Reasons for non-intensification of treatment in people with type 2 diabetes receiving oral monotherapy: Outcomes from the prospective DIAttitude study

OBJECTIVES

To describe the management of glucose-lowering agents in people with type 2 diabetes initially on oral monotherapy, cared for by French general practitioners, and to identify reasons underlying treatment non-intensification.

METHODS

People with type 2 diabetes on oral monotherapy were recruited by general practitioners and followed-up over 12 months. Patient characteristics, HbA1c, and glucose-lowering treatments were recorded electronically. Management objectives and reasons for treatment non-intensification were solicited from the general practitioners.

RESULTS

A total of 1212 patients were enrolled by 198 general practitioners; 937 patients (mean age 68 years) were treated with oral monotherapy, and 916 patients had at least two successive HbA1c values recorded. Of these, 390 patients (43%) had HbA1c≥6.5% on both occasions, and 164/390 (42%) had their treatment intensified. The 226 patients whose treatment was not intensified were older (69±11 years vs. 66±12 years, P=0.02) and had better glycaemic control at study inclusion (6.9%±0.6 vs. 7.3%±0.8, P<0.0001) than treatment intensified patients. Among uncontrolled patients, there were no differences in general practitioner treatment objectives at inclusion for treatment intensified and non-intensified patients; the main reason given by general practitioners for non-intensification was that the patient had an adequate HbA1c (66%). HbA1c did exceed the 6.5% target, but was less than 7.0% in 69% of cases.

CONCLUSIONS

General practitioners showed a patient-centred approach to treatment, but clinical inertia was apparent for 31% of the uncontrolled patients.

[Hypoglycemic treatment in type 2 diabetes patients suffering from moderate to severe renal failure in France. Aim of the study]

The purpose of this study is to describe the hypoglycemic agents prescribed to type 2 diabetes patients (T2D) with renal impairment (RI).

METHOD

Data were extracted from the database LPD-CEGEDIM, based on a sample of 1200 general practitioners. The analysis focused on T2D patients with RI, defined by a glomerular filtration rate (GFR) below 60 mL/min/1.73 m², estimated by the MDRD formula.

RESULTS

Of the 36 255 patients identified with T2D, a GFR was calculated for 8 647 patients (23.9%), 1 472 (22%) with a moderate RI (GFR=[30mL/min/1.73 m²-60mL/min/1.73 m²]) and 86 (1.0%) with a severe RI (GFR=[15mL/min/1.73 m-30mL/min/1.73 m²]); 47,6% of T2D patients with a moderate RI and 52,3% of T2D patients with a severe RI were treated with at least one drug contraindicated in patients with moderate or severe RI.

CONCLUSION

These findings suggest better informing doctors of these contraindications and show the value of having new hypoglycemic drugs that can be used in case of RI.

Characteristics and six-month outcomes in a cohort of 8288 diabetic and non-diabetic patients with previous history of acute coronary syndrome or stroke: the French PREVENIR 3 survey

AIMS

To evaluate the cardiovascular prognosis of 1845 Diabetic Patients (DP) and 6443 Non-Diabetic Patients (NDP) in secondary prevention.

METHODS

Patients were recruited prospectively if they had had a previous history of ischemic stroke or acute coronary syndrome (ACS) i.e. Myocardial Infarction (MI) or Unstable Angina (UA) within a period of five years preceding inclusion. For each patient, the number of hospitalizations and vital status were recorded each month over a 6-month period (mean follow-up: 4.8 months).

RESULTS

306 patients (9.5/100--person years; 95% CI, 8.5 to 10.6) had undergone at least one subsequent event (hospitalization for ACS, ischemic stroke, or cardiovascular death). A majority of these events were non-fatal ACS (n=248). The cumulative incidence rate of subsequent events was higher in DP: 12.6/100- person years (10.0 to 15.2) than in NDP: 8.6/100--person years (7.5 to 9.8). DP were significantly at higher risk of subsequent cardiovascular events (OR: 1.34; P=0.025) after adjustment for confounding factors. 93% of coronary DP and NDP underwent a recurrent event affecting the same location. When the index episode was a stroke, 71% of DP had a subsequent stroke vs. 47% of NDP.

CONCLUSION

in secondary prevention, the risk of mortality and subsequent vascular events is independently higher in French DP than in NDP. The locations affected by each type of subsequent cardiovascular event seemed correlated to the baseline diagnosis, whatever the diabetic status, even when the frequency of subsequent strokes increased (not significantly) in DP when compared to NDP.

