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Bongaerts B, Kuss O, Bonnet F, Chen H, Cooper A, Fenici P, Gomes MB, Hammar N, Ji L, Khunti K, Medina J, Nicolucci A, Shestakova MV, Watada H, Rathmann W. HbA 1c trajectories over 3 years in people with type 2 diabetes starting second-line glucose-lowering therapy: The prospective global DISCOVER study. Diabetes Obes Metab 2023. [PMID: 36906837 DOI: 10.1111/dom.15050] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Revised: 02/28/2023] [Accepted: 03/08/2023] [Indexed: 03/13/2023]
Abstract
AIM To identify distinct glycated haemoglobin (HbA1c ) trajectories in people with type 2 diabetes (T2D) starting second-line glucose-lowering therapy. MATERIALS AND METHODS DISCOVER was a 3-year observational study of individuals with T2D beginning second-line glucose-lowering therapy. Data were collected at initiation of second-line treatment (baseline) and at 6, 12, 24 and 36 months. Latent class growth modelling was used to identify groups with distinct HbA1c trajectories. RESULTS After exclusions, 9295 participants were assessed. Four distinct HbA1c trajectories were identified. Mean HbA1c levels decreased between baseline and 6 months in all groups; 72.4% of participants showed stable good levels of glycaemic control over the remainder of follow-up, 18.0% showed stable moderate levels of glycaemic control and 2.9% showed stable poor levels of glycaemic control. Only 6.7% of participants showed highly improved glycaemic control at month 6 and stable control over the rest of follow-up. For all groups, dual oral therapy use decreased over time, compensated for by the increasing use of other treatment regimens. Use of injectable agents increased over time in groups with moderate and poor glycaemic control. Logistic regression models suggested that participants from high-income countries were more likely to be in the stable good trajectory group. CONCLUSIONS Most people receiving second-line glucose-lowering treatment in this global cohort achieved stable good or highly improved long-term glycaemic control. One-fifth of participants showed moderate or poor glycaemic control during follow-up. Further large-scale studies are required to characterize possible factors associated with patterns of glycaemic control to inform personalized diabetes treatment. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Brenda Bongaerts
- Institute of General Practice, Medical Faculty of the Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Oliver Kuss
- Institute for Biometrics and Epidemiology, German Diabetes Center, Leibniz Institute for Diabetes Research at Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | | | | | | | - Peter Fenici
- Catholic University of the Sacred Heart, School of Medicine and Surgery, and Biomagnetism and Clinical Physiology International Center (BACPIC), Rome, and Medical Affairs, AstraZeneca S.p.A., Milan, Italy
| | | | - Niklas Hammar
- Institute of Environmental Medicine, Karolinska Institute, Stockholm, Sweden
- AstraZeneca, Gothenburg, Mölndal, Sweden
| | - Linong Ji
- Peking University People's Hospital, Beijing, China
| | | | | | - Antonio Nicolucci
- Center for Outcomes Research and Clinical Epidemiology, Pescara, Italy
| | | | | | - Wolfgang Rathmann
- Institute for Biometrics and Epidemiology, German Diabetes Center, Leibniz Institute for Diabetes Research at Heinrich Heine University Düsseldorf, Düsseldorf, Germany
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Charbonnel BH, Chen H, Cid-Ruzafa J, Cooper A, Fenici P, Gomes MB, Saraiva GL, Medina J, Nicolucci A, Shestakova MV, Shimomura I, Surmont F, Tang F, Vora J, Watada H, Khunti K. Treatment patterns and glycated haemoglobin levels over 36 months in individuals with type 2 diabetes initiating second-line glucose-lowering therapy: The global DISCOVER study. Diabetes Obes Metab 2023; 25:46-55. [PMID: 36111434 PMCID: PMC10087302 DOI: 10.1111/dom.14842] [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] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Revised: 08/08/2022] [Accepted: 08/16/2022] [Indexed: 12/14/2022]
Abstract
AIMS To describe glucose-lowering treatment regimens and glycated haemoglobin (HbA1c) trajectories in individuals with type 2 diabetes (T2D) over 36 months of follow-up from the start of second-line therapy. MATERIALS AND METHODS This data analysis from the 3-year, observational DISCOVER study programme included 14 687 participants from 37 countries with T2D initiating second-line glucose-lowering therapy. Treatment and HbA1c data were collected at baseline (start of second-line therapy) and at 6, 12, 24 and 36 months. Treatment regimen changes over follow-up were analysed using the McNemar test, with carry-forward imputation for intermediate missing values. RESULTS A total of 11 592 participants had treatment data at baseline and 36 months, and 11 882 had HbA1c data at baseline. At baseline and 36 months, respectively, rates of oral monotherapy use were 12.1% and 12.4% (P = 0.22), rates of dual oral therapy use were 63.4% and 47.6% (P < 0.0001), rates of ≥ triple oral therapy use were 17.5% and 25.4% (P < 0.0001), and rates of injectable treatment use were 7.0% and 13.7% (P < 0.0001). Use of injectable drugs was most common among participants with an HbA1c level ≥64 mmol/mol (≥8.0%). Overall, 42.9% of participants changed treatment during follow-up. Mean HbA1c levels at baseline and 6 months were 67 mmol/mol (8.3%) and 55 mmol/mol (7.2%), respectively, remaining stable thereafter. CONCLUSIONS Dual oral therapy was the most common treatment regimen at the start of second-line treatment, and over half of the participants remained on the same treatment during follow-up.
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Affiliation(s)
| | - Hungta Chen
- BioPharmaceuticals Medical, AstraZeneca, Gaithersburg, Maryland, USA
| | | | - Andrew Cooper
- BioPharmaceuticals Medical, AstraZeneca, Cambridge, UK
| | - Peter Fenici
- BioPharmaceuticals Medical, AstraZeneca, Milan, Italy
| | - Marilia B Gomes
- Department of Internal Medicine, Rio de Janeiro State University, Rio de Janeiro, Brazil
| | | | - Jesús Medina
- BioPharmaceuticals Medical, AstraZeneca, Madrid, Spain
| | - Antonio Nicolucci
- Center for Outcomes Research and Clinical Epidemiology, Pescara, Italy
| | - Marina V Shestakova
- Endocrinology Research Centre, Diabetes Institute, Moscow, Russian Federation
| | | | | | - Fengming Tang
- Saint Luke's Mid America Heart Institute, Kansas City, Missouri, USA
| | - Jiten Vora
- Royal Liverpool University Hospital, Liverpool, UK
| | - Hirotaka Watada
- Graduate School of Medicine, Juntendo University, Tokyo, Japan
| | - Kamlesh Khunti
- Diabetes Research Centre, University of Leicester, Leicester, UK
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Hejjaji V, Gorgojo-Martinez JJ, Tang F, Garnelo JB, Cooper A, Medina J, Mutiozabal MS, Khunti K, Nicolucci A, Shestakova MV, Ji L, Gomes MB, Watada H, Vora J, Malik AO, Kosiborod M, Arnold SV. Factors associated with weight loss in people with overweight or obesity living with type 2 diabetes mellitus: Insights from the global DISCOVER study. Diabetes Obes Metab 2022; 24:1734-1740. [PMID: 35546275 DOI: 10.1111/dom.14745] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Revised: 04/12/2022] [Accepted: 04/26/2022] [Indexed: 11/27/2022]
Abstract
AIMS To estimate real-world change in weight over 3 years and the factors influencing it in participants who are overweight and live with type 2 diabetes. MATERIALS AND METHODS DISCOVER is a multinational prospective observational study that enrolled participants with type 2 diabetes between December 2014 and June 2016 at the time of initiation of a second-line glucose-lowering medication (GLM). Demographic, anthropometric, and quality-of-life data were collected at baseline, and after 6, 12, 24 and 36 months of follow-up. Using a hierarchical, repeated-measures linear regression model, we examined factors associated with weight change over time. RESULTS Of 10 675 participants with type 2 diabetes who were overweight/obese (mean age 57.1 ± 11.1 years, 46% women), 21% lost ≥5% weight over 3 years, which was associated with modestly improved physical and mental health. Advancing age, female sex, and higher baseline weight were associated with weight loss. Most importantly, the type of GLM prescribed at previous visit had the strongest impact on weight change over time independent of participant factors, with use of a sodium-glucose cotransporter-2 inhibitor or glucagon-like peptide-1 receptor agonist associated with 1.0% weight loss versus a 0.6% weight gain with sulphonylureas, thiazolidinediones, meglitinides or insulin. CONCLUSION In this large contemporary prospective study, approximately one in five participants with early-stage type 2 diabetes and overweight/obesity lost ≥5% weight over 3 years. The type of GLM has the most impact on weight loss over time, highlighting the need for a careful selection of agents that takes baseline weight into consideration.
