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Liebergall-Wischnitzer M, Noble A, Raz I, Halperin O. A Correlational Study Of Midwives' Self-Compassion, Psychosocial Health, and Well-Being During the First Wave of COVID-19: What Have We Learned? J Midwifery Womens Health 2023; 68:645-651. [PMID: 37366627 DOI: 10.1111/jmwh.13509] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/28/2023]
Abstract
INTRODUCTION During the first wave of the COVID-19 pandemic, midwives worked in a threatening environment and worried about themselves and their families becoming infected. Self-compassion is defined as an attitude of self-kindness that is supported by a balanced attitude toward negative thoughts or feelings and may contribute to the psychosocial health and well-being. The purpose of this study was to describe midwives' self-compassion, psychosocial health, and well-being and the correlation between them. METHODS This was a descriptive correlational study using a survey administered online during May, 2020. Participants included midwives who worked in labor and delivery units across Israel during the beginning of the COVID-19 pandemic. Measures included a demographic questionnaire; the Self-Compassion Scale Short Form (SCS-SF), which has 12 items in 6 subscales; and the psychosocial health and well-being questionnaire, a short version of the Copenhagen Psychosocial Questionnaire, which has 24 items in 6 subscales. RESULTS Participants (N = 144) reported a moderate-high level of self-compassion with a mean (SD) SCS-SF score of 3.57 (0.69). The mean (SD) psychosocial well-being score was 30.72 (13.57). The burnout subscale score had the highest mean (46.27), representing a high level of burnout. A minority (11.3%) of midwives considered resigning their midwifery positions. A higher level of self-compassion correlated with better psychosocial well-being (r = -0.466; P < .001). The highest correlation was found between the SCS-SF and the psychosocial health and well-being subscale for depressive symptoms (r = -0.574; P < .001). DISCUSSION During the first wave of the COVID-19 pandemic, midwives had a moderate-high grade of self-compassion and good psychosocial well-being. Midwives with higher self-compassion had better psychosocial well-being. The findings could inform the development of programs to increase midwives' self-compassion, and psychosocial well-being and the quality of midwifery care, in times of stability and during future pandemics or disasters.
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Affiliation(s)
- Michal Liebergall-Wischnitzer
- Henrietta Szold Department of Nursing, Faculty of Medicine, Hadassah Medical Center/Hebrew University, Jerusalem, Israel
| | - Anita Noble
- Henrietta Szold Department of Nursing, Faculty of Medicine, Hadassah Medical Center/Hebrew University, Jerusalem, Israel
| | - Iris Raz
- Soroka Medical Center, Beer-Sheba, Israel
| | - Ofra Halperin
- Nursing Department, Max Stern Academic College of Emek-Yezreel, Israel
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Morieri ML, Raz I, Consoli A, Rigato M, Lapolla A, Broglio F, Bonora E, Avogaro A, Fadini GP. Short-term effectiveness of dapagliflozin versus DPP-4 inhibitors in elderly patients with type 2 diabetes: a multicentre retrospective study. J Endocrinol Invest 2023:10.1007/s40618-022-02002-2. [PMID: 36624223 DOI: 10.1007/s40618-022-02002-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Accepted: 12/29/2022] [Indexed: 01/11/2023]
Abstract
AIM To compare effectiveness of dapagliflozin versus DPP-4 inhibitors on individualized HbA1c targets and extra-glycaemic endpoints among elderly patients with type 2 diabetes (T2D). METHODS This was a multicentre retrospective study on patients aged 70-80 years with HbA1c above individualized target and starting dapagliflozin or DPP-4 inhibitors in 2015-2017. The primary outcome was the proportion reaching individualized HbA1c targets. Confounding by indication was addressed by inverse probability of treatment weighting (IPTW), multivariable adjustment (MVA), or propensity score matching (PSM). RESULTS Patients initiating dapagliflozin (n = 445) differed from those initiating DPP-4i (n = 977) and balance between groups was achieved with IPTW or PSM. The median follow-up was 7.5 months and baseline HbA1c was 8.3%. A smaller proportion of patients initiating dapagliflozin attained individualized HbA1c target as compared to those initiating DPP-4 inhibitors (RR 0.73, p < 0.0001). IPTW, MVA, and PSM yielded similar results. Between-group difference in the primary outcome was observed among patients with lower eGFR or longer disease duration. Dapagliflozin allowed greater reductions in body weight and blood pressure than DPP-4 inhibitors. CONCLUSIONS Elderly patients with T2D initiating dapagliflozin had a lower probability of achieving individualized HbA1c targets than those initiating DPP-4 inhibitors but displayed better improvements in extra-glycaemic endpoints.
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Affiliation(s)
- M L Morieri
- Department of Medicine, University of Padova, Via Giustiniani 2, 35128, Padua, Italy
| | - I Raz
- Department of Medicine, Hadassah Hebrew University Hospital, Jerusalem, Israel
| | - A Consoli
- DMSI & CAST, University G. d'Annunzio of Chieti-Pescara, Chieti, Italy
| | - M Rigato
- Department of Medicine, University of Padova, Via Giustiniani 2, 35128, Padua, Italy
- Diabetology Clinic, AULSS2 Marca Trevigiana, 31100, Treviso, Italy
| | - A Lapolla
- Department of Medicine, University of Padova, Via Giustiniani 2, 35128, Padua, Italy
| | - F Broglio
- Department of Medical Sciences, University of Turin, 10124, Turin, Italy
| | - E Bonora
- Department of Medicine, University and Hospital Trust of Verona, Verona, Italy
| | - A Avogaro
- Department of Medicine, University of Padova, Via Giustiniani 2, 35128, Padua, Italy
| | - G P Fadini
- Department of Medicine, University of Padova, Via Giustiniani 2, 35128, Padua, Italy.
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Moura F, Wiviott S, Chertow G, Dwyer J, Gause-Nilsson I, Johansson P, Langkilde A, McMurray J, Mosenzon O, Raz I, Rossing P, Wheeler D, Sabatine M, Heerspink H. Effects of dapagliflozin on cardiovascular and kidney events by baseline eGFR and UACR in patients with type 2 diabetes mellitus: a patient-level pooled analysis of DECLARE-TIMI 58 and DAPA-CKD trials. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.2407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Background
The sodium glucose co-transporter 2 (SGLT2) inhibitor dapagliflozin reduced the risk of hospitalization for heart failure (HHF) or cardiovascular death (CVD) and the risk of kidney events in patients type 2 diabetes mellitus (T2DM) and high cardiovascular risk or chronic kidney disease in the DECLARE-TIMI 58 and DAPA-CKD trials. These events are more common at lower levels of kidney function. Combining data from the two trials creates an opportunity to examine the effect of dapagliflozin across the spectrum of baseline kidney function.
Purpose
To determine the effects of dapagliflozin on HHF/CVD and kidney endpoints across a broad range of kidney function in the combined dataset.
Methods
We conducted a post hoc analysis of pooled patient-level data from DECLARE and DAPA-CKD. The effects of dapagliflozin compared with placebo on HHF/CVD and kidney endpoints (defined as sustained eGFR decrease ≥40%, end-stage kidney disease, or renal death) were assessed in the combined cohorts and in subgroups of baseline eGFR (<45, 45-<60, 60-<90, ≥90 mL/min/1.73 m2) and urinary albumin:creatinine ratio (UACR) (<30, 30-<300, 300-<1000, ≥1000 mg/g).
Results
A total of 19,748 patients with T2DM were included. Median (IQR) follow up time was 4.1 (3.7–4.4) years. Median eGFR was 85 (65–95) mL/min/1.73 m2 and UACR 18.2 (7–135) mg/g. Overall, dapagliflozin reduced the risk of HHF/CVD by 18% (HR 0.82, 95% CI 0.73–0.92, p<0.001) and kidney endpoints by 40% (HR 0.60, 95% CI 0.52–0.69, p<0.001). Overall rates of HHF/CVD and kidney endpoints were higher with lower eGFR (p<0.001) and with higher UACR (p<0.001). There were consistent relative risk reductions in HHF/CVD and kidney events with dapagliflozin across eGFR (p-interaction 0.25 and 0.32, respectively, Figure 1) and UACR (p-interaction 0.29 and 0.83, respectively, Figure 2) subgroups. The absolute rate difference (ARD) with dapagliflozin for CVD/HHF ranged from 0.1 events per 1000 patient years in patients in normal categories of eGFR and UACR to 1.0–1.7 events in patients in the most abnormal categories. Likewise, the ARD for kidney events ranged from 0.2 events per 1000 patient years in the normal eGFR and UACR groups to 2.5–4.3 events in patients in the most abnormal categories.
Conclusion
In this pooled analysis of pts with T2DM, there was higher risk of HHF/CVD and kidney events with lower eGFR and higher UACR. Dapagliflozin consistently reduced these events regardless of baseline eGFR and UACR, with large absolute risk reductions in patients with lower eGFR and higher UACR.
Funding Acknowledgement
Type of funding sources: None.
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Affiliation(s)
- F Moura
- Brigham and Women'S Hospital, Harvard Medical School, TIMI Study Group, Division of Cardiovascular Medicine , Boston , United States of America
| | - S Wiviott
- Brigham and Women'S Hospital, Harvard Medical School, TIMI Study Group, Division of Cardiovascular Medicine , Boston , United States of America
| | - G Chertow
- School of Medicine, Department of Epidemiology and Population Health and Department of Medicine , Stanford , United States of America
| | - J Dwyer
- University of Utah Health Care , Salt Lake City , United States of America
| | | | | | | | - J McMurray
- University of Glasgow, Institute of Cardiovascular and Medical Sciences , Glasgow , United Kingdom
| | - O Mosenzon
- University of Glasgow, Institute of Cardiovascular and Medical Sciences , Glasgow , United Kingdom
| | - I Raz
- The Hebrew University of Jerusalem, Diabetes Unit, Hadassah Medical Center , Jerusalem , Israel
| | - P Rossing
- University of Copenhagen, Department of Clinical Medicine , Copenhagen , Denmark
| | - D Wheeler
- University College London, Department of Renal Medicine , London , United Kingdom
| | - M Sabatine
- Brigham and Women'S Hospital, Harvard Medical School, TIMI Study Group, Division of Cardiovascular Medicine , Boston , United States of America
| | - H Heerspink
- University of Groningen, University Medical Center Groningen , Groningen , The Netherlands
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Halperin O, Noble A, Yakov G, Raz I, Liebergall-Wischnitzer M. Exploring Midwives Coping and Functioning in the Labor Wards during the Covid-19 Pandemic from the Labour Ward Head Nurses' Perspective: A Qualitative Study. J Nurs Manag 2022; 30:3074-3082. [PMID: 35695044 PMCID: PMC9349910 DOI: 10.1111/jonm.13710] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Revised: 06/10/2022] [Accepted: 06/10/2022] [Indexed: 10/31/2022]
Abstract
AIM To explore midwives' coping and functioning in the labor wards during the Covid-19 pandemic from the Labor Ward Head Nurses' perspective. BACKGROUND The World Health Organization announced the Covid-19 outbreak to be a pandemic in March 2020. Midwives worldwide were affected by this outbreak, working in risky environments, confronting the anxiety and fear of childbearing women. METHODS A qualitative study using thematic analysis was conducted using semi-structured interviews done over the telephone. Thirteen Labor Ward Head Nurses were interviewed, and the texts analyzed. The study took place in April, 2020 during the first Covid-19 lockdown in Israel. RESULTS Three main themes were generated in the coding process: (a) stress, fear and anxiety, (b) joint efforts, and (c) frustration. CONCLUSION Our study illustrates the difficulties that arose at the beginning of the pandemic, a new and unfamiliar chaotic period. Midwives' managers can use the current research to learn about actions that may assist in improving staff resilience and cohesion during times of crisis. IMPLICATIONS FOR NURSING MANAGEMENT Understanding the psychological impact of the Covid-19 pandemic among healthcare professionals is crucial for guiding policies and interventions to maintain staff's psychological well-being.