[Role of cardiologists in control of risk factors and prescription of secondary-preventive drugs in elderly patients with atherosclerotic cardiovascular disease. The French ELIAGE-MG survey]

Little information is available as regards risk factor control and use of secondary prevention medications in elderly populations with documented atherosclerotic disease. The ELIAGE-MG survey included 3247 patients with cardiovascular disease seen in ambulatory practice. Overall, both the control of risk factors and the use of secondary prevention medications was suboptimal in these patients. However, those having consulted a cardiologist at any time during the previous year had better control of risk factors (and particularly LDL cholesterol and smoking) and were more often prescribed recommended secondary prevention medications.

[Prognosis at six months for primary care patients: prognostics factors analysis]

AIM OF THE SURVEY: The aim of the PREVENIR III study was to assess, in secondary prevention, the risk of subsequent coronary and cerebrovascular events at six months in a population of patients in private practice.

METHODS

This was a prospective observational survey (6-month follow-up), including patients diagnosed with previous myocardial infarction, unstable angina or ischemic stroke, carried out by French general practitioners and cardiologists in private practice.

RESULTS

8288 patients were selected by 3746 physicians (2961 general practitioners and 785 cardiologists) representative of French metropolitan physicians in private practice. In this analysis the medical records of 6859 coronary patients were analyzed. After a 6-month follow-up, 84 patients had been hospitalized for a subsequent coronary or cerebrovascular event (1.2%) i.e. cumulative incidence 3.1 event per 100 person-years (95% CI 2.4-3.8). In the coronary population 77.4% of the subsequent vascular events were coronary events and 22.6% were cerebrovascular events. The event rate of coronary events was 0.9% and the cumulative incidence 2.3 event per 100 person-years (95% CI 1.8-2.8), the risk of secondary ischemic stroke was 0.3% and the cumulative incidence 0.7 event per 100 person-years (95% CI 0.4-1.0), and the all-cause mortality rate was 1.0% and the cumulative incidence 2.5 event per 100 person-years (95% CI 1.9-3.1). 61.0% of total death was cardiovascular deaths. Multivariate analysis showed that older age, recent index event, three vessel disease were more likely to undergo recurrent events.

CONCLUSION

Our survey enabled a better understanding of the prognosis at six months for a large sample of coronary patients recruited in private practice medicine. For coronary patients treated in private practice the risk of subsequent events and total mortality is far from insignificant.

Drug prescriptions and referral to cardiac rehabilitation after acute coronary events: comparison between men and women in the French PREVENIR Survey

BACKGROUND AND AIM

The problem of a possible gender bias in coronary heart disease management is still controversial. We studied gender differences in secondary preventive drug prescriptions and in referral to cardiac rehabilitation after acute coronary events in France.

METHODS

An observational survey was carried out in 1998-1999 in 150 French intensive cardiac care units. A sample of 2626 consecutive patients admitted for myocardial infarction or unstable angina and alive at discharge was included. Data were retrospectively collected from medical records after discharge.

RESULTS

The sample was composed of 1921 men and 705 women. At discharge, antiplatelet agents were prescribed in 93.4% of men and 91.5% of women (p=0.09), beta-blockers in 73.4% and 63.7% (p<0.0001), angiotensin-converting enzyme (ACE) inhibitors in 39.9% and 44.3% (p<0.05), and statins in 47.0% and 40.7% (p<0.01). The percentage of subjects referred to a cardiac rehabilitation program at discharge was 26.2% in men and 15.5% in women (p<0.0001). In multivariate analysis, taking into account confounding factors, gender did not appear as an independent determinant of drug prescriptions. Conversely, being a woman was independently associated with a lower probability to be referred to a cardiac rehabilitation program at discharge (adjusted female-to-male odds ratio: 0.44 (95% confidence interval: [0.31-0.64], p<0.0001).

CONCLUSIONS

In this study, gender was not an independent determinant of secondary preventive drug prescriptions after acute coronary events. Conversely, we found a gender bias in referral to cardiac rehabilitation programs at discharge.

[Trends in discharge prescriptions for patients hospitalized for acute coronary syndromes in France from 1995 to 2000. Data from the Usik 1995, Prevenir 1, Prevenir 2 and Usic 2000 surveys]

The use of cardiovascular secondary prevention medications in patients with acute coronary syndromes was compared in 4 sequential observational surveys carried out in France from 1995 to 2000. The Usik 1995 and Usic 2000 surveys included patients admitted for acute myocardial infarction, while the 2 Prevenir surveys (1998 and 1999) assessed the medications prescribed in patients with acute coronary syndromes. Antiplatelet agents were prescribed in 91% of the patients in 1995, 93% in 1998 and 1999 and 96% in 2000; for beta-blockers, the respective figures were: 64%, 68%, 75% and 76%. For ACE-Inhibitors, the figures were: 46%, 41%, 41% and 50%. For statins, the prescription increased from 10% to 36%, 59% and 64%. In 1995, 8% of the patients received both antiplatelet agents, beta-blockers and statins (4% of them also had an ACE-Inhibitor); in 2000, the respective figures were 53% and 27%. The results of the recent trials of secondary prevention medications have had a considerable impact on real-life practice in France during the late 1990s.