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Affiliation(s)
- Vittal Hejjaji
- Saint Luke's Mid America Heart Institute/University of Missouri-Kansas City, Kansas City, Missouri, USA
| | - Juan J Gorgojo-Martinez
- Unit of Endocrinology and Nutrition, Hospital Universitario Fundación Alcorcón Madrid, Madrid, Spain
| | - Fengming Tang
- Saint Luke's Mid America Heart Institute/University of Missouri-Kansas City, Kansas City, Missouri, USA
| | | | | | | | | | - Kamlesh Khunti
- Diabetes Research Centre, University of Leicester, Leicester, UK
| | - Antonio Nicolucci
- Center for Outcomes Research and Clinical Epidemiology, Pescara, Italy
| | - Marina V Shestakova
- Endocrinology Research Center, Diabetes Institute, Moscow, Russian Federation
| | - Linong Ji
- Peking University Subjects's Hospital, Beijing, China
| | | | - Hirotaka Watada
- Graduate School of Medicine, Juntendo University, Tokyo, Japan
| | | | - Ali O Malik
- Saint Luke's Mid America Heart Institute/University of Missouri-Kansas City, Kansas City, Missouri, USA
| | - Mikhail Kosiborod
- Saint Luke's Mid America Heart Institute/University of Missouri-Kansas City, Kansas City, Missouri, USA
| | - Suzanne V Arnold
- Saint Luke's Mid America Heart Institute/University of Missouri-Kansas City, Kansas City, Missouri, USA
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Arnold SV, Tang F, Cooper A, Chen H, Gomes MB, Rathmann W, Shimomura I, Vora J, Watada H, Khunti K, Kosiborod M. Global use of SGLT2 inhibitors and GLP-1 receptor agonists in type 2 diabetes. Results from DISCOVER. BMC Endocr Disord 2022; 22:111. [PMID: 35473607 PMCID: PMC9040320 DOI: 10.1186/s12902-022-01026-2] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [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: 12/06/2021] [Accepted: 03/28/2022] [Indexed: 01/24/2023] Open
Abstract
BACKGROUND Despite strong evidence of benefit, uptake of newer glucose-lowering medications that reduce cardiovascular risk has been low. We sought to examine global trends and predictors of use of SGLT2i and GLP-1 RA in patients with type 2 diabetes. METHODS DISCOVER is a global, prospective, observational study of patients with diabetes enrolled from 2014-16 at initiation of second-line glucose-lowering therapy and followed for 3 years. We used hierarchical logistic regression to examine factors associated with use of either an SGLT2i or GLP-1 RA at last follow-up and to assess country-level variability. RESULTS Among 14,576 patients from 37 countries, 1579 (10.8%) were started on an SGLT2i (1275; 8.7%) or GLP-1 RA (318; 2.2%) at enrollment, increasing to 16.1% at end of follow-up, with large variability across countries (range 0-62.7%). Use was highest in patients treated by cardiologists (26.1%) versus primary care physicians (10.4%), endocrinologists (16.9%), and other specialists (22.0%; p < 0.001). Coronary artery disease (OR 1.29, 95% CI 1.08-1.54) was associated with greater use of SGLT2i or GLP-1 RA while peripheral artery disease (OR 0.73, 95% CI 0.54-1.00) and chronic kidney disease (OR 0.73, 95% CI 0.58-0.94) were associated with lower use (OR 0.73, 95% CI 0.54-1.00). The country-level median odds ratio was 3.48, indicating a very large amount of variability in the use of SGLT2i or GLP-1 RA independent of patient demographic and clinical factors. CONCLUSIONS Global use of glucose-lowering medications with established cardiovascular benefits has increased over time but remains suboptimal, particularly in sub-groups most likely to benefit. Substantial country-level variability exists independent of patient factors, suggesting structural barriers may limit more widespread use of these medications.
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Affiliation(s)
- Suzanne V Arnold
- Saint Luke's Mid America Heart Institute, 4401 Wornall Rd, Kansas City, MO, 64111, USA.
- University of Missouri Kansas City, Kansas City, MO, USA.
| | - Fengming Tang
- Saint Luke's Mid America Heart Institute, 4401 Wornall Rd, Kansas City, MO, 64111, USA
| | | | | | | | - Wolfgang Rathmann
- Institute for Biometrics and Epidemiology, German Diabetes Center, Leibniz Institute for Diabetes Research at Heinrich Heine University, Düsseldorf, Germany
| | | | | | | | | | - Mikhail Kosiborod
- Saint Luke's Mid America Heart Institute, 4401 Wornall Rd, Kansas City, MO, 64111, USA
- University of Missouri Kansas City, Kansas City, MO, USA
- The George Institute for Global Health and University of New South Wales, Sydney, Australia
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Nicolucci A, Chen H, Cooper A, Fenici P, Gomes MB, Hammar N, Ji L, Khunti K, Kosiborod M, Medin J, Shestakova MV, Shimomura I, Tang F, Vora J, Watada H, Arnold SV. Quality of life in people with type 2 diabetes in the 3 years following initiation of second-line therapy: The DISCOVER study. Diabetes Res Clin Pract 2022; 185:109218. [PMID: 35114299 DOI: 10.1016/j.diabres.2022.109218] [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] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Revised: 12/23/2021] [Accepted: 01/25/2022] [Indexed: 11/19/2022]
Abstract
AIMS To assess changes in health-related quality of life (HRQoL) in DISCOVER, a 3-year, longitudinal, observational study of patients with type 2 diabetes initiating a second-line glucose-lowering therapy. METHODS HRQoL was assessed using the physical and mental component summary (PCS and MCS) scores of the 36-item Short-Form Health Survey version 2 (score ranges: 0-100; higher denotes better HRQoL) and the Hypoglycaemia Fear Survey II (HFS-II; score range: 0-132 scale; higher indicates greater fear of hypoglycaemia). Latent class growth modelling (LCGM) was used to identify patients with similar score trajectories. RESULTS Mean baseline PCS (n = 7428), MCS (n = 7453), and HFS-II (n = 5005) scores were 48.0, 45.4, and 15.4, respectively, and remained stable during follow-up. LCGM revealed subgroups with low or decreasing HRQoL. Patients in these subgroups tended to be older, had more comorbidities, and a lower socioeconomic status than in other subgroups. Use of insulin and sulfonylureas was highest in the subgroup with the highest fear of hypoglycaemia. CONCLUSIONS Overall, HRQoL remained stable in DISCOVER patients during follow-up. However, LCGM suggests that some patient characteristics and use of sulfonylureas or insulin are associated with low or decreasing HRQoL, potentially warranting the use of alternative therapies.
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Affiliation(s)
- Antonio Nicolucci
- Center for Outcomes Research and Clinical Epidemiology, Pescara, Italy.
| | - Hungta Chen
- AstraZeneca, Gaithersburg, MD, United States
| | | | | | | | - Niklas Hammar
- Institute of Environmental Medicine, Karolinska Institute, Stockholm, Sweden; AstraZeneca Gothenburg, Mölndal, Sweden
| | - Linong Ji
- Peking University People's Hospital, Beijing, China
| | | | - Mikhail Kosiborod
- Saint Luke's Mid America Heart Institute, Kansas City, MO, United States; University of Missouri, Kansas City, MO, United States; The George Institute for Global Health and University of New South Wales, Sydney, Australia
| | | | - Marina V Shestakova
- Endocrinology Research Center, Diabetes Institute, Moscow, Russian Federation
| | | | - Fengming Tang
- Saint Luke's Mid America Heart Institute, Kansas City, MO, United States
| | - Jiten Vora
- Royal Liverpool University Hospital, Liverpool, United Kingdom
| | - Hirotaka Watada
- Graduate School of Medicine, Juntendo University, Tokyo, Japan
| | - Suzanne V Arnold
- Saint Luke's Mid America Heart Institute, Kansas City, MO, United States; University of Missouri, Kansas City, MO, United States
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Arnold SV, Khunti K, Tang F, Chen H, Nicolucci A, Gomes MB, Ji L, Shestakova MV, Watada H, Cooper A, Fenici P, Hammar N, Medina J, Kosiborod M. Impact of micro‐ and macrovascular complications of type 2 diabetes on quality of life: Insights from the DISCOVER prospective cohort study. Endocrinol Diabetes Metab 2022; 5:e00321. [PMID: 35029066 PMCID: PMC8917866 DOI: 10.1002/edm2.321] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Revised: 11/14/2021] [Accepted: 12/20/2021] [Indexed: 11/25/2022] Open
Abstract
Background The key goals of management in patients with type 2 diabetes (T2D) are to prolong life and improve quality of life. Micro‐ and macrovascular complications of T2D not only increase the risk of morbidity and mortality, but cross‐sectional studies indicate they may also worsen quality of life. We prospectively examined the association of complications that developed during the follow‐up with concurrent changes in quality of life. Materials and methods DISCOVER is a multinational, prospective, observational cohort study of T2D patients enrolled at initiation of second‐line glucose‐lowering therapy. Quality of life was assessed with the SF‐36 Physical (PCS) and Mental Components Summary (MCS) scores at baseline, 6 months, and 1, 2 and 3 years. Hierarchical repeated measures regression models for PCS and MCS were constructed with complications included as time‐dependent covariates; first each complication was modelled alone and then second including all interval complications (to account for different complications occurring in the same patient). Results Among 7830 patients with T2D from 30 countries (mean age 56.6 years, 47.6% women, mean duration of T2D 5.6 years), baseline mean SF‐36 PCS was 48.0 ± 7.8 and SF‐36 MCS was 45.5 ± 10.4. At baseline, 1422 (18.2%) patients had a known microvascular complication, and 966 (12.3%) had a macrovascular complication. Over the 3 years of the study, 641 (12.0%) developed a new microvascular complication (most commonly neuropathy) and 372 (5.8%) developed a new macrovascular complication (most commonly coronary disease). New diagnoses of coronary disease, peripheral artery disease, heart failure and neuropathy were each associated with subsequent moderate reductions in SF‐36 PCS (range 0.7 to 1.6 points) and new cerebrovascular disease was associated with a reduction in SF‐36 MCS (2.6 points). Results were consistent when all interval complications were considered in the same model. Conclusion In a prospective, multinational study of patients with T2D, the development of macrovascular complications and neuropathy was associated with decreases in both physical and mental quality of life. Our results provide additional support for clinicians to focus on the prevention, detection and management of the complications of T2D.
