% (10.8%) for simultaneous control of all three risk factors. Younger age, obesity, smoking, and uncontrolled dyslipidemia were associated with poor glycemic control. The adjusted odds ratio of poor glycemic control was 0.58 (95% confidence interval, 0.46–0.73) for participants with treated but uncontrolled hypertension, and 0.47 (0.33–0.66) for participants with treated and controlled hypertension, as compared with participants without hypertension. There was no significant difference in HbA1c levels between participants with treated but uncontrolled hypertension and those with treated and controlled hypertension.

Conclusion

Data from a large working population, predominantly composed of men, suggest that achievement of HbA1c, BP, and LDL-C targets was less than optimal, especially in younger participants. Uncontrolled dyslipidemia was associated with poor glycemic control. Participants not receiving antihypertensive treatment had higher HbA1c levels.

Risk stratification by endocrinologists of patients with type 2 diabetes in a Danish specialised outpatient clinic: a cross-sectional study

Background

To target optimised medical care the Danish guidelines for diabetes recommend stratification of patients with type 2 diabetes (T2D) into three levels according to risk and complexity of treatment. The aim was to describe the T2D population in an outpatient clinic, measure the compliance of the endocrinologists’ to perform risk stratification, and investigate the level of concordance between stratification performed by the endocrinologists and objective assessments.

Methods

A cross-sectional study with data collected from medical records and laboratory databases. The Danish risk stratification model contained the following criteria: HbA_1c, blood pressure, metabolic complications, microvascular and macrovascular complications. Stratification levels encompassed: level 1 (uncomplicated), level 2 (intermediate risk) and level 3 (high risk). Objective assessments were conducted independently by two health professionals, and compared with the endocrinologists’ assessments. In order to test the degree of concordance, we conducted Cohen's kappa, McNemar’s test for marginal homogeneity, and Bowker’s test for symmetry.

Results

Of 245 newly referred patients, 209 (85 %) were stratified by the endocrinologists to level 1 (16 %), level 2 (55 %) and level 3 (29 %). By objective assessments, 4 % were stratified to level 1, 51 % to level 2 and 45 % to level 3. Of 419 long-term follow-up patients, 380 (91 %) were stratified by the endocrinologists to level 1 (5 %), level 2 (57 %), level 3 (38 %). By objective assessments, 3 % were stratified to level 1, 58 % to level 2 and 39 % to level 3. The concordance rate between endocrinologists’ and objective assessments was 63 % among newly referred (kappa 0.39; fair agreement) and 67 % for long-term follow-up (kappa 0.45; moderate agreement). Among newly referred patients, the endocrinologists stratified less patients at level 3 compared to objective assessments (p < 0.0001). There were no significant differences in marginal distribution within long-term follow-up patients.

Conclusion

Type 2 diabetes patients, newly referred to or allocated for long-term follow-up in the out-patient clinic, were mainly intermediate and high-risk, complicated patients (96 % and 95 %, respectively). Compliance of stratification by endocrinologists was high. The concordance between endocrinologists’ and objective assessments was not strong. Our data suggest that clinician-support for stratification level categorisation might be needed.

Current status of glucose, blood pressure and lipid management in type 2 diabetes clinic attendees in Isfahan, Iran

AIMS/INTRODUCTION

To estimate the prevalence of meeting American Diabetes Association clinical practice recommendations for hemoglobin A1c (HbA1c), blood pressure (BP) and low-density lipoprotein cholesterol (LDLC) among Iranian type 2 diabetes clinic attendees, and to identify the factors associated with therapeutic target achievement.

MATERIALS AND METHODS

A total of 2,640 patients with type 2 diabetes (944 men and 1,696 women) from Isfahan Endocrine and Metabolism Research Center outpatient clinics, Iran, were examined. The main outcome measures were HbA1c, BP and LDLC, in accordance with the American Diabetes Association recommendations. The mean (standard deviation) age of participants was 49.6 years (9.3 years) with a mean (standard deviation) duration of diabetes of 5.0 years (4.9 years) at initial registration.

RESULTS

The percentages of patients who had HbA1c <7%, BP <140/90 mmHg and LDLC <100 mg/dL was 37.4% (95% confidence interval [CI] 35.6-39.3), 35.3% (95% CI 33.5-37.3) and 48.9% (95% CI 47.0-50.8), respectively. The proportion of patients meeting all three goals was 7.7% (95% CI 6.7-8.8). Lower BP, cholesterol level and higher education at registration, and higher follow up but lower number of follow-up visits affected achievement of all three goals.