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Affiliation(s)
- Ofra Halperin
- Nursing Department, Max Stern Academic College of Emek-Yezreel, Israel
| | - Anita Noble
- Henrietta Szold Hadassah/Hebrew University Nursing department, Jerusalem, Israel
| | - Gila Yakov
- Nursing Department, Max Stern Academic College of Emek-Yezreel, Israel
| | - Iris Raz
- Soroka Medical Center, Beer-Sheba, Israel
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Oyama K, Raz I, Cahn A, Goodrich E, Bhatt D, Leiter L, McGuire D, Wilding J, Gause-Nilsson I, Mosenzon O, Sabatine M, Wiviott S. Influence of cardiovascular drugs on the efficacy and safety of dapagliflozin in patients with type 2 diabetes mellitus in the DECLARE-TIMI 58 trial. Eur Heart J 2021. [DOI: 10.1093/eurheartj/ehab724.2961] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
In DECLARE-TIMI 58, the sodium glucose co-transporter 2 inhibitor (SGLT2i) dapagliflozin reduced the risk of the composite of cardiovascular (CV) death or hospitalization for heart failure (HHF) in a broad range of patients with type 2 diabetes mellitus (T2DM). SGLT2i are known to have diuretic and anti-hypertensive effects. However, whether concomitant CV drugs influence the efficacy and safety of dapagliflozin in these populations is less well known.
Purpose
We examined whether dapagliflozin consistently reduced the risk of CV outcomes and whether the safety of dapagliflozin was similar with or without the concurrent use of various CV drugs.
Methods
DECLARE–TIMI 58 was a randomized trial of dapagliflozin versus placebo in patients with T2DM and either atherosclerotic cardiovascular disease (ASCVD) or multiple risk factors for CV disease followed for a median of 4.2 years. We stratified patients by the use of CV drugs at baseline commonly used for heart failure: angiotensin-converting-enzyme inhibitors or angiotensin-receptor blockers (ACEi/ARB), beta-blockers, diuretics, and mineralocorticoid receptor antagonists (MRA). Efficacy outcomes of interest were the composite of CV death/HHF and HHF alone. We used the Cox proportional-hazard model for these analyses.
Results
Of 17,160 patients, 13,950 (81%) used ACEi/ARB, 9,030 (53%) used beta-blockers, 6,967 (41%) used diuretics, and 762 (4%) used MRA at baseline. All were balanced by randomized treatment groups. Patients using CV drugs at baseline had a greater prevalence of atherosclerotic risk factors and established CV disease than those without. Dapagliflozin consistently reduced the risk of CV death/HHF regardless of the use of CV medications (Figure). For HHF alone, similar results were seen with no significant interactions for any of the classes. There were no significant treatment interactions by the concomitant use of any of CV drugs for adverse events including symptoms of volume depletion or acute kidney injury.
Conclusions
In this analysis from the DECLARE–TIMI 58 trial, dapagliflozin consistently reduced the risk of CV death/HHF and HHF alone irrespective of the concurrent use of various CV drugs without any treatment interaction for key safety events.
Funding Acknowledgement
Type of funding sources: Private company. Main funding source(s): The DECLARE–TIMI 58 trial was supported by AstraZeneca.
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Affiliation(s)
- K Oyama
- Brigham and Women's Hospital, Harvard Medical School, Division of Cardiovascular Medicine, Boston, United States of America
| | - I Raz
- Hadassah-Hebrew University Medical Center, Diabetes Unit, Jerusalem, Israel
| | - A Cahn
- Hadassah-Hebrew University Medical Center, Diabetes Unit, Jerusalem, Israel
| | - E Goodrich
- Brigham and Women's Hospital, Harvard Medical School, Division of Cardiovascular Medicine, Boston, United States of America
| | - D Bhatt
- Brigham and Women's Hospital, Harvard Medical School, Division of Cardiovascular Medicine, Boston, United States of America
| | - L Leiter
- University of Toronto, Toronto, Canada
| | - D McGuire
- University of Texas Southwestern Medical Center, Division of Cardiology, Dallas, United States of America
| | - J Wilding
- University of Liverpool, Department of Cardiovascular and Metabolic Medicine, Liverpool, United Kingdom
| | | | - O Mosenzon
- Hadassah-Hebrew University Medical Center, Diabetes Unit, Jerusalem, Israel
| | - M Sabatine
- Brigham and Women's Hospital, Harvard Medical School, Division of Cardiovascular Medicine, Boston, United States of America
| | - S Wiviott
- Brigham and Women's Hospital, Harvard Medical School, Division of Cardiovascular Medicine, Boston, United States of America
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Furtado R, Raz I, Goodrich E, Sabatine M, Wiviott S. Efficacy and safety of dapagliflozin according to baseline blood pressure – observations from DECLARE-TIMI 58 Trlial. Eur Heart J 2020. [DOI: 10.1093/ehjci/ehaa946.3063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
Type 2 diabetes mellitus (T2DM) is associated with heightened risk of cardio-renal complications. In DECLARE-TIMI 58, dapagliflozin, compared to placebo, reduced hospitalization for heart failure (HHF) and renal events (the composite of sustained decrease in glomerular filtration rate of at least 40%, progression to end-stage renal disease or death due to renal causes) in a broad range of patients with T2DM, without increase in volume depletion or amputations (two adverse events potentially related to blood pressure lowering). It is uncertain whether the cardio-renal effects of dapagliflozin are partially mediated by an anti-hypertensive effect and whether patients with normal blood pressure can be safely treated with this drug class. In this pre-specified analysis, we report the interaction of those results with baseline systolic blood pressure (SBP).
Purpose
To analyze efficacy and safety of dapagliflozin stratified according to baseline SBP.
Methods
DECLARE-TIMI 58 enrolled 17,160 patients with T2DM with either prior atherosclerotic disease or risk factors. Following the most recent guidelines, patients were categorized according to the following baseline SBP levels: <120, 120–129, 130–139, 140–159 and ≥160 mmHg (respectively, optimal, normal, high normal, grade 1 hypertension and grade 2–3 or severe hypertension). Additionally, spline models were developed to explore the association between SBP and the incidence rates of HHF and renal events. Models were adjusted for: diastolic blood pressure, prior coronary artery disease, prior stroke, peripheral artery disease, dyslipidemia, history of hypertension, prior HF, glomerular filtration rate <60 ml/min/1.73 m2, urinary albumin to creatinin ratio >300 mg/g, age, race, body mass index, DM duration and region.
Results
From the overall trial population, 2557, 3686, 4385, 5501 and 1031 patients were categorized as optimal, normal, high normal, grade 1 hypertension and grade 2–3 or severe hypertension, respectively. After adjustment for clinical co-variates, there was an independent association between SBP and HHF or renal events in the placebo arm, with a “U”-shaped association for both events. Moreover, patients with severe hypertension were at the highest risk for HHF and renal events (Figure 1, Panels A and B). While the HHF benefit of dapagliflozin was amplified in patients with severe hypertension (p-int=0.041), the benefit of dapagliflozin did not differ by SBP category for renal events (p-int=0.15), (Figure 1, Panels C and D). There was no increase in symptoms of volume depletion or amputation at any level of SBP (p-int = 0.93 and 0.28, respectively).
Conclusion
In patients with T2DM, baseline SBP was independently associated with HHF and renal events with a “U”-shaped relationship. Patients with severe hypertension experienced a greater benefit with dapagliflozin for HHF, and renal events were consistently reduced with dapagliflozin across all levels of SBP.
Figure 1. HHF and renal events according to SBP
Funding Acknowledgement
Type of funding source: Private grant(s) and/or Sponsorship. Main funding source(s): AstraZeneca
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Affiliation(s)
- R Furtado
- Hospital Israelita Albert Einstein, Sao Paulo, Brazil
| | - I Raz
- Hebrew University of Jerusalem, Diabetes Unit, Hadassah Medical Center, Jerusalem, Israel
| | - E.L Goodrich
- Brigham and Women'S Hospital, Harvard Medical School, TIMI Study Group, Boston, United States of America
| | - M.S Sabatine
- Brigham and Women'S Hospital, Harvard Medical School, TIMI Study Group, Boston, United States of America
| | - S.D Wiviott
- Brigham and Women'S Hospital, Harvard Medical School, TIMI Study Group, Boston, United States of America
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Zelniker TA, Raz I, Mosenzon O, Dwyer JP, Heerspink HJL, Cahn A, Im K, Bhatt DL, Leiter LA, McGuire DK, Wilding JPH, Gause-Nilsson IAM, Langkilde AM, Sabatine MS, Wiviott SD. 192Effect of dapagliflozin on cardiovascular outcomes in patients with type 2 diabetes according to baseline renal function and albuminuria status: Insights from DECLARE-TIMI 58. Eur Heart J 2019. [DOI: 10.1093/eurheartj/ehz747.0052] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Background
Renal dysfunction including both reduced estimated glomerular filtration rate (eGFR) and the presence of albuminuria have each been shown to predict cardiovascular (CV) outcomes. Sodium glucose co-transporter 2 inhibitors (SGLT2i), which promote glucose excretion in the kidneys, reduce CV events and hospitalizations for heart failure (HHF) in patients with type 2 diabetes mellitus (T2DM).
Purpose
To analyze the CV efficacy of dapagliflozin according to baseline renal function and albuminuria status in DECLARE-TIMI 58.
Methods
The DECLARE-TIMI 58 trial compared dapagliflozin vs. placebo in 17,160 patients with T2DM and a creatinine clearance >60 ml/min/1.73m2 at enrollment. The dual primary endpoints were CV death/HHF and MACE (MI, stroke, CV death). We categorized patients according baseline eGFR [<60 vs. ≥60 ml/min/1.73m2 according to the CKD-EPI formula] and urinary albumin:creatinine ratio (UACR) [<30 vs. ≥30 mg/g]. Cox regression models with interaction testing were applied. The Gail-Simon test was used to test for interaction of the absolute risk differences.