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Affiliation(s)
- Suzanne V. Arnold
- Saint Luke’s Mid America Heart Institute Kansas City Missouri USA
- University of Missouri Kansas City Missouri USA
| | | | - Fengming Tang
- Saint Luke’s Mid America Heart Institute Kansas City Missouri USA
| | | | - Antonio Nicolucci
- Center for Outcomes Research and Clinical Epidemiology Pescara Italy
| | | | - Linong Ji
- Peking University People’s Hospital Beijing China
| | | | | | | | | | - Niklas Hammar
- AstraZeneca Gothenburg Mölndal Sweden
- Institute of Environmental Medicine Karolinska Institutet Stockholm Sweden
| | | | - Mikhail Kosiborod
- Saint Luke’s Mid America Heart Institute Kansas City Missouri USA
- University of Missouri Kansas City Missouri USA
- The George Institute for Global Health and University of New South Wales Sydney Australia
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Arnold SV, Khunti K, Tang F, Chen H, Cid-Ruzafa J, Cooper A, Fenici P, Gomes MB, Hammar N, Ji L, Saraiva GL, Medina J, Nicolucci A, Ramirez L, Rathmann W, Shestakova MV, Shimomura I, Surmont F, Vora J, Watada H, Kosiborod M. Incidence rates and predictors of microvascular and macrovascular complications in patients with type 2 diabetes: Results from the longitudinal global discover study. Am Heart J 2022; 243:232-239. [PMID: 34666013 DOI: 10.1016/j.ahj.2021.10.181] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Accepted: 10/02/2021] [Indexed: 12/14/2022]
Abstract
BACKGROUND Micro- and macrovascular complications are a major cause of morbidity and mortality in people with type 2 diabetes (T2D). We sought to understand the global incidence rates and predictors of these complications. METHODS We examined the incidence of vascular complications over 3 years of follow-up in the DISCOVER study-a global, observational study of people with T2D initiating second-line glucose-lowering therapy. Hierarchical Cox proportional hazards regression models examined factors associated with development of micro- and macrovascular complications during follow-up. RESULTS Among 11,357 people with T2D from 33 countries (mean age 56.9 ± 11.7 years, T2D duration 5.7 ± 5.1 years, HbA1c 8.4 ± 1.7%), 19.0% had a microvascular complication at enrolment (most commonly neuropathy), and 13.2% had a macrovascular complication (most commonly coronary disease). Over 3 years of follow-up, 16.0% developed an incident microvascular complication, and 6.6% had an incident macrovascular complication. At the end of 3 years of follow-up, 31.5% of patients had at least one microvascular complication, and 16.6% had at least one macrovascular complication. Higher HbA1c and smoking were associated with greater risk of both incident micro- and macrovascular complications. Known macrovascular complications at baseline was the strongest predictor for development of new microvascular complications (HR 1.40, 95% CI 1.21 -1.61) and new macrovascular complications (HR 3.39, 95% CI 2.84 -4.06). CONCLUSIONS In this global study, both the prevalence and 3-year incidence of vascular complications were high in patients with relatively short T2D duration, highlighting the need for early risk-factor modification.
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Nicolucci A, Chen H, Cid-Ruzafa J, Cooper A, Fenici P, Gomes MB, Hammar N, Khunti K, Kosiborod M, Leigh P, Medin J, Rathmann W, Shestakova MV, Shimomura I, Siddiqui A, Tang F, Watada H, Ji L. Health-related quality of life in patients with type 2 diabetes initiating a second-line glucose-lowering therapy: The DISCOVER study. Diabetes Res Clin Pract 2021; 180:108974. [PMID: 34302913 DOI: 10.1016/j.diabres.2021.108974] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [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: 04/22/2021] [Revised: 07/14/2021] [Accepted: 07/19/2021] [Indexed: 11/19/2022]
Abstract
AIM To investigate factors associated with health-related quality of life (HRQoL) in patients with type 2 diabetes mellitus (T2D) at initiation of second-line glucose-lowering therapy. METHODS DISCOVER is a 3-year, prospective observational study of patients with T2D initiating second-line glucose-lowering therapy, conducted in 38 countries. HRQoL at baseline was assessed using the physical and mental component summary (PCS; MCS) scores of the 36-Item Short Form Health Survey version 2 (SF-36v2) in 31 countries (n = 8309) and the Hypoglycaemia Fear Survey-II (HFS-II) in 23 countries (n = 6516). Factors associated with differences in HRQoL were assessed using multivariable hierarchical regression models. RESULTS Mean PCS and MCS scores were 48.0 (standard deviation [SD]: 7.8) and 45.5 (SD: 10.4), respectively. Factors associated with significantly lower SF-36v2 scores included being female, having a history of macrovascular complications and first-line treatment with oral combinations (vs metformin monotherapy). Mean HFS-II behaviour and worry scores were 8.2 (SD: 9.9) and 7.3 (SD: 11.8), respectively. Increased fear of hypoglycaemia was significantly associated with lower SF-36v2 scores. CONCLUSIONS Several patient-, disease- and treatment-related characteristics correlated with HRQoL, indicating that a multifactorial approach is needed to maintain HRQoL in patients with T2D.
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Affiliation(s)
- Antonio Nicolucci
- Center for Outcomes Research and Clinical Epidemiology, Pescara, Italy.
| | | | | | | | | | | | - Niklas Hammar
- AstraZeneca Gothenburg, Mölndal, Sweden; Institute of Environmental Medicine, Karolinska Institute, Stockholm, Sweden
| | | | - Mikhail Kosiborod
- Saint Luke's Mid America Heart Institute, Kansas City, MO, USA; University of Missouri-Kansas City, Kansas City, MO, USA; The George Institute for Global Health, Sydney, NSW, Australia
| | | | | | | | - Marina V Shestakova
- Endocrinology Research Centre, Diabetes Institute, Moscow, Russian Federation
| | | | | | - Fengming Tang
- Saint Luke's Mid America Heart Institute, Kansas City, MO, USA
| | | | - Linong Ji
- Peking University People's Hospital, Beijing, China
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Khunti K, Charbonnel B, Chen H, Cherney DZ, Cooper A, Fenici P, Gomes MB, Hammar N, Heerspink HJL, Ji L, Medina J, Nicolucci A, Ramirez L, Rathmann W, Shestakova MV, Shimomura I, Tang F, Watada H, Kosiborod M. Prevalence and progression of chronic kidney disease among patients with type 2 diabetes: Insights from the DISCOVER study. Diabetes Obes Metab 2021; 23:1956-1960. [PMID: 33852196 DOI: 10.1111/dom.14401] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [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: 12/23/2020] [Revised: 04/06/2021] [Accepted: 04/08/2021] [Indexed: 01/21/2023]
Abstract
We report the prevalence and change in severity of chronic kidney disease (CKD) in DISCOVER, a global, 3-year, prospective, observational study of patients with type 2 diabetes (T2D) initiating second-line glucose-lowering therapy. CKD stages were defined according to estimated glomerular filtration rate (eGFR). Overall, 7843 patients from 35 countries had a baseline serum creatinine measurement. Of these (56.7% male; mean age: 58.1 years; mean eGFR: 87.5 mL/min/1.73 m2 ), baseline prevalence estimates for stage 0-1, 2, 3 and 4-5 CKD were 51.4%, 37.7%, 9.4% and 1.4%, respectively. A total of 5819 patients (74.2%) also had at least one follow-up serum creatinine measurement (median time between measurements: 2.9 years, interquartile range: 1.9-3.0 years). Mean eGFR decreased slightly to 85.7 mL/min/1.73 m2 over follow-up. CKD progression (increase of ≥1 stage) occurred in 15.7% of patients, and regression (decrease of ≥1 stage) in 12.0%. In summary, a substantial proportion of patients with T2D developed CKD or had CKD progression after the initiation of second-line therapy. Renal function should be regularly monitored in these patients, to ensure early CKD diagnosis and treatment.