CONCLUSIONS

The present study highlights that a substantial proportion of Iranian type 2 diabetes clinic attendees did not meet the American Diabetes Association clinical practice recommendations, and shows the difficult challenges physicians face when treating patients with type 2 diabetes.

Depression in Chinese patients with type 2 diabetes: associations with hyperglycemia, hypoglycemia, and poor treatment adherence

BACKGROUND

We hypothesize that depression in type 2 diabetes might be associated with poor glycemic control, in part due to suboptimal self-care. We tested this hypothesis by examining the associations of depression with clinical and laboratory findings in a multicenter survey of Chinese type 2 diabetic patients.

METHOD

2538 patients aged 18-75 years attending hospital-based clinics in four cities in China underwent detailed clinical-psychological-behavioral assessment during a 12-month period between 2011 and 2012. Depression was diagnosed if Patient Health Questionnaire-9 (PHQ-9) score ≥10. Diabetes self-care and medication adherence were assessed using the Summary of Diabetes Self-care Activities and the 4-item Morisky medication adherence scale respectively.

RESULTS

In this cross-sectional study (mean age: 56.4 ± 10.5[SD] years, 53% men), 6.1% (n = 155) had depression. After controlling for study sites, patients with depression had higher HbA(1c) (7.9 ± 2.0 vs. 7.7 ± 2.0%, P = 0.008) and were less likely to achieve HbA(1c) goal of <7.0% (36.2% vs 45.6%, P = 0.004) than those without depression. They were more likely to report hypoglycemia and to have fewer days of being adherent to their recommended diet, exercise, foot care and medication. In logistic regression, apart from young age, poor education, long disease duration, tobacco use, high body mass index, use of insulin, depression was independently associated with failure to attain HbA(1c) target (Odds Ratio [OR] = 1.56, 95%CI:1.05-2.32, P = 0.028). The association between depression and glycemic control became non-significant after inclusion of adherence to diet, exercise and medication (OR = 1.48, 95% CI 0.99-2.21, P = 0.058).

CONCLUSION

Depression in type 2 diabetes was closely associated with hyperglycemia and hypoglycemia, which might be partly mediated through poor treatment adherence.

Management status and its predictive factors in patients with type 2 diabetes in China: A Nationwide Multicenter Study: A Nationwide Multicenter Study

BACKGROUND

The prevalence of type 2 diabetes in China is increasing rapidly. Appropriate management of glycemia, blood pressure and dyslipidemia in this population is a major public health concern.

OBJECTIVE

The aim of this study was to assess metabolic control including glycated hemoglobin A1c (HbA1c ), blood pressure (BP) and low density lipoprotein cholesterol (LDL-c), in a large sample of patients with type 2 diabetes in China and to identify factors that correlated with the achievement of HbA1c, BP and LDL-c goals (ABCs).

METHOD

A nationwide survey was conducted in 50 medical centres across China from April to July of 2010. Baseline information on demographics, medical history, HbA1c , BP and LDL-c levels were measured in 5961 patients with type 2 diabetes.

RESULTS

Mean age, body mass index (BMI) and HbA1c were 59.5 ± 1.3 years, 24.5 ± 4.1 kg/m(2) and 8.3 ± 2.2%, respectively. With respect to generally accepted ABC treatment goals, 35.2% of participants had HbA1c <7%; 35.5% had BP < 140/80 mmHg, and 45.1% had LDL-c < 100 mg/dl. The proportion of patients who met all three targets was only 5.4%. Logistic regression revealed that smoking (P=0.000), higher BMI (P=0.001) and insulin use (P=0.000) were statistically significant predictors of failing to meet ABC targets.

CONCLUSION

The percentage of Chinese patients with type 2 diabetes who met recommended targets for HbA1c , BP and LDL-c in 2010 was low. Smoking, higher BMI and insulin use were the strongest determinants of failing to meet ABC targets.