[Baseline characteristics and management of patients less than 45 years of age hospitalized for acute coronary syndromes: results from the nationwide French PREVENIR 1 and PREVENIR 2 studies]

Of 2,626 patients admitted for acute coronary syndromes and participating in the PREVENIR 1 and 2 registries, 202 (8%) were aged less than 45 years. Younger patients were more often smokers (79% versus 37%), but systemic hypertension and diabetes were less frequent. Reperfusion therapy was more frequently used in the younger patients (63% versus 46%). At hospital discharge, aspirin and angiotensin converting enzyme inhibitors were prescribed as often in younger and older patients. In contrast, beta-blocking agents and statins were used more often in the younger patients. More younger patients participated in a cardiac rehabilitation programme. Left ventricular ejection fraction was less altered in the younger age group and none of the younger patients died between hospital discharge and six months follow-up.

[Impact of an information campaign on cardiovascular risk factors. 5-year results at the study town Epernon]

OBJECTIVES

Information campaigns are implemented to improve knowledge of cardiovascular disease and risk factors. The impact of these programs must be evaluated to determine whether they truly contribute to modifying risk factors in the population.

METHODS

A 5-year information campaign on cardiovascular disease and risk factors was conducted in Epernon, France. The main objectives of the campaign focused on stopping smoking, regular physical exercise and balanced nutrition. Data were collected from a representative sample of the female and male population aged 20 to 65 years selected from the study town Epernon (500 subjects), and in control towns, Magny-en-Vexin and Moret-sur-Loing (200 subjects). The study town and control towns were comparable for population, demographic characteristics and geographic localization (distance from Paris). The subjects were invited to respond to a questionnaire on demographic data, attitudes toward health, risk factors and diet and underwent a clinical examination with blood tests.

RESULTS

The initial sample included 961 subjects and 68.5% participated in the final survey. We were unable to evidence any significant difference in risk factors or the 10-year risk score calculated from the Framingham equation adapted to France. The information campaign was well accepted, the population not expression a feeling of lassitude. The campaign had a minimal effect on the way individuals relate to health. There was a fall in mean energy intake, mainly fat calories, which was similar in all three towns.

CONCLUSION

No major modification in cardiovascular risk factors was observed in this low-risk population, suggesting that future information campaigns should be aimed at targeted populations with a higher risk profile using simple and selected messages.

Efficacy of low-dose pravastatin in patients with mild hyperlipidemia associated with type II diabetes mellitus

A 16 week, randomized, double-blind, parallel, placebo-controlled study was designed to determine the effects of low-dose pravastatin on cholesterol concentrations in patients with mild hypercholesterolemia and non-insulin-dependent diabetes mellitus (NIDDM). Following a 6-to 8-week dietary run-in period, a mean serum total cholesterol (TC) level > 5.2 mmol/L (200 mg/dL), but < 7.8 mmol/L (300 mg/dL) was required for entry. Metabolic control of diabetes was determined by a hemoglobin Alc (HbAlc) level less than twice the upper limit of normal on two occasions. Eighty six (86) patients recruited in 5 French diabetic clinics, were randomized in a ratio of 1:1 (pravastatin 10 mg or placebo), and 74 completed the study. There were 12 discontinuations: 5 (11.6%) in the pravastatin group and 7 (16.3%) in the placebo group. Drop-out was due to an adverse event in 1 patient (2.3%) in the pravastatin group and in 5 patients (11.6%) in the placebo group. Thirty five (35) placebo patients and 14 pravastatin patients had their dose of treatment doubled at week 8: the dose of treatment was to be doubled at week 8 in the event of non-response to treatment (TC at week 7 > 5.2 mmol/L and TC decrease < 15% from baseline). At week 16, pravastatin lowered TC from 6.4 to 5.6 mmol/L (-13.8%, p < 0.001 versus placebo), low-density lipoprotein cholesterol (LDL-C) from 4.3 to 3.4 mmol/L (-20.4%, p < 0.001 versus placebo) and slightly increased high-density lipoprotein cholesterol (HDL-C) from 1.18 to 1.25 mmol/L (+6.7%). Side effects were similar in both groups. Blood glucose control was not altered as assessed by serial HbAlc measurements which were unchanged during treatment. This study demonstrated that low-dose pravastatin is effective in lowering cholesterol levels in patients with hypercholesterolemia and NIDDM.