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Affiliation(s)
- Kamlesh Khunti
- Diabetes Research Centre, University of Leicester, Leicester, UK
| | | | | | - David Z Cherney
- University Health Network, University of Toronto, Toronto, Ontario, Canada
| | | | | | - Marilia B Gomes
- Department of Internal Medicine, Rio de Janeiro State University, Rio de Janeiro, Brazil
| | - Niklas Hammar
- AstraZeneca Gothenburg, Mölndal, Sweden
- Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Hiddo J L Heerspink
- University of Groningen, University Medical Center, Groningen, the Netherlands
| | - Linong Ji
- Department of Endocrinology and Metabolism, Peking University People's Hospital, Beijing, China
| | | | - Antonio Nicolucci
- Department of Metabolic Medicine, Center for Outcomes Research and Clinical Epidemiology, Pescara, Italy
| | | | - Wolfgang Rathmann
- German Diabetes Center, Leibniz Center for Diabetes Research at Heinrich Heine University, Düsseldorf, Germany
| | - Marina V Shestakova
- Endocrinology Research Centre, Diabetes Institute, Moscow, Russian Federation
| | | | - Fengming Tang
- Saint Luke's Mid America Heart Institute, Kansas City, Missouri, USA
| | - Hirotaka Watada
- Graduate School of Medicine, Juntendo University, Tokyo, Japan
| | - Mikhail Kosiborod
- Saint Luke's Mid America Heart Institute, Kansas City, Missouri, USA
- University of Missouri, Kansas City, Missouri, USA
- The George Institute for Global Health and University of New South Wales, Sydney, New South Wales, Australia
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10
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Cortês Nascimento G, de Araujo Cortês Nascimento AGP, de Maria Ribeiro Veiga Parente C, Rodrigues VP, de Sousa Azulay RS, de Carvalho Rocha VC, da Silva Pereira Damianse S, Magalhães M, Dos Santos Faria M, Gomes MB. Pituitary neuroendocrine tumors and differentiated thyroid cancer: do metabolic and inflammatory risk factors play roles? J Endocrinol Invest 2021; 44:735-744. [PMID: 32681462 DOI: 10.1007/s40618-020-01357-8] [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] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Accepted: 07/07/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE It is postulated that patients with different types of pituitary neuroendocrine tumors (PitNETs) may present a higher incidence of cancer. Factors underlying individuals becoming overweight, such as insulin resistance, hyperleptinemia, and low-grade inflammation, may play a role in the risk of differentiated thyroid carcinoma (DTC) in such patients. This study aimed to investigate the frequency of and obesity-related risk factors associated with DTC in patients with PitNETs. METHODS This cross-sectional study involved 149 patients with nonacromegalic PitNETs (AG group), 71 patients with acromegaly (ACRO group), and 156 controls (CG group). All participants underwent insulin and blood glucose measurements with the determination of the homeostatic model assessment-insulin resistance (HOMA-IR) index, leptin, and high-sensitivity C-reactive protein (hsCRP), and they also underwent thyroid ultrasound. Clinically significant nodules were biopsied for subsequent cytopathological evaluation, and participants were operated on when indicated. RESULTS Patients in the AG group had high levels of insulin resistance and significantly higher levels of leptin and hsCRP compared with those of patients in the ACRO group. There were no cases of DTC in the AG group; two findings, one incidental, of DTC occurred in the CG group, and three cases of DTC were present in the ACRO group. Acromegaly was associated with DTC after adjusted analysis. CONCLUSIONS Our findings in patients with nonacromegalic PitNETs do not indicate a high risk for DTC despite the presence of metabolic and inflammatory risk factors for neoplastic events. In contrast, acromegaly promotes a greater risk of DTC.
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Affiliation(s)
- G Cortês Nascimento
- Service of Endocrinology, Presidente Dutra University Hospital, Federal University of Maranhão (UFMA), São Luís, MA, Brazil.
- Clinical Research Center, Presidente Dutra University Hospital, Federal University of Maranhão (UFMA), São Luís, MA, Brazil.
- Research Group in Clinical and Molecular Endocrinology and Metabology (ENDOCLIM), São Luís, MA, Brazil.
| | - A G P de Araujo Cortês Nascimento
- Clinical Research Center, Presidente Dutra University Hospital, Federal University of Maranhão (UFMA), São Luís, MA, Brazil
- Research Group in Clinical and Molecular Endocrinology and Metabology (ENDOCLIM), São Luís, MA, Brazil
- Department of Pathology, Presidente Dutra University Hospital, Federal University of Maranhão (UFMA), São Luís, MA, Brazil
| | | | - V P Rodrigues
- Research Group in Clinical and Molecular Endocrinology and Metabology (ENDOCLIM), São Luís, MA, Brazil
- Department of Morphology, Federal University of Maranhão (UFMA), São Luís, MA, Brazil
| | - R S de Sousa Azulay
- Service of Endocrinology, Presidente Dutra University Hospital, Federal University of Maranhão (UFMA), São Luís, MA, Brazil
- Clinical Research Center, Presidente Dutra University Hospital, Federal University of Maranhão (UFMA), São Luís, MA, Brazil
- Research Group in Clinical and Molecular Endocrinology and Metabology (ENDOCLIM), São Luís, MA, Brazil
| | - V C de Carvalho Rocha
- Service of Endocrinology, Presidente Dutra University Hospital, Federal University of Maranhão (UFMA), São Luís, MA, Brazil
- Clinical Research Center, Presidente Dutra University Hospital, Federal University of Maranhão (UFMA), São Luís, MA, Brazil
- Research Group in Clinical and Molecular Endocrinology and Metabology (ENDOCLIM), São Luís, MA, Brazil
| | - S da Silva Pereira Damianse
- Service of Endocrinology, Presidente Dutra University Hospital, Federal University of Maranhão (UFMA), São Luís, MA, Brazil
- Clinical Research Center, Presidente Dutra University Hospital, Federal University of Maranhão (UFMA), São Luís, MA, Brazil
- Research Group in Clinical and Molecular Endocrinology and Metabology (ENDOCLIM), São Luís, MA, Brazil
| | - M Magalhães
- Clinical Research Center, Presidente Dutra University Hospital, Federal University of Maranhão (UFMA), São Luís, MA, Brazil
- Research Group in Clinical and Molecular Endocrinology and Metabology (ENDOCLIM), São Luís, MA, Brazil
| | - M Dos Santos Faria
- Service of Endocrinology, Presidente Dutra University Hospital, Federal University of Maranhão (UFMA), São Luís, MA, Brazil
- Clinical Research Center, Presidente Dutra University Hospital, Federal University of Maranhão (UFMA), São Luís, MA, Brazil
- Research Group in Clinical and Molecular Endocrinology and Metabology (ENDOCLIM), São Luís, MA, Brazil
| | - M B Gomes
- Diabetes Unit-Department of Internal Medicine, State University of Rio de Janeiro (UERJ), Rio de Janeiro, RJ, Brazil
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11
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Arnold SV, Khunti K, Bonnet F, Charbonnel B, Chen H, Cid-Ruzafa J, Cooper A, Fenici P, Gomes MB, Hammar N, Ji L, Luporini-Saraiva G, Medina J, Nicolucci A, Ramirez L, Shestakova MV, Shimomura I, Surmont F, Tang F, Vora J, Watada H, Kosiborod M. Type 2 diabetes and heart failure: insights from the global DISCOVER study. ESC Heart Fail 2021; 8:1711-1716. [PMID: 33570253 PMCID: PMC8006680 DOI: 10.1002/ehf2.13235] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Revised: 12/04/2020] [Accepted: 01/19/2021] [Indexed: 01/18/2023] Open
Abstract
Aims Heart failure (HF) is increasingly recognized as a major cause of morbidity and mortality in patients with type 2 diabetes (T2D), but the global epidemiology and treatment of HF in T2D are not well defined. This study aimed to examine the global prevalence of HF and the incidence of HF over 3 years of follow‐up in patients with T2D [by presence and absence of co‐existing coronary artery disease (CAD)]. Methods and results DISCOVER was a 3 year, prospective, observational study of T2D patients enrolled at initiation of second‐line glucose‐lowering therapy. Among 14 057 patients with T2D from 36 countries, 289 (2.1%) had a diagnosis of HF at enrolment; median prevalence across countries was 2.0% (inter‐quartile range 1.0–3.1%). Patients with HF at baseline were more likely to be older [HF vs. no HF: 67 ± 12 vs. 57 ± 12 years, standardized difference (StDiff) = 84%] and have longer duration of T2D (8.1 ± 7.2 vs. 5.6 ± 5.2 years, StDiff = 40%), CAD (44% vs. 6%, StDiff = 97%), atrial fibrillation (21% vs. 1%, StDiff = 66%), and kidney disease (23% vs. 4%, StDiff = 55%). Patients with HF were less likely to be on metformin (66% vs. 79%, StDiff = 28%) and thiazolidinediones (5.5% vs. 10.6%, StDiff = 19%) but had similar use of other glucose‐lowering medications. Among 9313 patients with follow‐up data, there were 70 incident cases of HF, which translates to an incidence of 2.6 cases per 1000 person years. Of these incident HF cases, 60% occurred in the absence of pre‐existing or concomitant CAD, and 73% were diagnosed in the outpatient setting. Conclusions In a large, global cohort of patients with T2D, the majority of incident cases of HF occurred in outpatients and in the absence of known CAD. These findings highlight the need for greater awareness of HF risk in patients with T2D.