Borderline ankle-brachial index is associated with increased prevalence of micro- and macrovascular complications in type 2 diabetes: A cross-sectional analysis of 12,772 patients from the Joint Asia Diabetes Evaluation Program

Borderline ankle-brachial index is increasingly recognised as a marker of cardiovascular risk. We evaluated the impact of borderline ankle-brachial index in 12,772 Chinese type 2 diabetes patients from the Joint Asia Diabetes Evaluation Program between 2007 and 2012. Cardiovascular risk factors, complications and health-related quality of life were compared between patients with normal ankle-brachial index (1.0-1.4), borderline ankle-brachial index (0.90-0.99) and peripheral arterial disease (ankle-brachial index < 0.9). The prevalence of peripheral arterial disease and borderline ankle-brachial index was 4.6% and 9.6%, respectively. Borderline ankle-brachial index patients were older, more likely to be smokers and hypertensive, had longer duration of diabetes, poorer kidney function and poorer health-related quality of life than patients with normal ankle-brachial index. After adjustment for traditional cardiovascular risk factors, borderline ankle-brachial index was an independent predictor of diabetes-related micro- and macrovascular complications including retinopathy (odd ratios: 1.19 (95% confidence interval: 1.04-1.37)), macroalbuminuria (1.31 (1.10-1.56)), chronic kidney disease (1.22 (1.00-1.50)) and stroke (1.31 (1.05-1.64)). These findings suggest that patients with diabetes and borderline ankle-brachial index are at increased cardiovascular risk and may benefit from more intensive management.

Measuring depression with CES-D in Chinese patients with type 2 diabetes: the validity and its comparison to PHQ-9

BACKGROUND

The validity of the 20-item Center for Epidemiological Studies Depression (CES-D) scale for depression screening in Hong Kong Chinese patients with type 2 diabetes remains unknown. We aimed to validate CES-D, compare its psychometric properties with the 9-item Patient Health Questionnaire (PHQ-9), and explore whether one of the two is more suitable for depression screening in Chinese patients with type 2 diabetes.

METHODS

Between June 2010 and July 2011, 545 consecutive Chinese patients with type 2 diabetes who underwent structured comprehensive assessments completed the CES-D and PHQ-9. Forty patients were retested within 2-4 weeks by telephone interview and 97 patients were randomly selected to undergo the Mini International Neuropsychiatric Interview (MINI) by psychiatrists for clinical diagnosis of depression.

RESULTS

The internal consistency (Cronbach's α) of CES-D was 0.85, with a test-retest correlation coefficient of 0.64. The area under the curve for CES-D compared to the clinical diagnosis of major depression was 0.85. A cut-off score of ≥21 for CES-D provided the optimal balance between sensitivity (78.3 %) and specificity (74.3 %) and identified 17.8 % (n = 97) of patients with depression. CES-D and PHQ-9 showed moderate agreement in depression screening (Cohen's Kappa: 0.45). Compared to non-depressed patients, those who screened positive by PHQ-9 had a higher HbA1c whereas the glycemic differences were not significant when using CES-D.

CONCLUSION

The CES-D is a valid screening tool for depression in Chinese type 2 diabetic patients although the PHQ-9 was more discriminative in identifying those with suboptimal glycemic control.

Long-term effects of the multidisciplinary risk assessment and management program for patients with diabetes mellitus (RAMP-DM): a population-based cohort study

BACKGROUND

Studies on the long-term effectiveness of multidisciplinary risk-stratification based management in Chinese population were rare. This study aimed to evaluate the effectiveness of a multidisciplinary risk assessment and management program for patients with diabetes mellitus (RAMP-DM) in reducing the risks of cardiovascular complications and all-cause mortality.

METHODS

A prospective cohort study was conducted in 18,188 propensity score matched RAMP-DM participants and subjects with diabetes under usual primary care (9,094 subjects in each group). The study endpoints were the first occurrence of coronary heart disease (CHD), stroke, heart failure (HF), total cardiovascular disease (CVD) and all-cause mortality. We constructed multivariable Cox proportional hazard regressions to estimate the association between the RAMP-DM intervention and the first occurrence of study endpoints.

RESULTS

The median follow-up period was 36 months. Three hundred and ninety-nine CVD events occurred in the RAMP-DM group, as compared with 608 in the control group [adjusted hazard ratio, 0.629; 95% confidence interval (CI) 0.554-0.715; P < 0.001]. The total number of all-cause deaths in RAMP-DM group was less than half that of control group (202 vs 552, adjusted hazard ratio, 0.363; 95% CI, 0.308-0.428; P < 0.001). The adjusted hazard ratios of the RAMP-DM group for CHD, stroke, and HF were 0.570 (95% CI, 0.470-0.691; P < 0.001), 0.652 (95% CI, 0.546-0.780; P < 0.001), and 0.598 (95%CI, 0.446-0.802; P = 0.001), respectively.

CONCLUSIONS

The RAMP-DM intervention was associated with lower incidences of individual and total cardiovascular complications, as well as all-cause mortality over 3 years follow-up. The encouraging results provided evidence to support that the structured risk-stratification management leading by a multidisciplinary clinical team was an effective approach to reduce future cardiovascular complications in people with diabetes.