Results
In total, 5198 (30.3%) patients had albuminuria (UACR 30–300: n=4029; UACR >300: n=1169) and 1265 (7.4%) had an eGFR <60 ml/min/1.73m2. Accordingly, 10958 (63.9%) patients had no manifestation of CKD, 5367 (31.3%) had either an eGFR <60 ml/min/1.73m2 or albuminuria, and 548 (3.2%) patients had both manifestations. Patients with more abnormal markers had higher event rates for CV death/HHF (KM event rates at 4 years of 3.9%, 8.3%, 17.4%) and MACE (7.5%, 11.7%, and 18.9%) for no, 1, or 2 markers of CKD, respectively. The relative risk reductions for CV death/HHF and MACE were generally consistent across the subgroups (both P-interaction >0.29), though numerically greatest (42%) in patients with reduced eGFR and albuminuria. However, the absolute risk difference increased substantially in patients with greater kidney damage (absolute risk difference of CV death/HHF: −0.5%, −1.0%, and −8.3%, respectively; P-INT for ARD 0.002; Figure). See figure for MACE and component outcomes.
Conclusions
Patients with baseline renal disease had higher rates of adverse CV outcomes. Dapagliflozin reduced events with generally consistent relative risk, but reduced the absolute risk of CVD/HHF by the greatest amount in patients with kidney disease evidenced by both reduced eGFR and albuminuria.
Acknowledgement/Funding
AstraZeneca, Deutsche Forschungsgemeinschaft (ZE 1109/1-1)
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Affiliation(s)
- T A Zelniker
- TIMI Study Group, Brigham and Women's Hospital and Harvard Medical School, Boston, United States of America
| | - I Raz
- Hadassah University Medical Center, Jerusalem, Israel
| | - O Mosenzon
- Hadassah University Medical Center, Jerusalem, Israel
| | - J P Dwyer
- Vanderbilt University, Nashville, United States of America
| | - H J L Heerspink
- University Medical Center Groningen, Groningen, Netherlands (The)
| | - A Cahn
- Hadassah University Medical Center, Jerusalem, Israel
| | - K Im
- TIMI Study Group, Brigham and Women's Hospital and Harvard Medical School, Boston, United States of America
| | - D L Bhatt
- TIMI Study Group, Brigham and Women's Hospital and Harvard Medical School, Boston, United States of America
| | | | - D K McGuire
- University of Texas Southwestern Medical School, Dallas, United States of America
| | | | | | | | - M S Sabatine
- TIMI Study Group, Brigham and Women's Hospital and Harvard Medical School, Boston, United States of America
| | - S D Wiviott
- TIMI Study Group, Brigham and Women's Hospital and Harvard Medical School, Boston, United States of America
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Berg D, Wiviott S, Scirica B, Gurmu Y, Mosenzon O, Murphy S, Bhatt D, Leiter L, McGuire D, Wilding J, Johansson P, Langkilde A, Raz I, Braunwald E, Sabatine M. 410Heart failure risk stratification and efficacy of dapagliflozin in patients with type 2 diabetes mellitus. Eur Heart J 2019. [DOI: 10.1093/eurheartj/ehz747.0105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Background
Patients with type 2 diabetes mellitus (T2DM) are at increased risk of developing heart failure (HF). Treatment with sodium-glucose cotransporter-2 (SGLT2) inhibitors reduces the risk of hospitalization for HF (HHF) in patients with T2DM.
Purpose
To develop and validate a practical, multivariable clinical risk score for HHF in patients with T2DM and assess whether this score can identify high-risk patients with T2DM who have the greatest reduction in risk for HHF with an SGLT2 inhibitor.
Methods
We developed a clinical risk score for centrally-adjudicated HHF using independent clinical risk indicators of HHF in 8212 patients with T2DM in the placebo arm of SAVOR-TIMI 53. Candidate variables were assessed using multivariable Cox regression and independent clinical risk indicators achieving statistical significance of p<0.001 were included in the risk score and given weights proportional to the regression coefficients. We externally validated the score in 8578 patients with T2DM in the placebo arm of DECLARE-TIMI 58. Discrimination was assessed using Harrell's c-index. The relative and absolute risk reductions in HHF with the SGLT2 inhibitor dapagliflozin were assessed by baseline HHF risk.
Results
The 5 independent clinical risk indicators were prior heart failure, atrial fibrillation, coronary artery disease, estimated glomerular filtration rate (eGFR), and urine albumin/creatinine ratio (UACR) (Figure, left). A simple integer-based scheme using these predictors identified a strong >16-fold gradient of HHF risk (p-trend <0.001) in both the derivation and validation cohorts, with c-indices of 0.81 and 0.78, respectively. Whereas relative risk reductions were similar across the risk score (25–34%), absolute risk reductions were greater in those at higher baseline risk (interaction p-value for absolute risk reduction <0.01), with high-risk (2 points) and very high-risk patients (≥3 points) having 1.5% and 2.7% absolute risk reductions in HHF at 4 years with dapagliflozin, translating into NNTs of only 65 and 36, respectively (Figure, right).
Conclusion(s)
Risk stratification using a novel clinical risk score for HHF in patients with T2DM identifies patients at higher risk for HHF who derive greater benefit from treatment with the SGLT2 inhibitor dapagliflozin.
Acknowledgement/Funding
SAVOR-TIMI 53 and DECLARE-TIMI 58 were sponsored by AstraZeneca.
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Affiliation(s)
- D Berg
- Brigham and Womens Hospital, Boston, United States of America
| | - S Wiviott
- Brigham and Womens Hospital, Boston, United States of America
| | - B Scirica
- Brigham and Womens Hospital, Boston, United States of America
| | - Y Gurmu
- Brigham and Womens Hospital, Boston, United States of America
| | - O Mosenzon
- Hadassah University Medical Center, Jerusalem, Israel
| | - S Murphy
- Brigham and Womens Hospital, Boston, United States of America
| | - D Bhatt
- Brigham and Womens Hospital, Boston, United States of America
| | - L Leiter
- St. Michael's Hospital, Toronto, Canada
| | - D McGuire
- University of Texas Southwestern Medical School, Dallas, United States of America
| | - J Wilding
- Aintree University Hospital, Liverpool, United Kingdom
| | | | | | - I Raz
- Hadassah University Medical Center, Jerusalem, Israel
| | - E Braunwald
- Brigham and Womens Hospital, Boston, United States of America
| | - M Sabatine
- Brigham and Womens Hospital, Boston, United States of America
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Mann J, Fonseca V, Mosenzon O, Raz I, Frimer-Larsen H, Scholten BJ, Idorn T, Poulter N, Lüdemann J. Sicherheit von Liraglutid vs. Placebo bei Patienten mit T2D und CKD in der LEADER Studie. DIABETOL STOFFWECHS 2018. [DOI: 10.1055/s-0038-1641885] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Affiliation(s)
- J Mann
- KfH Nierenzentrum, München, Germany
| | - V Fonseca
- Tulane University Health Sciences Center, New Orleans, United States
| | - O Mosenzon
- Diabetes Unit, Hadassah Hebrew University Hospital, Jerusalem, Israel
| | - I Raz
- Diabetes Unit, Hadassah Hebrew University Hospital, Jerusalem, Israel
| | | | | | - T Idorn
- Novo Nordisk A/S, Søborg, Denmark
| | - N Poulter
- Imperial College London, London, United Kingdom
| | - J Lüdemann
- Schwerpunktpraxis für Diabetes, Gefäß- & Ernährungsmedizin, Falkensee, Germany
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Poulter N, Mann J, Fonseca V, Mosenzon O, Raz I, Frimer-Larsen H, Scholten BJ, Idorn T, Nauck M. Liraglutid reduzierte MACE (Major Cardiovascular Events, schwere unerwünschte kardiovaskuläre Ereignisse) bei Patienten mit chronischer Nierenerkrankung: Ergebnisse aus der LEADER Studie. DIABETOL STOFFWECHS 2018. [DOI: 10.1055/s-0038-1641882] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Affiliation(s)
- N Poulter
- Imperial College London, London, United Kingdom
| | - J Mann
- KfH Nierenzentrum, München, Germany
| | - V Fonseca
- Tulane University Health Sciences Center, New Orleans, United States
| | - O Mosenzon
- Diabetes Unit, Hadassah Hebrew University Hospital, Jerusalem, Israel
| | - I Raz
- Diabetes Unit, Hadassah Hebrew University Hospital, Jerusalem, Israel
| | | | | | - T Idorn
- Novo Nordisk A/S, Søborg, Denmark
| | - M Nauck
- Universitätsklinikum St. Josef-Hospital, Bochum, Germany
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Raz I, Bonaca MP, Mosenzon O, Kato ET, Cahn A, Silverman MG, Bhatt DL, Leiter LA, McGuire DK, Wilding JP, Gausse-Nilsson IAM, Langkilde AM, Johansson PA, Sabatine MS, Wiviott SD, Stürzenhofecker B. Ausgangscharakteristika der DECLARE-TIMI-58-Studienpopulation. DIABETOL STOFFWECHS 2018. [DOI: 10.1055/s-0038-1641965] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Affiliation(s)
- I Raz
- Hadassah Hebrew University Medical Center, Jeruslam, Israel
| | - MP Bonaca
- TIMI Study Group, Brigham and Women's Hospital, Boston, United States
| | - O Mosenzon
- Hadassah Hebrew University Medical Center, Jeruslam, Israel
| | - ET Kato
- Kyoto University Hospital, Kyoto, Japan
| | - A Cahn
- Hadassah Hebrew University Medical Center, Jeruslam, Israel
| | - MG Silverman
- TIMI Study Group, Brigham and Women's Hospital, Boston, United States
| | - DL Bhatt
- TIMI Study Group, Brigham and Women's Hospital, Boston, United States
| | - LA Leiter
- University of Toronto, Toronto, Canada
| | - DK McGuire
- University of Texas Southwestern Medical Center, Dallas, United States
| | - JP Wilding
- Institute of Ageing & Chronic Disease, Liverpool, United Kingdom
| | | | | | | | - MS Sabatine
- TIMI Study Group, Brigham and Women's Hospital, Boston, United States
| | - SD Wiviott
- TIMI Study Group, Brigham and Women's Hospital, Boston, United States
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Masmiquel L, Leiter LA, Vidal J, Bain S, Petrie J, Franek E, Raz I, Comlekci A, Jacob S, van Gaal L, Baeres FMM, Marso SP, Eriksson M. LEADER 5: prevalence and cardiometabolic impact of obesity in cardiovascular high-risk patients with type 2 diabetes mellitus: baseline global data from the LEADER trial. Cardiovasc Diabetol 2016; 15:29. [PMID: 26864124 PMCID: PMC4750199 DOI: 10.1186/s12933-016-0341-5] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2015] [Accepted: 01/22/2016] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Epidemiological data on obesity are needed, particularly in patients with type 2 diabetes mellitus (T2DM) and high cardiovascular (CV) risk. We used the baseline data of liraglutide effect and action in diabetes: evaluation of CV outcome results-A long term Evaluation (LEADER) (a clinical trial to assess the CV safety of liraglutide) to investigate: (i) prevalence of overweight and obesity; (ii) relationship of the major cardiometabolic risk factors with anthropometric measures of adiposity [body mass index (BMI) and waist circumference (WC)]; and (iii) cardiometabolic treatment intensity in relation to BMI and WC. METHODS LEADER enrolled two distinct populations of high-risk patients with T2DM in 32 countries: (1) aged ≥50 years with prior CV disease; (2) aged ≥60 years with one or more CV risk factors. Associations of metabolic variables, demographic variables and treatment intensity with anthropometric measurements (BMI and WC) were explored using regression models (ClinicalTrials.gov identifier: NCT01179048). RESULTS Mean BMI was 32.5 ± 6.3 kg/m(2) and only 9.1 % had BMI <25 kg/m(2). The prevalence of healthy WC was also extremely low (6.4 % according to International Joint Interim Statement for the Harmonization of the Metabolic Syndrome criteria). Obesity was associated with being younger, female, previous smoker, Caucasian, American, with shorter diabetes duration, uncontrolled blood pressure (BP), antihypertensive agents, insulin plus oral antihyperglycaemic treatment, higher levels of triglycerides and lower levels of high-density lipoprotein cholesterol. CONCLUSIONS Overweight and obesity are prevalent in high CV risk patients with T2DM. BMI and WC are related to the major cardiometabolic risk factors. Furthermore, treatment intensity, such as insulin, statins or oral antihypertensive drugs, is higher in those who are overweight or obese; while BP and lipid control in these patients are remarkably suboptimal. LEADER confers a unique opportunity to explore the longitudinal effect of weight on CV risk factors and hard endpoints.