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Affiliation(s)
- Suzanne V Arnold
- Saint Luke's Mid America Heart Institute, 4401 Wornall Rd, Kansas City, MO, 64111, USA.,University of Missouri, Kansas City, MO, USA
| | | | | | | | | | | | | | | | | | - Niklas Hammar
- AstraZeneca Gothenburg, Mölndal, Sweden.,Institute of Environmental Medicine, Karolinska Institute, Stockholm, Sweden
| | - Linong Ji
- Peking University People's Hospital, Beijing, China
| | | | | | - Antonio Nicolucci
- Center for Outcomes Research and Clinical Epidemiology, Pescara, Italy
| | | | - Marina V Shestakova
- Endocrinology Research Centre, Diabetes Institute, Moscow, Russian Federation
| | | | | | - Fengming Tang
- Saint Luke's Mid America Heart Institute, 4401 Wornall Rd, Kansas City, MO, 64111, USA
| | - Jiten Vora
- Royal Liverpool University Hospital, Liverpool, UK
| | - Hirotaka Watada
- Graduate School of Medicine, Juntendo University, Tokyo, Japan
| | - Mikhail Kosiborod
- Saint Luke's Mid America Heart Institute, 4401 Wornall Rd, Kansas City, MO, 64111, USA.,University of Missouri, Kansas City, MO, USA
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12
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Barros BSV, Santos DC, Melo LGN, Pizarro MH, Muniz LH, Silva DA, Porto LC, Gomes MB. Genomic ancestry and metabolic syndrome in individuals with type 1 diabetes from an admixed population: a multicentre, cross-sectional study in Brazil. Diabet Med 2021; 38:e14400. [PMID: 32918322 DOI: 10.1111/dme.14400] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [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: 03/31/2020] [Revised: 08/12/2020] [Accepted: 09/03/2020] [Indexed: 12/14/2022]
Abstract
AIMS To evaluate the relationship between self-reported colour-race, genomic ancestry, and metabolic syndrome in an admixed Brazilian population with type 1 diabetes. METHODS We included 1640 participants with type 1 diabetes. The proportions of European, African and Amerindian genomic ancestries were determined by 46 ancestry informative markers of insertion deletion. Two different sets of analyses were performed to determine whether self-reported colour-race and genomic ancestry were predictors of metabolic syndrome. RESULTS Metabolic syndrome was identified in 29.8% of participants. In the first model, the factors associated with metabolic syndrome were: female gender (odds ratio 1.95, P < 0.001); diabetes duration (odds ratio 1.04, P < 0.001); family history of type 2 diabetes (odds ratio 1.36, P = 0.019); and acanthosis nigricans (odds ratio 5.93, P < 0.001). Colour-race was not a predictive factor for metabolic syndrome. In the second model, colour-race was replaced by European genomic ancestry. The associated factors were: female gender (odds ratio 1.95, P < 0.001); diabetes duration (odds ratio 1.04, P < 0.001); family history of type 2 diabetes (odds ratio 1.39, P = 0.011); and acanthosis nigricans (odds ratio 6.12, P < 0.001). Physical exercise (≥3 times a week) was a protective factor (odds ratio 0.77, P = 0.041), and European genomic ancestry was not associated with metabolic syndrome but showed an odds ratio of 1.77 (P = 0.05). CONCLUSIONS Although a higher level of European genomic ancestry was observed among participants with metabolic syndrome in the univariate analysis, this association did not persist after multivariable adjustments. Further prospective studies in other highly admixed populations remain necessary to better evaluate whether the European ancestral component modulates the development of metabolic syndrome in type 1 diabetes.
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Affiliation(s)
- B S V Barros
- Department of Internal Medicine, Diabetes Unit, State University of Rio de Janeiro, Rio de Janeiro, RJ, Brazil
| | - D C Santos
- Department of Internal Medicine, Diabetes Unit, State University of Rio de Janeiro, Rio de Janeiro, RJ, Brazil
| | - L G N Melo
- Department of Ophthalmology, State University of Rio de Janeiro, Rio de Janeiro, RJ, Brazil
| | - M H Pizarro
- Department of Internal Medicine, Diabetes Unit, State University of Rio de Janeiro, Rio de Janeiro, RJ, Brazil
| | - L H Muniz
- Department of Internal Medicine, Diabetes Unit, State University of Rio de Janeiro, Rio de Janeiro, RJ, Brazil
| | - D A Silva
- DNA Diagnostic Laboratory, State University of Rio de Janeiro, Rio de Janeiro, RJ, Brazil
| | - L C Porto
- Histocompatibility and Cryopreservation Laboratory, State University of Rio de Janeiro, Rio de Janeiro, RJ, Brazil
| | - M B Gomes
- Department of Internal Medicine, Diabetes Unit, State University of Rio de Janeiro, Rio de Janeiro, RJ, Brazil
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13
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Patel KK, Gomes MB, Charbonnel B, Chen H, Cid‐Ruzafa J, Fenici P, Hammar N, Ji L, Kennedy KF, Khunti K, Kosiborod M, Pocock S, Shestakova MV, Shimomura I, Surmont F, Watada H, Arnold SV. Global patterns of comprehensive cardiovascular risk factor control in patients with type 2 diabetes mellitus: Insights from the DISCOVER study. Diabetes Obes Metab 2021; 23:39-48. [PMID: 32845558 PMCID: PMC7756755 DOI: 10.1111/dom.14180] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [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: 04/23/2020] [Revised: 08/06/2020] [Accepted: 08/23/2020] [Indexed: 12/25/2022]
Abstract
AIM To investigate global patterns of cardiovascular risk factor control in patients with type 2 diabetes mellitus (T2D). METHODS DISCOVER is an international, observational cohort study of patients with T2D beginning second-line glucose-lowering therapy. Risk factor management was examined among eligible patients (ie, those with the risk factor) at study baseline. Inter-country variability was estimated using median odds ratios (MORs). RESULTS Among 14 343 patients with T2D from 34 countries, the mean age was 57.4 ± 12.0 years and the median (interquartile range) duration of T2D was 4.2 (2.0-8.0) years; 11.8% had documented atherosclerotic cardiovascular disease (ASCVD). Among eligible patients, blood pressure was controlled in 67.5% (9284/13756), statins were prescribed in 43.7% (5775/13208), angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers were prescribed in 55.6% (5292/9512), aspirin was prescribed in 53.3% of those with established ASCVD (876/1645), and 84.4% (12 102/14343) were non-smoking. Only 21.5% of patients (3088/14343) had optimal risk factor management (defined as control of all eligible measures), with wide inter-country variability (10%-44%), even after adjusting for patient and site differences (MOR 1.47, 95% confidence interval 1.24-1.66). CONCLUSION Globally, comprehensive control of ASCVD risk factors is not being achieved in most patients, with wide variability among countries unaccounted for by patient and site differences. Better country-specific strategies are needed to implement comprehensive cardiovascular risk factor control consistently in patients with T2D to improve long-term outcomes.