CLINICAL TRIAL REGISTRY

NCT02034695, http://www.ClinicalTrials.gov.

The Efficacy and Safety of Chinese Herbal Medicine Jinlida as Add-On Medication in Type 2 Diabetes Patients Ineffectively Managed by Metformin Monotherapy: A Double-Blind, Randomized, Placebo-Controlled, Multicenter Trial

BACKGROUND

Metformin plays an important role in diabetes treatment. Studies have shown that the combined use of oral hypoglycemic medications is more effective than metformin monotherapy. In this double-blind, randomized, placebo-controlled, multicenter trial, we evaluated whether Jinlida, a Chinese herbal medicine, enhances the glycemic control of metformin in type 2 diabetes patients whose HbA1c was ineffectively controlled with metformin alone.

METHODS

A total of 186 diabetes patients were enrolled in this double-Blind, randomized, placebo-controlled, multicenter trial. Subjects were randomly allocated to receive either Jinlida (9 g) or the placebo TID for 12 consecutive weeks. All subjects in both groups also continuously received their metformin without any dose change. During this 12-week period, the HbA1c, FPG, 2 h PG, body weight, BMI were assessed. HOMA insulin resistance (HOMA-IR) and β-cell function (HOMA-β) were also evaluated.

RESULTS

At week 12, compared to the HbA1c level from week 0, the level of the Jinlida group was reduced by 0.92 ± 1.09% and that of the placebo group was reduced by 0.53 ± 0.94%. The 95% CI was 0.69-1.14 for the Jinlida group vs. 0.34-0.72 for the placebo group. There was a very significant HbA1c reduction between the two groups after 12 weeks (p < 0.01). Both FG and 2 h PG levels of the Jinlida group and placebo group were reduced from week 0. There were a very significant FG and 2 h PG level reductions between the two groups after 12 weeks (both p < 0.01). The Jinlida group also showed improved β-cell function with a HOMA-β increase (p < 0.05). No statistical significance was observed in the body weight and BMI changes. No serious adverse events were reported.

CONCLUSION

Jinlida significantly enhanced the hypoglycemic action of metformin when the drug was used alone. This Chinese herbal medicine may have a clinical value as an add-on medication to metformin monotherapy.

TRIAL REGISTRATION

Chinese Clinical Trial Register ChiCTR-TRC-13003159.

Cardiovascular risk profiles in Type 2 diabetes and the impact of geographical setting

Cardiovascular (CV) disease is a leading morbidity and mortality in Type 2 diabetes (T2DM). Previous studies have shown geographic differences in the prevalence of CV and renal diseases. A literature review of longitudinal (≥5 years) studies including ≥1000 T2DM patients and reporting CV endpoints was performed to compare risk profiles. Key differences between geographies included a relatively higher prevalence of microalbuminuria in East Asian relative to North American and European patients, which in turn is an important CV risk factor. Patients from East Asia also have a relatively higher incidence of stroke and lower incidence of coronary heart disease. Overall, there are differences in CV risk in T2DM patients between different regions and that long-term studies from Africa, the Middle East and Latin America are lacking.

Quality of diabetes care in low- and middle-income Asian and Middle Eastern countries (1993-2012): 20-year systematic review

OBJECTIVE

To assess the extent to which people with diabetes in low- and middle-income countries (LMIC) of Asia and the Middle East met evidence-based care recommendations through a systematic review of published literature.

METHODS

Electronic searches of Medline and Embase were carried out for studies assessing quality of care among people with diabetes in Asia and the Middle East between 1993 and 2012. Benchmarking against American Diabetes Association guidelines, we reported level and proportions meeting recommended risk factor control (glycated hemoglobin [HbA1c], blood pressure, and low density lipoprotein-cholesterol [LDL]) and preventive care processes across different settings.

RESULTS

One hundred and fifteen publications met eligibility for inclusion (91 reported risk factor control, 7 reported preventive processes, and 17 reported both). Only China, Thailand, Malaysia and Philippines had nationally representative data. Mean HbA1c (6.5-11% or 48-97 mmol/mol), SBP (120-152 mm Hg), and LDL (2.4-3.8 mmol/l) varied greatly. Despite variation in availability of data, studies consistently showed that recommended care goals were not being achieved.

CONCLUSIONS

The practice of auditing and benchmarking against evidence-based guidelines appears to be uncommon in Asia and the Middle East and there was heterogeneity of reporting across studies, populations, and methods used. The available data showed inadequate care.

