Are we optimizing gestational diabetes treatment with glyburide? The pharmacologic basis for better clinical practice

Glyburide's pharmacokinetics (PK) and pharmacodynamics have not been studied in women with gestational diabetes mellitus (GDM). The objective of this study was to assess steady-state PK of glyburide, as well as insulin sensitivity, beta-cell responsivity, and overall disposition indices after a mixed-meal tolerance test (MMTT) in women with GDM (n = 40), nonpregnant women with type 2 diabetes mellitus (T2DM) (n = 26), and healthy pregnant women (n = 40, MMTT only). At equivalent doses, glyburide plasma concentrations were approximately 50% lower in pregnant women than in nonpregnant subjects. The average umbilical cord/maternal plasma glyburide concentration ratio at the time of delivery was 0.7 +/- 0.4. Insulin sensitivity was approximately fivefold lower in women with GDM as compared with healthy pregnant women. Despite comparable beta-cell responsivity indices, the average beta-cell function corrected for insulin resistance was more than 3.5-fold lower in women with glyburide-treated GDM than in healthy pregnant women. Women with GDM in whom glyburide treatment has failed may benefit from alternative medication or dosage escalation; however, fetal safety should be kept in mind.

Time from diagnosis to treatment initiation in advanced non-small cell lung cancer (NSCLC): Time trends and racial differences

6037

Background: Historical survival evaluation of clinical trials for advanced NSCLC suggests that median survival improved by 0.4 months over a 22 year period. Survival in clinical trails is evaluated from treatment initiation and not from diagnosis. If treatment is initiated earlier over time, this may create a lead-time effect on survival analysis and thus may explain the apparent discrepancy between trial findings and outcomes in the community. Objective: Investigate if, over time, there has been a shortening of the time between the diagnosis of NSCLC and the initiation of chemotherapy. Methods: We evaluated patients with NSCLC stages IIIB and IV between 01/01/1994 and 12/31/1999. Date of diagnosis was obtained from Surveillance, Epidemiology, and End Results (SEER). Treatment data was obtained from Medicare claims and is restricted to patients above age 65. Differences were compared using analysis of variance (ANOVA). Results: A total of 11,995 patients were identified. Patient’s characteristics: median age 74 years; 57% of patients were males; racial distribution: white (82.4%), black (9.4%), Asian (3.2%), Hispanics (1.2%), others (3.8%); stage distribution: IIIB (38%), IV (62%). Chemotherapy was given to 3,377 (28%) patients. There was an increase in chemotherapy utilization over time: 10% in 1994 to 35% in 1999. Over time there was a shortening from diagnosis to chemotherapy initiation from 1.6 months in 1994 to 1.3 months in 1999 (p = 0.0004). Among those receiving chemotherapy, median survival from diagnosis did not change over this time period. Black patients had a longer time between diagnosis and treatment initiation: 1.7 months vs. 1.4 months (p < 0.01). Conclusions: Over time, there has been a shortening of the time between diagnosis and chemotherapy initiation. This difference, although small, seems to account for much of the apparent historical survival benefit observed. This finding puts additional limitation on the historical comparisons of survival between trials. Racial differences may help explain, in part, observed differences in outcome.

No significant financial relationships to disclose.

Tramadol and seizures: a surveillance study in a managed care population

STUDY OBJECTIVE

To investigate the occurrence of tramadol-associated seizures.

DESIGN

Retrospective cohort and case-control studies.

SETTING

UnitedHealth Group-affiliated independent practice model health plans, from different regions of the United States, contracting with large networks of physicians.

INTERVENTION

Analysis of administrative data from a large U.S. managed care population.

PATIENTS

A cohort of 9218 adult tramadol users and 37,232 concurrent nonusers.