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Affiliation(s)
- L Masmiquel
- Endocrinology and Nutrition Department, Hospital Son Llàtzer, University Institute of Health Science Research (IUNICS-IdISPa), Universitat de les Illes Balears, Palma, Majorca, Spain.
| | - L A Leiter
- Divisions of Endocrinology and Metabolism, Li Ka Shing Knowledge Institute and Keenan Research Centre for Biomedical Science, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada.
| | - J Vidal
- Endocrinology and Nutrition Department, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain.
| | - S Bain
- Institute of Life Science, Swansea University, Swansea, UK.
| | - J Petrie
- Institute of Cardiovascular and Medical Science, BHF Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, UK.
| | - E Franek
- Mossakowski Medical Research Centre, Polish Academy of Sciences and Central Clinical Hospital MSW, Warsaw, Poland.
| | - I Raz
- Diabetes Unit, Internal Medicine Division, Hadassah Hebrew University Hospital, Jerusalem, Israel.
| | - A Comlekci
- Department of Internal Medicine, Division of Endocrinology, Inciralti, Izmir, Turkey.
| | - S Jacob
- Praxis für Prävention und Therapie, Kardio Metabolischen Instituts, Villingen-Schwenningen, Germany.
| | - L van Gaal
- Department of Endocrinology, Diabetology, and Metabolism, Faculty of Medicine, Antwerp University Hospital, Edegem, Antwerp, Belgium.
| | | | - S P Marso
- Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, TX, USA.
| | - M Eriksson
- Department of Endocrinology, Metabolism and Diabetes, Karolinska University Hospital, Stockholm, Sweden.
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Leiter LA, Teoh H, Mosenzon O, Cahn A, Hirshberg B, Stahre CAM, Hoekstra JBL, Alvarsson M, Im K, Scirica BM, Bhatt DL, Raz I. Frequency of cancer events with saxagliptin in the SAVOR-TIMI 53 trial. Diabetes Obes Metab 2016; 18:186-90. [PMID: 26443993 DOI: 10.1111/dom.12582] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2015] [Revised: 09/22/2015] [Accepted: 09/27/2015] [Indexed: 12/14/2022]
Abstract
The Saxagliptin Assessment of Vascular Outcomes Recorded in Patients with Diabetes Mellitus (SAVOR)-Thrombolysis in Myocardial Infarction (TIMI) 53 trial randomized trial of 16,492 patients (placebo, n = 8212; saxagliptin, n = 8280) treated and followed for a median of 2.1 years afforded an opportunity to explore whether there was any association with cancer reported as a serious adverse event. At least one cancer event was reported by 688 patients (4.1%): 362 (4.3%) and 326 (3.8%) in the placebo and saxagliptin arms, respectively (p = 0.13). There were 59 (0.6%) deaths adjudicated as malignancy deaths with placebo and 53 (0.6%) with saxagliptin. Stratification by gender, age, race and ethnicity, diabetes duration, baseline glycated haemoglobin and pharmacotherapy did not show any clinically meaningful differences between the two study arms. The overall number of cancer events and malignancy-associated mortality rates were generally balanced between the placebo and saxagliptin groups, suggesting a null relationship with saxagliptin use over the median follow-up of 2.1 years. Multivariable modelling showed that male gender, dyslipidaemia and current smoking were independent predictors of cancer. These randomized data with adequate numbers of cancer cases are reassuring but limited, by the short follow-up in a trial not designed to test this hypothesis.
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Affiliation(s)
- L A Leiter
- Division of Endocrinology & Metabolism, Li Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | - H Teoh
- Division of Endocrinology & Metabolism, Li Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
- Division of Cardiac Surgery, Li Ka Shing Knowledge Institute and Keenan Research Centre for Biomedical Science, St. Michael's Hospital, Toronto, ON, Canada
| | - O Mosenzon
- Diabetes Unit, Division of Internal Medicine, Hadassah Hebrew University-Medical Center, Jerusalem, Israel
| | - A Cahn
- Diabetes Unit, Division of Internal Medicine, Hadassah Hebrew University-Medical Center, Jerusalem, Israel
| | | | | | - J B L Hoekstra
- Internal Medicine, University of Amsterdam, Amsterdam, Netherlands
| | - M Alvarsson
- Molecular Medicine and Surgery, Endocrinology, Metabolism and Diabetes, Karolinska Institutet Solna, Stockholm, Sweden
| | - K Im
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - B M Scirica
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - D L Bhatt
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - I Raz
- Diabetes Unit, Division of Internal Medicine, Hadassah Hebrew University-Medical Center, Jerusalem, Israel
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Scirica BM, Braunwald E, Raz I, Cavender MA, Morrow DA, Jarolim P, Udell JA, Mosenzon O, Im K, Umez-Eronini AA, Pollack PS, Hirshberg B, Frederich R, Lewis BS, McGuire DK, Davidson J, Steg PG, Bhatt DL. Heart Failure, Saxagliptin, and Diabetes Mellitus: Observations from the SAVOR-TIMI 53 Randomized Trial. Circulation 2016; 132:e198. [PMID: 26459088 DOI: 10.1161/cir.0000000000000330] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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Dungan KM, Raz I, Skrivanek Z, Sealls W, Fahrbach JL. Achieving the composite endpoint of glycated haemoglobin <7.0%, no weight gain and no hypoglycaemia in the once-weekly dulaglutide AWARD programme. Diabetes Obes Metab 2016; 18:49-55. [PMID: 26362460 PMCID: PMC5061097 DOI: 10.1111/dom.12575] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2015] [Revised: 08/17/2015] [Accepted: 08/28/2015] [Indexed: 11/29/2022]
Abstract
AIM To compare the effectiveness of dulaglutide 1.5 and 0.75 mg with active comparators and placebo with regard to a composite endpoint of glycated haemoglobin (HbA1c), weight and hypoglycaemia, using post hoc analyses. METHODS A logistic regression analysis was performed on the intention-to-treat population, using data from the last observation carried forward, and the composite endpoint of HbA1c <7.0% (53 mmol/mol), no weight gain (≤0 kg) and no hypoglycaemia (glucose <3.0 mmol/l or severe hypoglycaemia) after 26 weeks for each trial in the AWARD programme separately. RESULTS At 26 weeks, within each study, 37-58% of patients on dulaglutide 1.5 mg, 27-49% of patients on dulaglutide 0.75 mg, and 9-61% of patients on active comparators achieved the composite endpoint. Significantly more patients reached the composite endpoint with dulaglutide 1.5 mg than with metformin, sitagliptin, exenatide twice daily or insulin glargine: odds ratio (OR) 1.5 [95% confidence interval (CI) 1.0, 2.2; p < 0.05], OR 4.5 (95% CI 3.0, 6.6; p < 0.001), OR 2.6 (95% CI 1.8, 3.7; p < 0.001) and OR 7.4 (95% CI 4.4, 12.6; p < 0.001), respectively, with no difference between dulaglutide 1.5 mg and liraglutide 1.8 mg. In addition, significantly more patients reached the composite endpoint with dulaglutide 0.75 mg than with sitagliptin or insulin glargine: OR 3.3 (95% CI 2.2, 4.8; p < 0.001) and OR 4.5 (95% CI 2.7, 7.8; p < 0.001), respectively. CONCLUSIONS Dulaglutide is an effective treatment option, resulting in a similar or greater proportion of patients reaching the HbA1c target of <7.0% (53 mmol/mol), without weight gain or hypoglycaemia compared with active comparators.
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Affiliation(s)
- K M Dungan
- Division of Endocrinology, Diabetes and Metabolism, Ohio State University, Columbus, OH, USA
| | - I Raz
- Hadassah Hebrew University Hospital, Jerusalem, Israel
| | - Z Skrivanek
- Eli Lilly and Company, Indianapolis, IN, USA
| | - W Sealls
- Eli Lilly and Company, Indianapolis, IN, USA
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Raz I, Cahn A, Mosenzon O, Scirica BM, Bhatt DL. Response to: 'Baseline differences in SAVOR trial'-- prespecified vs. post hoc analysis--a potential source of bias. Diabetes Obes Metab 2015; 17:1203-4. [PMID: 26419822 DOI: 10.1111/dom.12579] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2015] [Revised: 09/21/2015] [Accepted: 09/21/2015] [Indexed: 11/28/2022]
Affiliation(s)
| | - A Cahn
- Diabetes Unit, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | - O Mosenzon
- Diabetes Unit, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | - B M Scirica
- Heart and Vascular Center, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - D L Bhatt
- Heart and Vascular Center, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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Raz I, Novack L, Yitshak-Sade M, Shahar Y, Wiznitzer A, Sergienko R, Warshawsky-Livne L. Effects of changes in copayment for obstetric emergency room visits on the utilization of obstetric emergency rooms. Health Policy 2015; 119:1358-65. [PMID: 26341842 DOI: 10.1016/j.healthpol.2015.08.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2013] [Revised: 04/03/2015] [Accepted: 08/12/2015] [Indexed: 11/19/2022]
Abstract
In view of the growing proportion of "non-urgent" admissions to obstetric emergency rooms (OERs) and recent changes in copayment policies for OER visits in Israel, we assessed factors contributing to OER overcrowding. The changes investigated were (a) exemption from copayment for women with birth contractions, (b) allowing phone referrals to the OER and (c) exemption from copayment during primary care clinic closing hours. We analyzed data of a large tertiary hospital with 37 deliveries per day. Counts of women discharged to home from the OER were an indicator of "non-urgent" visits. The annual number of non-urgent visits increased at a higher rate (3.4%) than the natural increase in deliveries (2.1%). Exemption from copayment for visits during non-working hours of primary care clinics was associated with increases in OER admissions (IRR=1.22) and in non-urgent OER visits (IRR=1.54). Younger and first-time mothers with medically unjustified complaints were more likely to be discharged to home. We showed that the changes in the policy for OER copayment meant to attract new clients to the HMO had an independent impact on OER utilization, and hence, added to the workload of medical personnel. The change in HMO policy regulating OER availability requires rigorous assessment of possible health system implications.