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Affiliation(s)
- Krishna K. Patel
- Saint Luke's Mid America Heart InstituteKansas CityMissouriUSA
- University of Missouri‐Kansas CityKansas CityMissouriUSA
| | | | | | | | | | | | - Niklas Hammar
- Institute of Environmental MedicineKarolinska InstituteStockholmSweden
| | - Linong Ji
- Peking University People's HospitalBeijingPeople's Republic of China
| | | | | | - Mikhail Kosiborod
- Saint Luke's Mid America Heart InstituteKansas CityMissouriUSA
- University of Missouri‐Kansas CityKansas CityMissouriUSA
| | - Stuart Pocock
- London School of Hygiene and Tropical MedicineLondonUK
| | | | | | | | | | - Suzanne V. Arnold
- Saint Luke's Mid America Heart InstituteKansas CityMissouriUSA
- University of Missouri‐Kansas CityKansas CityMissouriUSA
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14
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Khunti K, Gomes MB, Kosiborod M, Nicolucci A, Pocock S, Rathmann W, Shestakova MV, Shimomura I, Watada H, Chen H, Cid-Ruzafa J, Fenici P, Hammar N, Tang F, Ji L. Metformin discontinuation in patients beginning second-line glucose-lowering therapy: results from the global observational DISCOVER study programme. BMJ Open 2020; 10:e034613. [PMID: 32868349 PMCID: PMC7462233 DOI: 10.1136/bmjopen-2019-034613] [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] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVES To evaluate the extent to which patients with type 2 diabetes discontinue metformin therapy when initiating second-line treatment and factors associated with metformin discontinuation, using baseline data from the DISCOVER study programme. DESIGN DISCOVER is a 3-year, prospective, observational study programme including data from 38 countries across 6 continents from 2014 to 2019. SETTING Primary and secondary healthcare centres, hospitals and specialist diabetes centres in both urban and rural locations. PARTICIPANTS A total of 15 992 patients with type 2 diabetes initiating second-line glucose-lowering therapy. PRIMARY AND SECONDARY OUTCOME MEASURES The proportion of patients who discontinued metformin as a second-line therapy and the factors associated with this treatment change. RESULTS Of the 14 668 patients (from 37 countries) with valid treatment data, 11 837 (80.7%) received metformin as first-line glucose-lowering therapy; 8488 (71.7%) received metformin monotherapy and 3349 (28.3%) received metformin as part of a combination therapy. Overall, treatment with metformin was discontinued in 15.1% (1782) of patients who received first-line metformin (14.1% (1194) and 17.6% (588) in those who received metformin as monotherapy and as part of a combination, respectively); this proportion varied across regions from 6.9% (54) in Africa to 20.6% (628) in South-East Asia. On metformin discontinuation, 73.6% (1311) of patients received a non-insulin monotherapy at second line. Factors associated with an increased odds of metformin discontinuation were older age (≥75 years) and having a history of chronic kidney disease. The probability of metformin monotherapy discontinuation was lower in patients from Africa than in those from Europe. CONCLUSIONS A substantial number of patients discontinued taking metformin when beginning second-line therapy. Most of these patients subsequently received a non-insulin monotherapy at second line, in contradiction to international guidelines and potentially leaving them at an increased risk of hyperglycaemia and associated adverse outcomes. TRIAL REGISTRATION NUMBERS NCT02322762 and NCT02226822.
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Affiliation(s)
- Kamlesh Khunti
- Diabetes Research Centre, University of Leicester, Leicester, UK
| | - Marilia B Gomes
- Department of Internal Medicine, Rio de Janeiro State University, Rio de Janeiro, RJ, Brazil
| | - Mikhail Kosiborod
- Department of Cardiovascular research, Saint Luke's Mid America Heart Institute, Kansas City, Missouri, USA
- Department of Internal Medicine, University of Missouri Kansas City, Kansas City, Missouri, USA
- The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Antonio Nicolucci
- Department of Metabolic Medicine, Center for Outcomes Research and clinical Epidemiology (CORE), Pescara, Italy
| | - Stuart Pocock
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, UK
| | - Wolfgang Rathmann
- Institute for Biometrics and Epidemiology, German Diabetes Center, Düsseldorf, Germany
| | - Marina V Shestakova
- Feberal Scientific Centre of Endocrinology, Endocrinology Research Centre, Moscow, Russian Federation
| | - Iichiro Shimomura
- Department of Metabolic Medicine, Osaka University Hospital, Suita, Osaka, Japan
| | - Hirotaka Watada
- Department of Metabolism and Endocrinology, Juntendo University, Bunkyo-ku, Tokyo, Japan
| | | | | | | | - Niklas Hammar
- Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
- AstraZeneca, Gothenburg, Sweden
| | - Fengming Tang
- Department of Cardiovascular research, Saint Luke's Mid America Heart Institute, Kansas City, Missouri, USA
| | - Linong Ji
- Department of Endocrinology and Metabolism, Peking University People's Hospital, Beijing, China
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15
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Gomes MB, Muniz LH, Melo LGN, Pizarro MH, Barros BSV, Santos DC, Negrato CA. Health literacy and glycemic control in patients with diabetes: a tertiary care center study in Brazil. Diabetol Metab Syndr 2020; 12:11. [PMID: 32042313 PMCID: PMC6998814 DOI: 10.1186/s13098-020-0519-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2019] [Accepted: 01/24/2020] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND The primary objective of our study was to determine which factors influence health literacy (HL) in patients with type 1 diabetes (T1D) and type 2 diabetes (T2D), and the secondary one was to evaluate the influence of HL on glycemic control. METHODS This was an observational, cross-sectional study with 347 patients (144 with T1D and 203 with T2D), conducted between December 2014/December 2017. Data were obtained from medical records and/or questionnaire. The short test of Functional Health Literacy (S-TOFHLA) was used to evaluate HL. RESULTS Age and years of school attendance were the most important variables associated with better performance in S-TOFHLA mainly in patients with T1D. A correlation between age and years of school attendance with S-TOFHLA score was observed in both groups of patients. After an unadjusted analysis, more patients with T1D presented adequate HL [119 (82.6%) vs 87 (44.8%, p < 0.001)]. Patients with T1D had higher scores than patients with T2D (84.4 ± 21.4 vs 61.6 ± 26.8 points, p < 0.001), respectively. This difference did not persist after adjustment for age and years of school attendance (73.04 ± 2.14 ± vs 70.04 ± 1.76 points) respectively, p = 0.348). No difference was found in HbA1c levels according to S-TOFHLA. All patients with T1D and HbA1c levels < 7.0% (53 mmol/mol) had adequate HL. CONCLUSIONS A considerable number of patients with either T1D or T2D did not have adequate HL. Overall, age and years of school attendance were the most important variables associated with better performance of S-TOFHLA. Although no difference was found in HbA1c levels according to S-TOFHLA, patients with T1D who self-reported as White, with more years of school attendance, and higher HL score reached more frequently a good glycemic control. Finally, in addition to therapeutic regimens, approaches on diabetes management should also include patients' HL evaluation along with psychological and social aspects.
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Affiliation(s)
- Marilia B. Gomes
- Diabetes Unit, Department of Internal Medicine, State University Hospital of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Luiza Harcar Muniz
- Diabetes Unit, Department of Internal Medicine, State University Hospital of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Laura Gomes Nunes Melo
- Diabetes Unit, Department of Internal Medicine, State University Hospital of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Marcela Haas Pizarro
- Diabetes Unit, Department of Internal Medicine, State University Hospital of Rio de Janeiro, Rio de Janeiro, Brazil
| | | | - Deborah Conte Santos
- Diabetes Unit, Department of Internal Medicine, State University Hospital of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Carlos Antonio Negrato
- Medical Doctor Program, University of São Paulo-School of Dentistry, Bauru, São Paulo, Brazil
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16
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Khunti K, Chen H, Cid‐Ruzafa J, Fenici P, Gomes MB, Hammar N, Ji L, Kosiborod M, Pocock S, Shestakova MV, Shimomura I, Tang F, Watada H, Nicolucci A. Glycaemic control in patients with type 2 diabetes initiating second-line therapy: Results from the global DISCOVER study programme. Diabetes Obes Metab 2020; 22:66-78. [PMID: 31468637 PMCID: PMC6916552 DOI: 10.1111/dom.13866] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [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: 02/28/2019] [Revised: 07/31/2019] [Accepted: 08/25/2019] [Indexed: 12/16/2022]
Abstract
AIM To assess glycaemic control and factors associated with poor glycaemic control at initiation of second-line therapy in the DISCOVER programme. MATERIALS AND METHODS DISCOVER (NCT02322762 and NCT02226822) comprises two similar prospective observational studies of 15 992 people with type 2 diabetes (T2D) initiating second-line glucose-lowering therapy in 38 countries across six regions (Africa, Americas, South-East Asia, Eastern Mediterranean, Europe and Western Pacific). Data were collected using a standardized case report form. Glycated haemoglobin (HbA1c) levels were measured according to standard clinical practice in each country, and factors associated with poor glycaemic control (HbA1c >8.0%) were evaluated using hierarchical regression models. RESULTS HbA1c levels were available for 80.9% of patients (across-region range [ARR] 57.5%-97.5%); 92.2% (ARR 59.2%-99.1%) of patients had either HbA1c or fasting plasma glucose levels available. The mean HbA1c was 8.3% (ARR 7.9%-8.7%). In total, 26.7% of patients had an HbA1c level ≥9.0%, with the highest proportions in South-East Asia (35.6%). Factors associated with having HbA1c >8.0% at initiation of second-line therapy included low education level, low country income, and longer time since T2D diagnosis. CONCLUSIONS The poor levels of glycaemic control at initiation of second-line therapy suggest that intensification of glucose-lowering treatment is delayed in many patients with T2D. In some countries, HbA1c levels are not routinely measured. These findings highlight an urgent need for interventions to improve monitoring and management of glycaemic control worldwide, particularly in lower-middle- and upper-middle-income countries.