Delivery of integrated diabetes care using logistics and information technology--the Joint Asia Diabetes Evaluation (JADE) program

Diabetes is a global epidemic, and many affected individuals are undiagnosed, untreated, or uncontrolled. The silent and multi-system nature of diabetes and its complications, with complex care protocols, are often associated with omission of periodic assessments, clinical inertia, poor treatment compliance, and care fragmentation. These barriers at the system, patient, and care-provider levels have resulted in poor control of risk factors and under-usage of potentially life-saving medications such as statins and renin-angiotensin system inhibitors. However, in the clinical trial setting, use of nurses and protocol with frequent contact and regular monitoring have resulted in marked differences in event rates compared to epidemiological data collected in the real-world setting. The phenotypic heterogeneity and cognitive-psychological-behavioral needs of people with diabetes call for regular risk stratification to personalize care. Quality improvement initiatives targeted at patient education, task delegation, case management, and self-care promotion had the largest effect size in improving cardio-metabolic risk factors. The Joint Asia Diabetes Evaluation (JADE) program is an innovative care prototype that advocates a change in clinic setting and workflow, coordinated by a doctor-nurse team and augmented by a web-based portal, which incorporates care protocols and a validated risk engine to provide decision support and regular feedback. By using logistics and information technology, supported by a network of health-care professionals to provide integrated, holistic, and evidence-based care, the JADE Program aims to establish a high-quality regional diabetes database to reflect the status of diabetes care in real-world practice, confirm efficacy data, and identify unmet needs. Through collaborative efforts, we shall evaluate the feasibility, acceptability, and cost-effectiveness of this "high tech, soft touch" model to make diabetes and chronic disease care more accessible, affordable, and sustainable.

Effects of the Multidisciplinary Risk Assessment and Management Program for Patients with Diabetes Mellitus (RAMP-DM) on biomedical outcomes, observed cardiovascular events and cardiovascular risks in primary care: a longitudinal comparative study

BACKGROUND

To assess whether the Multidisciplinary Risk Assessment and Management Program for Patients with Diabetes Mellitus (RAMP-DM) led to improvements in biomedical outcomes, observed cardiovascular events and predicted cardiovascular risks after 12-month intervention in the primary care setting.

METHODS

A random sample of 1,248 people with diabetes enrolled to RAMP-DM for at least 12 months was selected and 1,248 people with diabetes under the usual primary care were matched by age, sex, and HbA1c level at baseline as the usual care group. Biomedical and cardiovascular outcomes were measured at baseline and at 12-month after the enrollment. Difference-in-differences approach was employed to measure the effect of RAMP-DM on the changes in biomedical outcomes, proportion of subjects reaching treatment targets, observed and predicted cardiovascular risks.

RESULTS

Compared to the usual care group, RAMP-DM group had lower cardiovascular events incidence (1.21% vs 2.89%, P = 0.003), and net decrease in HbA1c (-0.20%, P < 0.01), SBP (-3.62 mmHg, P < 0.01) and 10-year cardiovascular disease (CVD) risks (total CVD risk, -2.06%, P < 0.01; coronary heart disease (CHD) risk, -1.43%, P < 0.01; stroke risk, -0.71%, P < 0.01). The RAMP-DM subjects witnessed significant rises in the proportion of reaching treatment targets of HbA1c, and SBP/DBP. After adjusting for confounding variables, the significance remained for HbA1c, predicted CHD and stroke risks.

CONCLUSIONS

The RAMP-DM resulted in greater improvements in HbA1c and reduction in observed and predicted cardiovascular risks at 12 months follow-up, which indicated a risk-stratification multidisciplinary intervention was an effective strategy for managing Chinese people with diabetes in the primary care setting.

TRIAL REGISTRY

ClinicalTrials.gov, NCT02034695.

Diabetes in South-East Asia: an update

According to the recent estimates by the International Diabetes Federation (IDF), South East-Asia (SEA) Region consisting of India, Sri Lanka, Bangladesh, Bhutan, Mauritius and Maldives, is home to more than 72 million adults with diabetes in 2013 and is expected to exceed 123 million in 2035. Nearly 95% of people with diabetes have type 2 diabetes (T2DM). Although type 1 diabetes (T1DM) is relatively rare in these countries, its prevalence is also rising. Furthermore, a large number (24.3 million) of people also have impaired glucose tolerance (IGT). Several characteristic differences are seen in the clinical and immunological presentation of these people when compared with their European counterparts. A sharp increase in the prevalence of T2DM has been observed in the SEA Region, both in urban and rural areas, which is mostly associated with the lifestyle transitions towards urbanisation and industrialisation. Evidence suggests that a large portion of T2DM may be preventable by lifestyle modification. However, morbidity and early mortality occur as a result of inadequate healthcare facilities for early detection and initiation of therapy, as well as suboptimal management of diabetes and associated morbidities. This is largely preventable by primary prevention of diabetes and enhancing awareness about the disease among the public and the healthcare providers. There is an urgent need for concerted efforts by government and non-governmental sectors to implement national programmes aimed at prevention, management and surveillance of the disease.