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Affiliation(s)
- Iris Raz
- Obstetrics and Gynecology Division, Soroka University Medical Center, Beer-Sheva, Israel
| | - Lena Novack
- Department of Public Health, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel.
| | - Maayan Yitshak-Sade
- Clinical Research Center, Soroka University Medical Center, Beer-Sheva, Israel
| | - Yemima Shahar
- Obstetrics and Gynecology Division, Soroka University Medical Center, Beer-Sheva, Israel
| | - Arnon Wiznitzer
- Obstetrics and Gynecology Division, The Rabin Medical Center, Petach-Tikva, Israel
| | - Ruslan Sergienko
- Department of Public Health, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
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Leibowitz G, Cahn A, Bhatt DL, Hirshberg B, Mosenzon O, Wei C, Jermendy G, Sheu WHH, Sendon JL, Im K, Braunwald E, Scirica BM, Raz I. Impact of treatment with saxagliptin on glycaemic stability and β-cell function in the SAVOR-TIMI 53 study. Diabetes Obes Metab 2015; 17:487-94. [PMID: 25656169 DOI: 10.1111/dom.12445] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2014] [Revised: 01/18/2015] [Accepted: 01/31/2015] [Indexed: 12/20/2022]
Abstract
AIMS To study the effects of saxagliptin, a dipeptidyl peptidase-4 inhibitor, on glycaemic stability and β-cell function in the SAVOR-TIMI 53 trial. METHODS We randomized 16,492 patients with type 2 diabetes (T2D) to saxagliptin or placebo, added to current antidiabetic medications, and followed them for a median of 2.1 years. Glycaemic instability was defined by: (i) a glycated haemoglobin (HbA1c) increase of ≥ 0.5% post-randomization; (ii) the initiation of new antidiabetic medications for ≥ 3 months; or (iii) an increase in dose of oral antidiabetic medication or ≥ 25% increase in insulin dose for ≥ 3 months. β-cell function was assessed according to fasting homeostatic model 2 assessment of β-cell function (HOMA-2β) values at baseline and at year 2 in patients not treated with insulin. RESULTS Compared with placebo, participants treated with saxagliptin had a reduction in the development of glycaemic instability (hazard ratio 0.71; 95% confidence interval 0.68-0.74; p < 0.0001). In participants treated with saxagliptin compared with placebo, the occurrence of an HbA1c increase of ≥ 0.5% was reduced by 35.2%; initiation of insulin was decreased by 31.7% and the increases in doses of an oral antidiabetic drug or insulin were reduced by 19.5 and 23.5%, respectively (all p < 0.0001). At 2 years, HOMA-2β values decreased by 4.9% in participants treated with placebo, compared with an increase of 1.1% in those treated with saxagliptin (p < 0.0001). CONCLUSIONS Saxagliptin improved glycaemia and prevented the reduction in HOMA-2β values. Saxagliptin may reduce the usual decline in β-cell function in T2D, thereby slowing diabetes progression.
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Affiliation(s)
- G Leibowitz
- The Diabetes Unit, Hadassah University Hospital, Jerusalem, Israel; The Endocrine Service, Hadassah University Hospital, Jerusalem, Israel
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Pfützner A, Hermanns N, Funke K, Forst T, Behnke T, Bitton G, Nagar R, Raz I, Haak T. The Barmer study: impact of standardized warming of the injection site to enhance insulin absorption and reduce prandial insulin requirements and hypoglycemia in obese patients with diabetes mellitus. Curr Med Res Opin 2014; 30:753-60. [PMID: 24392996 DOI: 10.1185/03007995.2014.880049] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND The primary objective of this prospective controlled study was to investigate the impact of standardized injection-site warming on prandial rapid acting insulin dose and glycemic control when studied under real-world conditions. METHODS All 145 participating patients (51 female, 94 male, 13 type 1 and 132 type 2 patients, age: 61.6 ± 8.4 yrs, HbA1c: 7.19 ± 0.50%) were treated with intensive insulin glargine and short-acting insulin analog therapy. After a 4 week treatment optimization run-in period, patients were randomized to continue therapy for three months without (control) or with a local injection-site warming device (InsuPad * ). Observation parameters included HbA1c, insulin dose, frequency of hypoglycemia, body weight and adverse events. RESULTS HbA1c improved in both arms until study end (control group: 6.3 ± 0.5%; injection-site warming device: 6.3 ± 0.5%; both p < 0.001 vs. baseline). To achieve this good control, patients in the control group needed to increase the daily prandial insulin dose by 8.1% (from 66 ± 31 U to 71 ± 38 U, p < 0.05) with stable basal insulin requirements. Patients who used the injection-site warming device required less prandial insulin (70 ± 43 U to 55 ± 34 U; -19%, p < 0.001) and slightly more basal insulin (+3.9%). Total daily insulin dose increased in the control group (+3.7%) and decreased with warming device use (-8.6%, p < 0.001). The number of hypoglycemic events (<63 mg/dL) during the observation period was higher in the control group (6.2 ± 9.9/patient vs. injection-site warming device: 3.3 ± 4.8/patient, p < 0.05). Main study limitations can be seen in the open label design reliability of the collected dose information and the very obese patient cohort. CONCLUSION When treating obese patients to target with insulin therapy, use of an injection-site warming device for 3 months resulted in a lower frequency of hypoglycemic events and a reduction in prandial insulin analog requirements. If these results are confirmed in other patient populations, an injection-site warming device may be useful in achieving treatment targets with a safer and more efficient basal bolus therapy in insulin-treated patients with type 1 and type 2 diabetes.
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Affiliation(s)
- A Pfützner
- IKFE Services - Institute of Clinical Research and Development , Mainz , Germany
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Smink PA, Miao Y, Eijkemans MJC, Bakker SJL, Raz I, Parving HH, Hoekman J, Grobbee DE, de Zeeuw D, Lambers Heerspink HJ. The Importance of Short-Term Off-Target Effects in Estimating the Long-Term Renal and Cardiovascular Protection of Angiotensin Receptor Blockers. Clin Pharmacol Ther 2013; 95:208-15. [DOI: 10.1038/clpt.2013.191] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2013] [Accepted: 09/06/2013] [Indexed: 11/09/2022]
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Mosenzon O, Raz I, Scirica BM, Hirshberg B, Stahre CI, Steg PG, Davidson J, Ohman P, Price DL, Frederich B, Udell JA, Braunwald E, Bhatt DL. Baseline characteristics of the patient population in the Saxagliptin Assessment of Vascular Outcomes Recorded in patients with diabetes mellitus (SAVOR)-TIMI 53 trial. Diabetes Metab Res Rev 2013; 29:417-26. [PMID: 23564755 DOI: 10.1002/dmrr.2413] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2013] [Accepted: 03/18/2013] [Indexed: 01/04/2023]
Abstract
BACKGROUND AND AIMS SAVOR-TIMI 53 was designed to study the effects of the DPP-4 inhibitor saxagliptin on cardiovascular outcomes in high risk type 2 diabetes patients with diverse levels of diabetes control and background anti-diabetic drugs. The goal of this article is to describe the baseline characteristics of this hypothesis driven study. MATERIALS AND METHODS A total of 16 496 diabetic patients from North America (31.9%), Western Europe (26.0%), Eastern Europe (17.3%), Latin America (16.4%) and Asia (8.3%), with either established cardiovascular disease (78.3%) or with ≥two additional cardiovascular risk factors (21.7%) were randomised to saxagliptin or placebo. Biomarkers of inflammation and insulin resistance were taken at baseline and 2 years later in order to correlate saxagliptin effect on cardiovascular outcome to its effect on inflammation and insulin resistance. RESULTS Mean [+/-standard deviation (SD)] age was 65.0 (+/-8.6) years, 66.9% were male, body mass index was 31.2 kg/m² (+/-5.6), mean diabetes duration was 11.9 years (+/-8.9) and the mean HbA1c 8.0% (+/-1.4%). HbA1c < 7% was most prevalent among North Americans (30.8%) and least among Asians (15.1%), whereas HbA1c > 9% was 30.7% in Latin America 27.0% in Asia and 15.1% in North America. Diabetic retinopathy was reported in 12.3% of patients, nephropathy in 17.7% and amputation in 2.5%. Diabetic treatments categories were as follows: no medication (5.4%), 1 oral anti-diabetic drug (OAD) (25.0%), ≥2 OAD (27.7%) and/or insulin (40.9%). The prevalence of micro-albuminuria was twice as high among insulin users compared with users of ≥2 OAD. Baseline statin use (78.3% overall) varied by region. CONCLUSION The SAVOR-TIMI 53 patient population, with differing background diabetes control and anti-diabetic treatment, provides global representation of diabetic patients with established cardiovascular disease or at high risk for cardiovascular disease and is well-positioned to determine the effect of saxagliptin on cardiovascular events.
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Affiliation(s)
- O Mosenzon
- Diabetes Unit, Department of Medicine, Hadassah University Hospital, Jerusalem, Israel
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Pfützner A, Bitton G, Feldman D, Alon T, Nagar R, Raz I. Einfluss des InsuPad Gerätes auf die postprandialen Glukoseexkursionen bei Insulininjektion nach der Mahlzeit. DIABETOL STOFFWECHS 2013. [DOI: 10.1055/s-0033-1341682] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Mosenzon O, Raz I. Potential cardiovascular effects of dipeptidyl peptidase-4 inhibitors in patients with type 2 diabetes: current evidence and ongoing trials. Eur Heart J Suppl 2012. [DOI: 10.1093/eurheartj/sus003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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Dankner R, Chetrit A, Shanik MH, Raz I, Roth J. Basal state hyperinsulinemia in healthy normoglycemic adults heralds dysglycemia after more than two decades of follow up. Diabetes Metab Res Rev 2012; 28:618-24. [PMID: 22865584 DOI: 10.1002/dmrr.2322] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
BACKGROUND In a preliminary report, we found an association between hyperinsulinemia in the basal (fasting) state and the development of diabetes. OBJECTIVES The current analysis further explored the long term link between basal hyperinsulinemia and conversion to dysglycemia. METHODS This is a prospective study with up to 24 years of follow-up of 515 normoglycemic individuals (mean age at follow up = 70.3 ± 7.0; range 58-94) of an Israeli cohort. Fasting glucose and insulin were measured, and dysglycemia was defined as fasting glucose > 100 mg/dL. RESULTS At the end of the follow-up period, almost half had progressed to dysglycemia. Male sex and elevated baseline levels of basal insulin, body mass index, blood glucose and blood pressure each favoured progression to dysglycemia over the subsequent two decades. A multivariate logistic regression model identified basal hyperinsulinemia as the strongest predictor for progression to dysglycemia (odds ratio = 1.79; 95% confidence interval 1.12-2.88), while controlling for ethnicity, blood pressure, fasting glucose, male sex, body mass index and age. CONCLUSIONS Basal hyperinsulinemia in normoglycemic adults constitutes an independent risk factor for metabolic deterioration to dysglycemia over adulthood, and may help to identify apparently healthy subjects at increased risk for diabetes.