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Affiliation(s)
| | | | | | | | | | - Niklas Hammar
- Institute of Environmental MedicineKarolinska InstitutetStockholmSweden
| | - Linong Ji
- Peking University People's HospitalBeijingPeople's Republic of China
| | - Mikhail Kosiborod
- Saint Luke's Mid America Heart InstituteKansas CityMissouri
- University of MissouriKansas CityMissouri
- George Institute for Global HealthSydneyAustralia
| | - Stuart Pocock
- London School of Hygiene and Tropical MedicineLondonUK
| | | | | | - Fengming Tang
- Saint Luke's Mid America Heart InstituteKansas CityMissouri
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17
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Gomes MB, Rathmann W, Charbonnel B, Khunti K, Kosiborod M, Nicolucci A, Pocock SJ, Shestakova MV, Shimomura I, Tang F, Watada H, Chen H, Cid-Ruzafa J, Fenici P, Hammar N, Surmont F, Ji L. Treatment of type 2 diabetes mellitus worldwide: Baseline patient characteristics in the global DISCOVER study. Diabetes Res Clin Pract 2019; 151:20-32. [PMID: 30904743 DOI: 10.1016/j.diabres.2019.03.024] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [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: 12/13/2018] [Revised: 03/01/2019] [Accepted: 03/14/2019] [Indexed: 01/24/2023]
Abstract
AIMS To describe the characteristics and treatment of patients with type 2 diabetes mellitus initiating a second-line glucose-lowering therapy in the global DISCOVER study programme. METHODS DISCOVER comprises two similar 3-year prospective observational studies (NCT02322762 and NCT02226822), involving 15,992 patients initiating a second-line glucose-lowering therapy in 38 countries across six regions (Africa, Americas, South-East Asia, Eastern Mediterranean, Europe and Western Pacific). RESULTS Overall, 54.2% of patients were male (across region range [ARR]: 37.7-58.6%). At baseline, mean age and time since diagnosis of type 2 diabetes mellitus were 57.2 (ARR: 53.1-61.9)and 5.6 (ARR: 4.6-6.9) years, respectively. Median glycated haemoglobin (HbA1c) was 63.9 mmol/mol (8.0%; ARR: 7.6-8.3%). Microvascular and macrovascular complications were reported in 18.9% (ARR: 14.5-23.5%) and 12.7% (ARR: 5.0-26.6%) of patients, respectively. First-line treatments were mostly metformin monotherapy (55.6%; ARR: 42.5-83.6%) and combinations of metformin with a sulfonylurea (14.4%; ARR: 5.8-31.1%). The most commonly prescribed second-line therapies were combinations of metformin with a dipeptidyl peptidase-4 inhibitor (23.5%; ARR: 2.2-29.6%) or a sulfonylurea (20.9%; ARR: 13.6-57.1%). CONCLUSIONS DISCOVER demonstrates considerable global variation in the treatment of type 2 diabetes mellitus, and a need for more aggressive risk factor control.
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Affiliation(s)
| | - Wolfgang Rathmann
- German Diabetes Center, Leibniz Center for Diabetes Research at Heinrich Heine University, Düsseldorf, Germany.
| | | | | | - Mikhail Kosiborod
- Saint Luke's Mid America Heart Institute, Kansas City, MO, USA; University of Missouri, Kansas City, MO, USA.
| | - Antonio Nicolucci
- Center for Outcomes Research and Clinical Epidemiology, Pescara, Italy.
| | | | - Marina V Shestakova
- Endocrinology Research Center, Diabetes Institute, Moscow, Russian Federation
| | | | - Fengming Tang
- Saint Luke's Mid America Heart Institute, Kansas City, MO, USA.
| | - Hirotaka Watada
- Graduate School of Medicine, Juntendo University, Tokyo, Japan
| | | | | | | | - Niklas Hammar
- Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden.
| | | | - Linong Ji
- Peking University People's Hospital, Beijing, PR China.
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Kosiborod M, Gomes MB, Nicolucci A, Pocock S, Rathmann W, Shestakova MV, Watada H, Shimomura I, Chen H, Cid-Ruzafa J, Fenici P, Hammar N, Surmont F, Tang F, Khunti K. Vascular complications in patients with type 2 diabetes: prevalence and associated factors in 38 countries (the DISCOVER study program). Cardiovasc Diabetol 2018; 17:150. [PMID: 30486889 PMCID: PMC6260731 DOI: 10.1186/s12933-018-0787-8] [Citation(s) in RCA: 122] [Impact Index Per Article: 20.3] [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: 07/30/2018] [Accepted: 11/06/2018] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND The global prevalence of type 2 diabetes-related complications is not well described. We assessed prevalence of vascular complications at baseline in DISCOVER (NCT02322762; NCT02226822), a global, prospective, observational study program of 15,992 patients with type 2 diabetes initiating second-line therapy, conducted across 38 countries. METHODS Patients were recruited from primary and specialist healthcare settings. Data were collected using a standardized case report form. Prevalence estimates of microvascular and macrovascular complications at baseline were assessed overall and by country and region, and were standardized for age and sex. Modified Poisson regression was used to assess factors associated with the prevalence of complications. RESULTS The median duration of type 2 diabetes was 4.1 years (interquartile range [IQR]: 1.9-7.9 years), and the median glycated hemoglobin (HbA1c) level was 8.0% (IQR: 7.2-9.1%). The crude prevalences of microvascular and macrovascular complications were 18.8% and 12.7%, respectively. Common microvascular complications were peripheral neuropathy (7.7%), chronic kidney disease (5.0%), and albuminuria (4.3%). Common macrovascular complications were coronary artery disease (8.2%), heart failure (3.3%) and stroke (2.2%). The age- and sex-standardized prevalence of microvascular complications was 17.9% (95% confidence interval [CI] 17.3-18.6%), ranging from 14.2% in the Americas to 20.4% in Europe. The age- and sex-standardized prevalence of macrovascular complications was 9.2% (95% CI 8.7-9.7%), ranging from 4.1% in South-East Asia to 18.8% in Europe. Factors positively associated with vascular complications included age (per 10-year increment), male sex, diabetes duration (per 1-year increment), and history of hypoglycemia, with rate ratios (95% CIs) for microvascular complications of 1.14 (1.09-1.19), 1.30 (1.20-1.42), 1.03 (1.02-1.04) and 1.45 (1.25-1.69), respectively, and for macrovascular complications of 1.41 (1.34-1.48), 1.29 (1.16-1.45), 1.02 (1.01-1.02) and 1.24 (1.04-1.48), respectively. HbA1c levels (per 1.0% increment) were positively associated with microvascular (1.05 [1.02-1.08]) but not macrovascular (1.00 [0.97-1.04]) complications. CONCLUSIONS The global burden of microvascular and macrovascular complications is substantial in these patients with type 2 diabetes who are relatively early in the disease process. These findings highlight an opportunity for aggressive early risk factor modification, particularly in regions with a high prevalence of complications. Trial registration ClinicalTrials.gov; NCT02322762. Registered 23 December 2014. https://clinicaltrials.gov/ct2/show/NCT02322762 . ClinicalTrials.gov; NCT02226822. Registered 27 August 2014. https://clinicaltrials.gov/ct2/show/NCT02226822.