Diabetes in the Western Pacific Region--past, present and future

In the 2013 issue of the International Diabetes Federation (IDF) Diabetes Atlas, the prevalence of diabetes in the Western Pacific (WP) Region was reported to be 8.6% in 2013, or 138 million adults, and estimated to rise to 11.1%, or 201 million adults, in 2035. The prevalence estimates of impaired glucose tolerance in 2013 and 2035 were 6.8% and 9.0%, respectively. Over 50% of people with diabetes were undiagnosed. In 2013, 187 million deaths were attributable to diabetes, 44% of which occurred in the under the age of 60. The WP Region is home to one quarter of the world's population, and includes China with the largest number of people with diabetes as well as Pacific Islands countries with the highest prevalence rates. There is a rapid increase in diabetes prevalence in the young-to-middle aged adults, possibly driven by high rates of childhood obesity and gestational diabetes as well as rapid demographic and sociocultural transitions. Differences in genetics, ethnicity, cultures and socioeconomic development have led to complex host-environment-lifestyle interactions with marked disease heterogeneity, further influenced by access to care and treatment. Despite these challenges, the WP Region has provided notable examples to prevent and control diabetes.

Prevalence of complications among Chinese diabetic patients in urban primary care clinics: a cross-sectional study

BACKGROUND

A territory-wide diabetes management program (Risk Assessment Management Program - RAMP) was recently established, providing comprehensive management for all diabetics, helping to delineate current level of control and complications prevalence among primary care diabetic patients in Hong Kong.

METHOD

This cross-sectional study captured anonymous clinical data from RAMP patients. Data obtained include sociodemographic details, type of diabetes, illness duration, family history, drug usage, coexisting illnesses, diabetic complications and other clinical parameters.

RESULTS

Data from 15,856 type 2 diabetic patients were analyzed. 57.1% were above 60 years old, with mean disease duration of 7.3 years. Hypertension was the commonest coexisting chronic illness (57.6%). 30.2% and 61.8% have their systolic and diastolic pressure controlled to below 130 mmHg and 80 mmHg respectively. Over half (51.5%) had an HbA1c level of less than 7.0%. 88.4% did not achieve target lipid level. 15% were on diet control alone. Only 22.2% were on statins. In patients with microalbuminuria and macroalbuminuria, 40.7% and 54.5% were on angiotensin converting enzyme inhibitor (ACEI) or angiotensin receptor blocker (ARB) respectively. 12.9%, 38.8% and 2.4% had diabetic retinopathy, nephropathy and neuropathy respectively. Overall, 37.9%, 7.3% and 0.4% had single, two and three concurrent microvascular complications respectively.

CONCLUSION

The level of diabetic control is comparable with other developed countries. We demonstrated a high prevalence of microvascular complications among Chinese primary care patients despite achieving adequate HbA1c levels, highlighting the importance of managing all aspects of diabetes including weight, lipid and blood pressure. Efforts to improve holistic management must be tailored according to the needs of our population, with the challenges that the majority have low educational background and in the older age group.

Glycemic control among patients in China with type 2 diabetes mellitus receiving oral drugs or injectables

BACKGROUND

The prevalence of type 2 diabetes mellitus (T2DM) is increasing rapidly among Chinese adults, and limited data are available on T2DM management and the status of glycemic control in China. We assessed the efficacy of oral antidiabetes drugs (OADs), glucagon-like peptide-1 (GLP-1) receptor agonists, and insulin for treatment of T2DM across multiple regions in China.

METHODS

This was a multicenter, cross-sectional survey of outpatients conducted in 606 hospitals across China. Data from all the patients were collected between April and June, 2011.