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Affiliation(s)
- R Dankner
- Unit for Cardiovascular Epidemiology, The Gertner Institute for Epidemiology and Health Policy Research, Tel-Hashomer, Israel.
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Pfützner A, Bitton G, Raz I, Feldman D, Alon T, Liviatan L, Nagar R. Die Verwendung des InsuPad-Gerätes führt zur Verbesserung der postprandialen Blutzuckerverläufe bei Patienten mit Typ 2-Diabetes. DIABETOL STOFFWECHS 2012. [DOI: 10.1055/s-0032-1314774] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Pfützner A, Feldmann D, Bitton G, Liviatan L, Nagar R, Raz I. Die Anwendung des Insupad-Geräts verbessert das pharmakokinetische Profil von schnellwirksamen Analoginsulinen - Ergebnisse einer Pilotstudie. DIABETOL STOFFWECHS 2012. [DOI: 10.1055/s-0032-1314563] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Schroeder JE, Liebergall M, Raz I, Egleston R, Ben Sussan G, Peyser A, Eldor R. Benefits of a simple glycaemic protocol in an orthopaedic surgery ward: a randomized prospective study. Diabetes Metab Res Rev 2012; 28:71-5. [PMID: 21584922 DOI: 10.1002/dmrr.1217] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND Hyperglycaemia and diabetes mellitus are common in patients hospitalized in the orthopaedic surgery ward. However, glycaemic control obtained during hospitalization is often suboptimal. No method for achieving adequate glycaemic control in this population has been validated in an in-hospital setting. INTERVENTION An intervention including an intensive subcutaneous insulin protocol in the orthopaedic department. METHODS All diabetic patients admitted to the Department of Orthopaedic Surgery were prospectively randomized during a 6-month period. One group (n = 30) received standard care with sliding scale insulin and the other group (n = 35) received the intervention protocol. During the intervention period, the staff was briefed on the importance of glucose monitoring and control. An intensive multiple-injection protocol consisting of four daily regular/neutral protamine hagedorn (NPH) insulin injections was initiated in diabetic patients. The programme was followed up by a consulting diabetologist. RESULTS Mean blood glucose levels throughout the hospitalization were 161.48 ± 3.8 mg/dL in the intervention group versus 175.29 ± 2.3 mg/dL in the control group (p < 0.0005). Hospitalization was shorter by 2 days in the intervention group (p < 0.05). The number of severe hyperglycaemic events (blood glucose level above 400 mg%) was significantly lower (p < 0.05) in the intervention group. There was no significant difference in the number of hypoglycaemic events. CONCLUSIONS The suggested four-step intervention regimen improved glycaemic control of hospitalized patients in the orthopaedic department and simplified the 'in-house' treatment of the diabetic patient. Hospital stays were reduced on average by two days (p < 0.05).
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Affiliation(s)
- Josh E Schroeder
- The Orthopedic Surgery Department, Hadassah Hebrew University Medical Center, Jerusalem, Israel.
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Halperin O, Goldblatt H, Noble A, Raz I, Zvulunov I, Liebergall Wischnitzer M. Stressful Childbirth Situations: A Qualitative Study of Midwives. J Midwifery Womens Health 2011; 56:388-394. [DOI: 10.1111/j.1542-2011.2011.00030.x] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Halperin O, Raz I, Ben-Gal L, Or-Chen K, Granot M. Prediction of Perineal Trauma During Childbirth by Assessment of Striae Gravidarum Score. J Obstet Gynecol Neonatal Nurs 2010; 39:292-7. [DOI: 10.1111/j.1552-6909.2010.01137.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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Unnikrishnan AG, Tibaldi J, Hadley-Brown M, Krentz AJ, Ligthelm R, Damci T, Gumprecht J, Gero L, Mu Y, Raz I. Practical guidance on intensification of insulin therapy with BIAsp 30: a consensus statement. Int J Clin Pract 2009; 63:1571-7. [PMID: 19780866 PMCID: PMC2780562 DOI: 10.1111/j.1742-1241.2009.02192.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Basal insulin and premix insulin are commonly prescribed first-line insulin therapies for patients failing to maintain glycaemic control on oral therapy. When control on these insulins starts to drift, premix analogues, such as biphasic insulin aspart 30/70 (BIAsp 30), are a simple and effective tool for intensification as they can be injected up to three-times daily (TID). However, at present, international recommendations for intensification of insulin therapy using premix analogues are limited and specific guidance on dosing is not available for many scenarios. METHODS In October 2008, an international expert panel met to review the current guidelines for insulin intensification with BIAsp 30 in patients with type 2 diabetes, with the aim of developing practical guidance for general and specialist practitioners. RESULTS Simple treatment algorithms have been developed for (i) patients on basal insulin (human or analogue) once daily or twice daily (BID) who need intensification to BIAsp 30 BID, and (ii) patients on BIAsp 30 once daily or BID who can be intensified to BIAsp 30 BID or TID. As well as these algorithms, specific guidance has been provided on dose transfer (from basal insulin to BIAsp 30), dose split (when intensifying from once daily to BID), and combination oral therapies. In addition, a guide to dose titration is included. CONCLUSIONS The guidelines presented here should enable general or specialist practitioners to use BIAsp 30 to intensify the insulin therapy of patients failing on basal insulin or BIAsp 30 once or twice daily.
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Affiliation(s)
- A G Unnikrishnan
- Department of Endocrinology and Diabetes, Amrita Institute of Medical Sciences, Kochi, Kerala 682 026, India.
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Chertok IRA, Raz I, Shoham I, Haddad H, Wiznitzer A. Effects of early breastfeeding on neonatal glucose levels of term infants born to women with gestational diabetes. J Hum Nutr Diet 2009; 22:166-9. [PMID: 19226355 DOI: 10.1111/j.1365-277x.2008.00921.x] [Citation(s) in RCA: 69] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Infants born to diabetic women are at higher risk for hypoglycaemia related to hyperinsulinism in response to maternal hyperglycaemia during pregnancy. As such, recommendations to prevent neonatal hypoglycaemia include infant feeding in the early postpartum period. The present study aimed to examine the effect of early breastfeeding and type of nutrition used for the first feed (human milk or formula) on glucose levels in infants born to women with gestational diabetes. METHODS The prospective pilot study of 84 infants born to gestational diabetic women examined the glycaemic levels of infants who were breastfed in the delivery room compared to glycaemic levels of those who were not. The study also compared the glycaemic levels of infants who breastfed with those who received formula for their first feed. RESULTS Infants who were breastfed in the delivery room had a significantly lower rate of borderline hypoglycaemia than those who were not breastfed in the early postpartum period (10% versus 28%; Fisher's exact test., P = 0.05,). Likewise, infants breastfed in the delivery room had significantly higher mean blood glucose level compared to infants who were not breastfed in the delivery room (3.17 versus 2.86 mmol L(-1), P = 0.03). Additionally, breastfed infants had a significantly higher mean blood glucose level compared to those who were formula fed for their first feed (3.20 versus 2.68 mmol L(-1), P = 0.002). CONCLUSIONS Early breastfeeding may facilitate glycaemic stability in infants born to women with gestational diabetes.
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Affiliation(s)
- I R A Chertok
- Department of Health Promotion, West Virginia University, School of Nursing, Morgantown, WV 26506, USA.
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Khamaisi M, Raz I, Shilo V, Shina A, Rosenberger C, Dahan R, Abassi Z, Meidan R, Lecht S, Heyman S. Diabetes and radiocontrast media increase endothelin converting enzyme-1 in the kidney. Kidney Int 2008; 74:91-100. [DOI: 10.1038/ki.2008.112] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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Mei-dan E, Walfisch A, Raz I, Levy A, Hallak M. Perineal massage during pregnancy: a prospective controlled trial. Isr Med Assoc J 2008; 10:499-502. [PMID: 18751626] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
BACKGROUND Women frequently suffer perineal trauma while giving birth. Interventions to increase the possibility for an intact perineum are needed. OBJECTIVES To evaluate the effectiveness of antenatal perineal massage in increasing the likelihood of delivering with an intact perineum. METHODS This single blinded prospective controlled trial included 234 nulliparous women with a singleton fetus. Women allocated to the study group were instructed to practice a 10 minute perineal massage daily from the 34th week of gestation until delivery. Primary outcome measures included the episiotomy rate; first, second, third and fourth-degree perineal tear rates; and intact perineum. Secondary outcomes were related to specific tear locations and the amount of suture material required for repair. RESULTS Episiotomy rates, overall spontaneous tears and intact perineum rates were similar in the study and control groups. Women in the massage group had slightly lower rates of first-degree tears (73.3% vs. 78.9%, P = 0.39) and slightly higher rates of second-degree tears (26.7% vs. 19.3%, P= 0.39), although both of these outcomes did not reach statistical significance. The rates of anterior perineal tears were significantly higher in the massage group (9.5% vs. 3%, P = 0.05), whereas internal lateral tears rates were slightly lower but without statistical significance (11.5% vs.13.1%, P=0.44). CONCLUSIONS The practice of antenatal perineal massage showed neither a protective nor a detrimental significant effect on the occurrence of perineal trauma.
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Affiliation(s)
- Elad Mei-dan
- Department of Obstetrics and Gynecology, Hillel Yaffe Medical Center, Hadera, Israel.