MEASUREMENTS AND MAIN RESULTS

Fewer than 1% of users (80) had a presumed incident seizure claim after the first tramadol prescription. Risk of seizure claim was increased 2- to 6-fold among users adjusted for selected comorbidities and concomitant drugs. Risk was highest among those aged 25-54 years, those with more than four tramadol prescriptions, and those with history of alcohol abuse, stroke, or head injury. A case-control study among users was conducted to validate incident seizure outcomes from medical records. Only eight cases were confirmed, and all had cofactors associated with increased seizure risk.

CONCLUSION

In a general population, risk of seizure may be associated with long-term therapy with tramadol or the presence of cofactors, or confined to a small sensitive population subset.

Patient-level estimates of the cost of complications in diabetes in a managed-care population

OBJECTIVE

To develop incidence-based estimates of the cost of several diabetes-related complications.

DESIGN AND SETTING

This was a retrospective cohort study in a large health maintenance organisation. A total of 8905 patients with type 1 (insulin-dependent) and type 2 (non-insulin-dependent) diabetes mellitus and 36,520 age- and gender-matched controls without diabetes were observed from 1992 to 1995. Incidence rates of 6 major diabetes-related complications were computed for both populations. Annual health expenditures in the first and second year following diagnosis were computed for each complication. For comparison, annual costs were derived for individuals without diabetes or the complication of interest.

MAIN OUTCOME MEASURES AND RESULTS

Over 3 years of observation, incidence rates for the groups with and without diabetes were as follows: myocardial infarction 9.0 versus 3.2%; stroke 8.7 versus 3.8%; hypertension 26.2 versus 16.9%; end-stage renal disease 5.9 versus 1.4%; foot ulcer 7.9 versus 1.1%; and eye disease 44.3 versus 2.8%. Expressed as a multiple of the average annual cost of care for those without diabetes [$US3400/year (1995 dollars) for those over 65 years of age] and the related complication of interest, excess expenditures for those with diabetes were as follows for the first year following diagnosis: no complications 1.59; myocardial infarction 4.1; stroke 3.5; hypertension 2.56; end-stage renal disease 4.32; foot ulcer 4.0; and eye disease 2.46. For younger cohorts (less prevalent in the sample), incremental costs for each complication were generally greater than in the older group.

CONCLUSIONS

The high incidences and costs may support the value of aggressive early intervention for patients with diabetes. These data will be useful for pharmacoeconomic modelling of the cost effectiveness of new and existing therapies for this condition.

Incidence, outcomes, and cost of foot ulcers in patients with diabetes

OBJECTIVE

To determine the incidence of foot ulcers in a large cohort of patients with diabetes, the risk of developing serious complications after diagnosis, and the attributable cost of care compared with that in patients without foot ulcers.

RESEARCH DESIGN AND METHODS

Retrospective cohort study of patients with diabetes in a large staff-model health maintenance organization from 1993 to 1995. Patients with diabetes were identified by algorithm using administrative, laboratory, and pharmacy records. The data were used to calculate incidence of foot ulcers, risk of osteomyelitis, amputation, and death after diagnosis of foot ulcer, and attributable costs in foot ulcer patients compared with patients without foot ulcers.

RESULTS

Among 8,905 patients identified with type 1 or type 2 diabetes, 514 developed a foot ulcer over 3 years of observation (cumulative incidence 5.8%). On or after the time of diagnosis, 77 (15%) patients developed osteomyelitis and 80 (15.6%) required amputation. Survival at 3 years was 72% for the foot ulcer patients versus 87% for a group of age- and sex-matched diabetic patients without foot ulcers (P < 0.001). The attributable cost for a 40- to 65-year-old male with a new foot ulcer was $27,987 for the 2 years after diagnosis.

CONCLUSIONS

The incidence of foot ulcers in this cohort of patients with diabetes was nearly 2.0% per year. For those who developed ulcers, morbidity, mortality, and excess care costs were substantial compared with those for patients without foot ulcers. The results appear to support the value of foot-ulcer prevention programs for patients with diabetes.