RESULTS

A total of 238,639 patients were included in the survey. Eligible patients were treated with either OADs alone (n=157,212 [65.88%]), OADs plus insulin (n=80,973 [33.93%]), or OADs plus GLP-1 receptor agonists (n=454 [0.19%]). The OAD monotherapy, OAD + insulin, and OAD + GLP-1 receptor agonist groups had mean glycosylated hemoglobin (HbA1c) levels (±SD) of 7.67% (±1.58%), 8.21% (±1.91%), and 7.80% (±1.76%), respectively. Among those three groups, 34.63%, 26.21%, and 36.12% met the goal of HbA1c <7.0%, respectively. Mean HbA1c and achievement of A1c <7.0% was related to the duration of T2DM.

CONCLUSIONS

Less than one third of the patients had achieved the goal of HbA1c <7.0%. Glycemic control decreased and insulin use increased with the duration of diabetes.

Personalized management of hyperglycemia in type 2 diabetes: reflections from a Diabetes Care Editors' Expert Forum

In June 2012, 13 thought leaders convened in a Diabetes Care Editors' Expert Forum to discuss the concept of personalized medicine in the wake of a recently published American Diabetes Association/European Association for the Study of Diabetes position statement calling for a patient-centered approach to hyperglycemia management in type 2 diabetes. This article, an outgrowth of that forum, offers a clinical translation of the underlying issues that need to be considered for effectively personalizing diabetes care. The medical management of type 2 diabetes has become increasingly complex, and its complications remain a great burden to individual patients and the larger society. The burgeoning armamentarium of pharmacological agents for hyperglycemia management should aid clinicians in providing early treatment to delay or prevent these complications. However, trial evidence is limited for the optimal use of these agents, especially in dual or triple combinations. In the distant future, genotyping and testing for metabolomic markers may help us to better phenotype patients and predict their responses to antihyperglycemic drugs. For now, a personalized ("n of 1") approach in which drugs are tested in a trial-and-error manner in each patient may be the most practical strategy for achieving therapeutic targets. Patient-centered care and standardized algorithmic management are conflicting approaches, but they can be made more compatible by recognizing instances in which personalized A1C targets are warranted and clinical circumstances that may call for comanagement by primary care and specialty clinicians.

Age ≥ 60 years was an independent risk factor for diabetes-related complications despite good control of cardiovascular risk factors in patients with type 2 diabetes mellitus

Providing effective medical care for older patients with type 2 diabetes mellitus (T2D) that may contribute to their active aging has always been challenging. We examined the independent effect of age ≥ 60 years on disease control and its relationship with diabetes-related complications in patients with T2D in Malaysia. This was a cross-sectional study using secondary data from the electronic diabetes registry database Adult Diabetes Control and Management (ADCM). A total of 303 centers participated and contributed a total of 70,889 patients from May 2008 to the end of 2009. Demographic data, details on diabetes, hypertension, dyslipidemia and their treatment modalities, various risk factors and complications were updated annually. Independent associated risk factors were identified using multivariate regression analyses. Fifty-nine percent were female. Malay comprised 61.9%, Chinese 19% and Indian 18%. There were more Chinese, men, longer duration of diabetes and subjects that were leaner or had lower BMI in the older age group. Patients aged ≥ 60 years achieved glycemic and lipid targets but not the desired blood pressure. After adjusting for duration of diabetes, gender, ethnicity, body mass index, disease control and treatment, a significantly higher proportion of patients ≥ 60 years suffered from reported diabetes-related complications. Age ≥ 60 years was an independent risk factor for diabetes-related complications despite good control of cardiovascular risk factors. Our findings caution against the currently recommended control of targets in older T2D patients with more longstanding diseases and complications.

Type 2 diabetes in East Asians: similarities and differences with populations in Europe and the United States

There is an epidemic of diabetes in Asia. Type 2 diabetes develops in East Asian patients at a lower mean body mass index (BMI) compared with those of European descent. At any given BMI, East Asians have a greater amount of body fat and a tendency to visceral adiposity. In Asian patients, diabetes develops at a younger age and is characterized by early β cell dysfunction in the setting of insulin resistance, with many requiring early insulin treatment. The increasing proportion of young-onset and childhood type 2 diabetes is posing a particular threat, with these patients being at increased risk of developing diabetic complications. East Asian patients with type 2 diabetes have a higher risk of developing renal complications than Europeans and, with regard to cardiovascular complications, a predisposition for developing strokes. In addition to cardiovascular-renal disease, cancer is emerging as the other main cause of mortality. While more research is needed to explain these interethnic differences, urgent and concerted actions are needed to raise awareness, facilitate early diagnosis, and encourage preventive strategies to combat these growing disease burdens.