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Heerspink HL, Greene T, Lewis JB, Raz I, Rohde RD, Hunsicker LG, Schwartz SL, Aronoff S, Katz MA, Eisner GM, Mersey JH, Wiegmann TB. Effects of sulodexide in patients with type 2 diabetes and persistent albuminuria. Nephrol Dial Transplant 2008; 23:1946-54. [DOI: 10.1093/ndt/gfm893] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Bachrach G, Muster Z, Raz I, Chaushu G, Stabholz A, Nussbaum G, Gutner M, Chaushu S. Assessing the levels of immunoglobulins in the saliva of diabetic individuals with periodontitis using checkerboard immunodetection. Oral Dis 2007; 14:51-9. [DOI: 10.1111/j.1601-0825.2006.01345.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Bakris GL, Ruilope L, Locatelli F, Ptaszynska A, Pieske B, de Champlain J, Weber MA, Raz I. Treatment of microalbuminuria in hypertensive subjects with elevated cardiovascular risk: Results of the IMPROVE trial. Kidney Int 2007; 72:879-85. [PMID: 17667984 DOI: 10.1038/sj.ki.5002455] [Citation(s) in RCA: 81] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Microalbuminuria independently predicts increased cardiovascular risk in hypertensive patients, especially in those with concomitant diabetes or established cardiovascular disease. Drugs that target the renin-angiotensin-aldosterone system reduce microalbuminuria regardless of diabetic status. The Irbesartan in the Management of PROteinuric patients at high risk for Vascular Events was a multicenter, randomized, double-blind, placebo-controlled paralleled group study in which hypertensive patients with microalbuminuria and increased cardiovascular risk were randomized to 20 weeks treatment with ramipril plus irbesartan or to ramipril plus placebo. Patients discontinued or tapered previous antihypertensive therapy during a 14-day placebo lead-in period. Change in albumin excretion rate from baseline to week 20 was the primary end point. Adjusted week 20 baseline geometric ratios for ramipril plus irbesartan and ramipril plus placebo were not significantly different. Although differences in blood pressure reductions were observed between the two treatments, these changes did not affect microalbuminuria. More patients on dual therapy achieved target blood pressure goals at week 20 than with monotherapy. The incidence of adverse effects and treatment-related adverse effects was similar in both groups. Our results suggest that patients with cardiovascular risk and relatively low albumin excretion rates in early-stage disease may only require monotherapy with renin-angiotensin-aldosterone blocking agents.
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Affiliation(s)
- G L Bakris
- Department of Medicine, Hypertension Center, University of Chicago-Pritzker School of Medicine, Chicago, Illinois 60637, USA.
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Bachrach G, Muster Z, Raz I, Chaushu G, Stabholz A, Nussbaum G, Gutner M, Chaushu S. Assessing the levels of immunoglobulins in the saliva of diabetic individuals with periodontitis using checkerboard immunodetection. Oral Dis 2007. [DOI: 10.1111/j.1601-0825.2007.01345.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Ryden L, Standl E, Bartnik M, Berghe GVD, Betteridge J, de Boer MJ, Cosentino F, Jonsson B, Laakso M, Malmberg K, Priori S, Ostergren J, Tuomilehto J, Thrainsdottir I, Vanhorebeek I, Stramba-Badiale M, Lindgren P, Qiao Q, Priori SG, Blanc JJ, Budaj A, Camm J, Dean V, Deckers J, Dickstein K, Lekakis J, McGregor K, Metra M, Morais J, Osterspey A, Tamargo J, Zamorano JL, Deckers JW, Bertrand M, Charbonnel B, Erdmann E, Ferrannini E, Flyvbjerg A, Gohlke H, Juanatey JRG, Graham I, Monteiro PF, Parhofer K, Pyorala K, Raz I, Schernthaner G, Volpe M, Wood D. Guidelines on diabetes, pre-diabetes, and cardiovascular diseases: full text: The Task Force on Diabetes and Cardiovascular Diseases of the European Society of Cardiology (ESC) and of the European Association for the Study of Diabetes (EASD). Eur Heart J Suppl 2007. [DOI: 10.1093/eurheartj/ehl261] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Raz I, Avron A, Tamir M, Metzger M, Symer L, Eldor R, Cohen IR, Elias D. Treatment of new-onset type 1 diabetes with peptide DiaPep277 is safe and associated with preserved beta-cell function: extension of a randomized, double-blind, phase II trial. Diabetes Metab Res Rev 2007; 23:292-8. [PMID: 17124720 DOI: 10.1002/dmrr.712] [Citation(s) in RCA: 81] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
BACKGROUND Treatment with DiaPep277, a peptide derived from HSP60, has been shown to preserve beta-cell function in non-obese diabetic mouse (NOD) mice and in a trial with newly diagnosed human patients with type 1 diabetes treated over a 10-month period. This article extends the clinical trial observations to a total of 20 months of treatment to determine the safety and the effects of repeated doses of DiaPep277 on endogenous insulin secretion, metabolic control, and exogenous insulin requirements. METHODS Thirty-five male patients (aged 16-58) with a basal C-peptide greater than 0.1 nmol/L were assigned to periodic treatment with DiaPep277 (1 mg) or placebo for a 12-month treatment and 18-month observation protocol, later extended to an additional year of treatment. Stimulated C-peptide, HbA1c, and an exogenous insulin dose were the clinical endpoints. RESULTS At 18 months, stimulated C-peptide concentrations had fallen in the placebo group (p = 0.0005) but were maintained in the DiaPep277 group. The need for exogenous insulin was higher in the placebo group than in the DiaPep277 group. Mean HbA1c concentrations were similar in both groups. After extension of the study, patients continuing treatment with DiaPep277 and those switched from placebo to DiaPep277 manifested a trend towards a greater preservation of beta-cell function compared to patients maintained on or switched to placebo. The safety profile of DiaPep277 was similar between the treatment and placebo groups, and no drug-related adverse events occurred. CONCLUSIONS Periodic treatment of subjects with DiaPep277 over 2 years was safe and associated preservation of endogenous insulin secretion up to 18 months was observed.
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Affiliation(s)
- I Raz
- Department of Internal Medicine, Hadassah-Hebrew University Medical School, Jerusalem, Israel
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Paamoni-Keren O, Silberstein T, Burg A, Raz I, Mazor M, Saphier O, Weintraub AY. Oxidative stress as determined by glutathione (GSH) concentrations in venous cord blood in elective cesarean delivery versus uncomplicated vaginal delivery. Arch Gynecol Obstet 2007; 276:43-6. [PMID: 17333227 DOI: 10.1007/s00404-006-0304-2] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2006] [Accepted: 12/05/2006] [Indexed: 10/23/2022]
Abstract
OBJECTIVE To determine whether neonates are subject to oxidative stress by the labor process and the mode of delivery by measuring glutathione (GSH) concentrations in umbilical cord venous blood. STUDY DESIGN Forty-eight women with singleton term pregnancies were prospectively recruited and classified as follows: 26 women had a spontaneous uncomplicated vaginal delivery (VD), and 22 women had an elective cesarean delivery (CD). GSH concentration in umbilical venous blood samples was determined by a spectroscopic method. RESULTS Umbilical cord venous blood GSH levels were significantly lower in the elective CD group than in the VD group (2.2 and 2.7 mM, respectively, P = 0.0003). There was a significantly negative correlation between cord blood pO(2) and GSH levels; however, the negative correlation was significantly higher in the elective CD group (P < 0.05). CONCLUSION Neonates delivered by CD were exposed to a higher oxidative stress as determined by GSH levels compared to those who had an uncomplicated VD.
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Affiliation(s)
- Orit Paamoni-Keren
- Department of Obstetrics and Gynecology, Soroka University Medical center, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
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Paamoni-Keren O, Silberstein T, Burg A, Raz I, Mazor M, Saphier O. Oxidative stress as indicated by gluthatione (GSH) levels is higher in elective cesarean delivery than in uncomplicated vaginal delivery. Am J Obstet Gynecol 2006. [DOI: 10.1016/j.ajog.2006.10.376] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Raz I, Hanefeld M, Xu L, Caria C, Williams-Herman D, Khatami H. Efficacy and safety of the dipeptidyl peptidase-4 inhibitor sitagliptin as monotherapy in patients with type 2 diabetes mellitus. Diabetologia 2006; 49:2564-71. [PMID: 17001471 DOI: 10.1007/s00125-006-0416-z] [Citation(s) in RCA: 419] [Impact Index Per Article: 23.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2006] [Accepted: 07/11/2006] [Indexed: 12/13/2022]
Abstract
AIMS/HYPOTHESIS The aim of this study was to assess the efficacy and safety of sitagliptin (MK-0431) as monotherapy in patients with type 2 diabetes mellitus and inadequate glycaemic control (HbA(1c) > or =7% and < or =10%) on exercise and diet. METHODS A total of 521 patients aged 27-76 years with a mean baseline HbA(1c) of 8.1% were randomised in a 1:2:2 ratio to treatment with placebo, sitagliptin 100 mg once daily, or sitagliptin 200 mg once daily, for 18 weeks. The efficacy analysis was based on an all-patients-treated population using an analysis of covariance, excluding data obtained after glycaemic rescue. RESULTS After 18 weeks, HbA(1c) was significantly reduced with sitagliptin 100 mg and 200 mg compared with placebo (placebo-subtracted HbA(1c) reduction: -0.60% and -0.48%, respectively). Sitagliptin also significantly decreased fasting plasma glucose relative to placebo. Patients with higher baseline HbA(1c) (> or =9%) experienced greater placebo-subtracted HbA(1c) reductions with sitagliptin (-1.20% for 100 mg and -1.04% for 200 mg) than those with HbA(1c) <8% (-0.44% and -0.33%, respectively) or > or =8% to 8.9% (-0.61% and -0.39%, respectively). Homeostasis model assessment beta cell function index and fasting proinsulin:insulin ratio, markers of insulin secretion and beta cell function, were significantly improved with sitagliptin. The incidence of hypoglycaemia and gastrointestinal adverse experiences was not significantly different between sitagliptin and placebo. Sitagliptin had a neutral effect on body weight. CONCLUSIONS/INTERPRETATION Sitagliptin significantly improved glycaemic control and was well tolerated in patients with type 2 diabetes mellitus who had inadequate glycaemic control on exercise and diet.
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Affiliation(s)
- I Raz
- Diabetes Research Center, Hadassah University Hospital, Jerusalem, Israel
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Bakris GL, Ruilope L, Locatelli F, Ptaszynska A, Pieske B, Raz I, Voors AA, Dechamplain J, Weber MA. Rationale and design of a study to evaluate management of proteinuria in patients at high risk for vascular events: the IMPROVE trial. J Hum Hypertens 2006; 20:693-700. [PMID: 16710287 DOI: 10.1038/sj.jhh.1002050] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Declining kidney function predicts increasing cardiovascular risk in people with hypertension. Microalbuminuria is a marker for cardiovascular risk and declining kidney function. Agents that block the renin-angiotensin-aldosterone system (RAAS), notably angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs), reduce proteinuria and microalbuminuria, lower blood pressure and slow the progression of proteinuric kidney disease. Evidence is accumulating that the combination of an ACE inhibitor and an ARB is the optimal means of RAAS blockade in this setting, slowing the progression of nephropathy independently of blood pressure lowering to a greater degree than can be achieved using maximum approved doses of either agent alone. However, the emerging therapeutic potential of ACE inhibitor/ARB combination therapy in hypertensive kidney disease requires further characterization. The Irbesartan in the Management of PROteinuric patients at high risk for Vascular Events trial aims to determine definitively whether the combination therapy of an ARB, irbesartan and an ACE inhibitor, ramipril, is more effective than ramipril alone in reducing the urinary albumin excretion rate in patients at high cardiovascular risk with hypertension and proteinuria or microalbuminuria.