Trends of ABC control 2006-2011: a National Survey of Diabetes Health Promotion Institutes in Taiwan

AIMS

To understand the trends of ABC control in 5 years interval in Taiwan.

METHODS

We compared two waves of nationwide surveys (n=7541 and n=5599, mainly type 2 diabetes) to examine the trends of ABC control across 5 years in accredited Diabetes Health Promotion Institutes in Taiwan.

RESULTS

The percentages of subjects who had HbA1c lower than 7% (A), both SBP and DBP lower than 130/80 mmHg (B), and total cholesterol lower than 160 mg/dl or LDL cholesterol lower than 100mg/dl (C) increased by 6.5% (from 32.4% to 34.5%), 22.0% (from 30.9% to 37.7%), and 57.8% (from 35.3% to 55.7%), respectively, with a resulting total ABC attainment rate from 4.1% to 8.6%. A subgroup of 720 diabetic subjects who participated in both surveys showed the same pattern of changes in B and C but had a slight deterioration of glycemic control. Logistic regression analysis revealed that diagnosis of type 1 diabetes, lower BMI and individuals not requiring insulin were independently associated with attainment of ABC goals in 2006 and 2011. An accountabilities examination revealed that annular tests of HbA1c, BP and lipids were all above 90% in both surveys.

CONCLUSIONS

We observed an improvement of individual and overall attainments of ABC goals across 5 years in Taiwan owing to recent implementation of several diabetes care models and initiatives. We anticipate that these improvements will translate into reductions of both macrovascular and microvascular complications.

Prevalence, awareness, treatment and control of hypertension in adults with diagnosed diabetes: the Fourth Korea National Health and Nutrition Examination Survey (KNHANES IV)

We evaluated the prevalence, awareness, treatment and control of hypertension in Korean adults with diagnosed diabetes using nationally representative data. Among subjects aged ≥30 years who participated in the Fourth Korea National Health and Nutrition Examination Survey in 2007 and 2008, a total of 745 subjects (336 men and 409 women) with a previous diagnosis of diabetes mellitus were analyzed. The prevalence of hypertension in adults with diagnosed diabetes was 55.5%. The rates of awareness, treatment and control were 88.0, 94.2, and 30.8%, respectively. Compared with the general population, the prevalence of hypertension in adults with diagnosed diabetes was higher in all age groups in both genders. Factors independently associated with a high prevalence of hypertension included being male, increasing age, single, <9 years of education, the presence of chronic kidney disease risk, hypercholesterolemia (≥240 mg dl(-1)) and high body mass index (≥25 kg m(-2)). Regular medical screening was positively associated with hypertension control, whereas a high triglyceride level (≥150 mg dl(-1)) was inversely associated. A high prevalence and a low control rate of hypertension in adults with diagnosed diabetes suggest that stringent efforts are needed to control blood pressure in diabetic patients.

Obesity and low target attainment rates in Chinese with type 2 diabetes

BACKGROUND

Although it is known that the prevalence of type 2 diabetes and obesity is increasing in China, there is little research into how obese or non-obese patients may differ in their attainment of treatment goals for type 2 diabetes. To do this, we assessed the attainment of American Diabetes Association (ADA)-recommended goals in Chinese with type 2 diabetes stratified by body mass index (BMI).

METHODS

This cross-sectional study enrolled 520 Chinese with type 2 diabetes to find out if they had attained the following ADA-recommended goals: HbA1c<7%, SBP<130 mm Hg, DBP<80 mm Hg, LDL-C<100mg/dl, TG<150 mg/dl, HDL-C>40 mg/dl for men and >50mg/dl for women.

RESULTS

Only 44.4% of all participants achieved the blood pressure goal, 20.8% the HbA1c goal, 44.8% the LDL-C goal, 43.3% the HDL-C goal, and 66.8% the triglyceride goal. Obese patients were less likely than normal weight patients to achieve the blood pressure goal (OR, 0.474; 95% CI, 0.231-0.973; p = 0.01), the HDL goal (OR, 0.365; 95% CI, 0.163-0.817; p = 0.01), or the triglyceride goal (OR, 0.416; 95% CI, 0.212-0.817; p = 0.01), after adjusting for confounders. Compared to normal weight participants, the obese patients had a significantly higher prescription rates for statin, metformin and anti-hypertensive drugs.

CONCLUSION

Obese diabetic patients were less likely to achieve the blood pressure, LDL-C, HDL-C and triglyceride targets even when they were receiving several drugs to help them meet their target treatment goals. More strategies are needed to improve the treatment of Chinese with type 2 diabetes, particularly those who are obese.