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Affiliation(s)
- G L Bakris
- Department of Preventive Medicine, Rush University Medical Center, Chicago, IL 60612, USA.
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Hillel J, Gefel D, Kalman R, Ben-Ari G, David L, Orion O, Feldman MW, Bar-On H, Blum S, Raz I, Schaap T, Shpirer I, Lavi U, Shafrir E, Ziv E. Evidence for a major gene affecting the transition from normoglycaemia to hyperglycaemia in Psammomys obesus. Heredity (Edinb) 2005; 95:158-65. [PMID: 15931239 DOI: 10.1038/sj.hdy.6800701] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
We investigated the mode of inheritance of nutritionally induced diabetes in the desert gerbil Psammomys obesus (sand rat), following transfer from low-energy (LE) to high-energy (HE) diet which induces hyperglycaemia. Psammomys selected for high or low blood glucose level were used as two parental lines. A first backcross generation (BC(1)) was formed by crossing F(1) males with females of the diabetes-prone line. The resulting 232 BC(1) progeny were assessed for blood glucose. All progeny were weaned at 3 weeks of age (week 0), and their weekly assessment of blood glucose levels proceeded until week 9 after weaning, with all progeny maintained on HE diet. At weeks 1 to 9 post weaning, a clear bimodal distribution statistically different from unimodal distribution of blood glucose was observed, normoglycaemic and hyperglycaemic at a 1:1 ratio. This ratio is expected at the first backcross generation for traits controlled by a single dominant gene. From week 0 (prior to the transfer to HE diet) till week 8, the hyperglycaemic individuals were significantly heavier (4--17%) than the normoglycaemic ones. The bimodal blood glucose distribution in BC(1) generation, with about equal frequencies in each mode, strongly suggests that a single major gene affects the transition from normo- to hyperglycaemia. The wide range of blood glucose values among the hyperglycaemic individuals (180 to 500 mg/dl) indicates that several genes and environmental factors influence the extent of hyperglycaemia. The diabetes-resistant allele appears to be dominant; the estimate for dominance ratio is 0.97.
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Affiliation(s)
- J Hillel
- The Robert H Smith Institute of Plant Sciences & Genetics, The Hebrew University of Jerusalem, Rehovot 76100, Israel.
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Wainstein J, Metzger M, Boaz M, Minuchin O, Cohen Y, Yaffe A, Yerushalmy Y, Raz I, Harman-Boehm I. Insulin pump therapy vs. multiple daily injections in obese Type 2 diabetic patients. Diabet Med 2005; 22:1037-46. [PMID: 16026370 DOI: 10.1111/j.1464-5491.2005.01597.x] [Citation(s) in RCA: 103] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
AIMS To compare the efficacy of insulin pump treatment with multiple daily injections in the treatment of poorly controlled obese Type 2 diabetic patients already receiving two or more daily injections of insulin plus metformin. METHODS Forty obese Type 2 diabetic subjects (using insulin) were randomized to treatment with continuous subcutaneous infusion pump (CSII) (Minimed) or multiple daily insulin injections (MDI). At the end of the first 18-week treatment period, patients underwent a 12-week washout period during which they were treated with MDI plus metformin. They were then crossed-over to the other treatment for an 18-week follow-up period. Patients performed 4-point daily self blood-glucose monitoring (SBGM) on a regular basis and 7-point monitoring prior to visits 2, 8, 10 and 16. A subset of patients underwent continuous glucose monitoring using the Minimed(R) continuous glucose monitoring system (CGMS) at visits 2, 8, 10 and 16. A standard meal test was performed in which serum glucose was tested at fasting and once each hour for 6 h following a test meal. Glucose levels were plotted against time and the area under the curve (AUC) was calculated. HbA(1c), weight, daily insulin dose and hypoglycaemic episodes were recorded. RESULTS In obese Type 2 diabetic patients already treated with insulin, treatment with CSII significantly reduced HbA(1c) levels compared with treatment with MDI. An additional CSII treatment benefit was demonstrated by reduced meal-test glucose AUC. Initial reduction of daily insulin requirement observed in CSII-treated subjects during the first treatment period was attributable to a period effect and did not persist over time. CONCLUSIONS In the intent-to-treat analysis, CSII appeared to be superior to MDI in reducing HbA(1c) and glucose AUC values without significant change in weight or insulin dose in obese, uncontrolled, insulin-treated Type 2 diabetic subjects.
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Affiliation(s)
- J Wainstein
- Diabetes Unit, Wolfson Medical Center, Holon, Israel
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Fujioka K, Brazg RL, Raz I, Bruce S, Joyal S, Swanink R, Pans M. Efficacy, dose-response relationship and safety of once-daily extended-release metformin (Glucophage XR) in type 2 diabetic patients with inadequate glycaemic control despite prior treatment with diet and exercise: results from two double-blind, placebo-controlled studies. Diabetes Obes Metab 2005; 7:28-39. [PMID: 15642073 DOI: 10.1111/j.1463-1326.2004.00369.x] [Citation(s) in RCA: 54] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
AIM The efficacy, dose-response relationships and safety of an extended-release formulation of metformin (Glucophage) XR) were evaluated in two double-blind, randomized, placebo-controlled studies of 24 and 16 weeks' duration, in patients with inadequate glycaemic control despite diet and exercise. Protocol 1 provided an evaluation of metformin XR at a commonly used dosage. Protocol 2 evaluated different dosages of metformin XR. METHODS In Protocol 1, 240 patients were randomized to receive metformin XR 1000 mg once daily. or placebo in a 2:1 ratio for 12 weeks (patients could receive metformin XR 1500 mg during weeks 12-24 if required). In Protocol 2, 742 patients were randomized to receive metformin XR 500 mg once daily, 1000 mg once daily, 1500 mg once daily, 2000 mg once daily, 1000 mg twice daily or placebo for 16 weeks. The primary endpoint in each study was the change from baseline in HbA(1C) at 12 weeks (Protocol 1) or 16 weeks (Protocol 2). RESULTS Metformin XR reduced HbA(1C) in Protocol 1, with mean treatment differences for 1000 mg once daily vs. placebo of -0.7% at 12 weeks and -0.8% at 24 weeks (p < 0.001 for each). In Protocol 2, a clear dose-response relationship was evident at doses up to 1500 mg, with treatment differences vs. placebo of -0.6% (500 mg once daily), -0.7% (1000 mg once daily), -1.0% (1500 mg once daily) and -1.0% (2000 mg once daily). The efficacy of metformin XR 2000 mg once daily and 1000 mg twice daily were similar (mean treatment differences vs. placebo in HbA(1C) were -1.0% and -1.2%, respectively). More patients achieved HbA(1C) < 7.0% with metformin XR vs. placebo in Protocol 1 (29% vs. 14% at 12 weeks) and with once-daily metformin XR in Protocol 2 (up to 36% vs. 10% at 16 weeks). No significant changes in fasting insulin or body weight occurred. Total and low-density lipoprotein (LDL)-cholesterol improved (p < 0.05-p < 0.001) in metformin XR groups in Protocol 2. Metformin XR was well tolerated; gastrointestinal side effects were more common with metformin XR vs. placebo, but few patients withdrew for this reason (1.3% vs. 1.3% in Protocol 1 and 1.6% vs. 0.9% in Protocol 2). CONCLUSIONS Once-daily metformin XR presents an effective and well-tolerated therapeutic option for delivering metformin in a convenient manner, which supports good compliance with therapy.
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Affiliation(s)
- K Fujioka
- Department of Endocrinology, Scripps Clinic, La Jolla, San Diego, CA 92130, USA.
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Mei-Dan E, Walfisch A, Raz I, Harlev S, Levi A, Hallak M. Effect of perineal massage during pregnancy on perineal trauma: A prospective controlled trial. Am J Obstet Gynecol 2004. [DOI: 10.1016/j.ajog.2004.10.582] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Abstract
Diabetic foot ulcers occur in up to 15% of all diabetic patients and are a leading cause of nontraumatic amputation worldwide. Neuropathy, abnormal foot biomechanics, peripheral vascular disease and external trauma are the major contributors to the development of a foot ulcer in the diabetic patient. Therapy today includes repeated debridement, offloading, and dressings, for lower grade ulcers, and broad spectrum antibiotics and occasionally limited or complete amputation for higher grades, requiring a team effort of health care workers from various specialties. The large population affected by diabetic foot ulcers and the high rates of failure ending with amputation even with the best therapeutic regimens, have resulted in the development of new therapies and are the focus of this review. These include new off loading techniques, dressings from various materials, methods to promote wound closure using artificial skin grafts, different growth factors or wound bed modulators and methods of debridement. These new techniques are promising but still mostly unproven and traditional approaches cannot be replaced. New and generally more expensive therapies should be seen as adding to traditional approaches.
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Affiliation(s)
- R Eldor
- Diabetes Research Centre, Hadassah University Hospital, Ein Kerem, Jerusalem 91120, Israel.
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Raslová K, Bogoev M, Raz I, Leth G, Gall MA, Hâncu N. Insulin detemir and insulin aspart: a promising basal-bolus regimen for type 2 diabetes. Diabetes Res Clin Pract 2004; 66:193-201. [PMID: 15533587 DOI: 10.1016/j.diabres.2004.03.003] [Citation(s) in RCA: 152] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2003] [Revised: 03/02/2004] [Accepted: 03/09/2004] [Indexed: 11/24/2022]
Abstract
This trial compared the efficacy and safety of basal-bolus therapy using either the soluble basal insulin analogue insulin detemir (IDet) in combination with meal-time rapid-acting analogue insulin aspart (IAsp), or NPH insulin (NPH) in combination with meal-time regular human insulin (HSI). This was a 22-week, multinational, open-labelled, symmetrically randomised, parallel group trial including 395 people with type 2 diabetes (IDet + IAsp: 195, NPH + HSI: 200). At 22 weeks, HbA1c was comparable between treatments (IDet + IAsp: 7.46%, NPH + HSI: 7.52%, P = 0.515) with decreases from baseline of 0.65% and 0.58%, respectively. Treatment with IDet + IAsp was associated with a significantly lower within-person variation in self-measured fasting plasma glucose (FPG) (SD:1.20 versus 1.54 mmol/L, p < 0.001), as well as a lower body weight gain (0.51 versus 1.13 kg, p = 0.038) than with NPH + HSI. The risk of nocturnal hypoglycaemia was 38% lower with IDet + IAsp than with NPH + HSI, but statistical significance was not attained (P = 0.14). The overall safety profile was similar between the two treatments. Basal-bolus treatment with IDet + IAsp is an effective and well tolerated insulin regimen in people with type 2 diabetes, resulting in glycaemic control comparable to that of NPH + HSI, but with the advantages of less weight gain and a lower day-to-day within-person variation in FPG.
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Affiliation(s)
- K Raslová
- Metabolic Center, Institute of Preventive and Clinical Medicine, Limbova 14, 833 01 Bratislava, Slovak Republic.
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