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Affiliation(s)
- Mikhail Kosiborod
- Saint Luke’s Mid America Heart Institute, 4401 Wornall Road, Kansas City, MO 64111 USA
- University of Missouri, Kansas City, 5100 Rockhill Rd, Kansas City, MO 64110 USA
| | - Marilia B. Gomes
- Rio de Janeiro State University, Av 28 de Setembro 77, Rio de Janeiro, CEP20555-030 Brazil
| | - Antonio Nicolucci
- Center for Outcomes Research and Clinical Epidemiology, Via Tiziano Vecellio, 2, 65124 Pescara, Italy
| | - Stuart Pocock
- London School of Hygiene and Tropical Medicine, Keppel St, Bloomsbury, London, WC1E 7HT UK
| | - Wolfgang Rathmann
- Institute for Biometrics and Epidemiology, German Diabetes Center, Auf’m Hennekamp 65, 40225 Düsseldorf, Germany
| | - Marina V. Shestakova
- Endocrinology Research Center, Moskvorech’ye Ulitsa, 1, Moscow, 115478 Russian Federation
| | - Hirotaka Watada
- Graduate School of Medicine, Juntendo University, 2-1-1 Hongo, Bunkyo-ku, Tokyo, 113-8421 Japan
| | - Iichiro Shimomura
- Graduate School of Medicine, Osaka University, 2-2 Yamadaoka, Suita, Osaka 565-0871 Japan
| | - Hungta Chen
- AstraZeneca, 950 Wind River Ln, Gaithersburg, MD 20878 USA
| | | | - Peter Fenici
- AstraZeneca, 132 Hills Rd, Cambridge, CB2 1PG UK
| | - Niklas Hammar
- AstraZeneca Gothenburg, Pepparedsleden 1, 431 50 Mölndal, Sweden
- Institute of Environmental Medicine, Karolinska Institutet, Solnavägen 1, 171 77 Solna, Sweden
| | - Filip Surmont
- AstraZeneca, 600 Capability Green, Luton, LU1 3LU UK
| | - Fengming Tang
- Saint Luke’s Mid America Heart Institute, 4401 Wornall Road, Kansas City, MO 64111 USA
| | - Kamlesh Khunti
- University of Leicester, University Rd, Leicester, LE1 7RH UK
| | - for The DISCOVER investigators
- Saint Luke’s Mid America Heart Institute, 4401 Wornall Road, Kansas City, MO 64111 USA
- University of Missouri, Kansas City, 5100 Rockhill Rd, Kansas City, MO 64110 USA
- Rio de Janeiro State University, Av 28 de Setembro 77, Rio de Janeiro, CEP20555-030 Brazil
- Center for Outcomes Research and Clinical Epidemiology, Via Tiziano Vecellio, 2, 65124 Pescara, Italy
- London School of Hygiene and Tropical Medicine, Keppel St, Bloomsbury, London, WC1E 7HT UK
- Institute for Biometrics and Epidemiology, German Diabetes Center, Auf’m Hennekamp 65, 40225 Düsseldorf, Germany
- Endocrinology Research Center, Moskvorech’ye Ulitsa, 1, Moscow, 115478 Russian Federation
- Graduate School of Medicine, Juntendo University, 2-1-1 Hongo, Bunkyo-ku, Tokyo, 113-8421 Japan
- Graduate School of Medicine, Osaka University, 2-2 Yamadaoka, Suita, Osaka 565-0871 Japan
- AstraZeneca, 950 Wind River Ln, Gaithersburg, MD 20878 USA
- Evidera, Metro Building, 6th Floor, 1 Butterwick, London, W6 8DL UK
- AstraZeneca, 132 Hills Rd, Cambridge, CB2 1PG UK
- AstraZeneca Gothenburg, Pepparedsleden 1, 431 50 Mölndal, Sweden
- Institute of Environmental Medicine, Karolinska Institutet, Solnavägen 1, 171 77 Solna, Sweden
- AstraZeneca, 600 Capability Green, Luton, LU1 3LU UK
- University of Leicester, University Rd, Leicester, LE1 7RH UK
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M. Porto LC, Santos DC, Hanhoerster LM, Gabrielli AB, Motta JP, Silva DA, Fabricio-Silva GM, Gomes E, Pizarro MH, Barros BS, Negrato CA, Dib SA, Gomes MB. P084 Type 1 Diabetes DQA1∼DQB1∼DRB1 haplotypes in an admixed brazilian population. Hum Immunol 2018. [DOI: 10.1016/j.humimm.2018.07.143] [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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Patel KK, Charbonnel B, Chen H, Cid-Rufaza J, Fenici P, Hammar N, Ji L, Kennedy KF, Khunti K, Kosiborod M, Pocock S, Shestakova M, Shimomura I, Surmont F, Watada H, Gomes MB. Abstract 261: Global Patterns of Comprehensive Cardiovascular Risk Factor Control in Patients With Type 2 Diabetes Mellitus: Insights From the Global DISCOVER Registry. Circ Cardiovasc Qual Outcomes 2018. [DOI: 10.1161/circoutcomes.11.suppl_1.261] [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: 11/16/2022]
Abstract
Background:
Guidelines recommend optimal control of cardiovascular risk factors such as blood pressure, lipids and smoking in addition to glycemic control to reduce the risk of micro and macro-vascular complications in patients with type 2 diabetes mellitus (T2D). However, the extent of comprehensive cardiovascular risk factor control in T2D internationally is not well-known.
Methods:
A total of 14,169 T2D patients initiating second-line therapy across 37 countries were enrolled in the DISCOVER registry. Optimal cardiovascular risk factor management at study baseline was defined as control of the following risk factors among eligible patients: 1) Systolic BP <140mmHg for all T2D patients; 2) statin prescription in all T2D patients ≥ 40 years, high-intensity statin for those with T2D and ASCVD; 3) non-smoking status for all T2D patients; 4) treatment with ACE-Inhibitor/Angiotensin Receptor Blocker (ACEI/ARB) in patients with T2D and 5) hypertension (HTN)/albuminuria and secondary ASCVD prevention with low-dose aspirin (ASA) in those with T2D and ASCVD. Global and country specific rates of individual and combined risk factor control were calculated. Inter-country variability was estimated using median odds ratios (MOR).
Results:
Mean age of the DISCOVER cohort was 56.6 (SD= 11.7) years; 7534 (53.2%) were male, mean BMI was 29.6 (SD= 5.9) kg/m
2
, median duration of T2D was 4.1 (IQR 2.0, 7.8) years. A total of 1643 (11.9%) patients had ASCVD, 7221 (51.0%) had HTN and 606 (4.3%) had albuminuria. Overall, among eligible patients, BP was controlled in 67.2% (9043/13457); statin treatment was prescribed in 38.3% (4977/12987); 85.2% (12,075/14169) were not smoking; ACEI/ARB treatment was prescribed in 53.7% (4917/9151), and ASA for secondary prevention was prescribed in 51.6% (847/1643) patients with ASCVD. Of 13,118 patients with 3 or more risk factors, 5312 (40.5%) had optimal control of at least 3 risk factors with wide inter-country variability.
Conclusion:
In a global registry of individuals with T2D from 37 countries, comprehensive control of ASCVD risk factors was not achieved in most patients, with wide variability among countries. Better strategies are needed to consistently provide comprehensive cardiovascular risk factor control in patients with T2D to improve long term outcomes.
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Affiliation(s)
| | | | | | | | | | - Niklas Hammar
- Institute of Environmental Medicine, Karolinska Institute, Astra Zeneca, Stockholm, Sweden
| | - Linong Ji
- Peking Univ People’s Hosp, Beijing, China
| | | | | | | | - Stuart Pocock
- London Sch of Hygiene and Tropical Medicine, London, United Kingdom
| | - Marina Shestakova
- Endocrinology Rsch Cntr, Diabetes Institute, Moscow, Russian Federation
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Khunti K, Godec TR, Medina J, Garcia‐Alvarez L, Hiller J, Gomes MB, Cid‐Ruzafa J, Charbonnel B, Fenici P, Hammar N, Hashigami K, Kosiborod M, Nicolucci A, Shestakova MV, Ji L, Pocock S. Patterns of glycaemic control in patients with type 2 diabetes mellitus initiating second-line therapy after metformin monotherapy: Retrospective data for 10 256 individuals from the United Kingdom and Germany. Diabetes Obes Metab 2018; 20:389-399. [PMID: 28817227 PMCID: PMC5813147 DOI: 10.1111/dom.13083] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [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: 05/22/2017] [Revised: 08/10/2017] [Accepted: 08/12/2017] [Indexed: 12/28/2022]
Abstract
AIM To investigate determinants of change in glycated haemoglobin (HbA1c) in patients with type 2 diabetes mellitus (T2DM) at 6 months after initiating uninterrupted second-line glucose-lowering therapies. MATERIALS AND METHODS This cohort study utilized retrospective data from 10 256 patients with T2DM who initiated second-line glucose-lowering therapy (switch from or add-on to metformin) between 2011 and 2014 in Germany and the UK. Effects of pre-specified patient characteristics on 6-month HbA1c changes were assessed using analysis of covariance. RESULTS Patients had a mean (standard error [SE]) baseline HbA1c of 8.68% (0.02); 28.5% of patients discontinued metformin and switched to an alternative therapy and the remainder initiated add-on therapy. Mean (SE) unadjusted 6-month HbA1c change was -1.27% (0.02). When adjusted for baseline HbA1c, 6-month changes depended markedly on the magnitude of the baseline HbA1c (HbA1c <9%, -0.45% per unit increase in HbA1c; HbA1c ≥9%, -0.87% per unit increase in HbA1c). Adjusted mean 6-month HbA1c reductions showed slight treatment differences (range, 0.92-1.09%; P < .001). Greater reductions in HbA1c were associated with second-line treatment initiation within 6 months of T2DM diagnosis (1.36% vs 1.03% [P < .001]) and advanced age (≥70 years, 1.13%; <70 years, 1.02% [P < .001]). CONCLUSIONS Many patients with T2DM have very high HbA1c levels when initiating second-line therapy, indicating the need for earlier treatment intensification. Patient-specific factors merit consideration when making treatment decisions.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | - Niklas Hammar
- AstraZeneca GothenburgMölndalSweden
- Institute of Environmental Medicine, Karolinska InstitutetStockholmSweden
| | | | - Mikhail Kosiborod
- Saint Luke's Mid America Heart InstituteKansas CityMissouri
- University of MissouriKansas CityMissouri
| | | | - Marina V. Shestakova
- Endocrinology Research Centre, Diabetes InstituteMoscowRussian Federation
- I. M. Sechenov First Moscow State Medical UniversityMoscowRussian Federation
| | - Linong Ji
- Peking University People's HospitalBeijingChina
| | - Stuart Pocock
- London School of Hygiene and Tropical MedicineLondonUK
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22
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Khunti K, Gomes MB, Pocock S, Shestakova MV, Pintat S, Fenici P, Hammar N, Medina J. Therapeutic inertia in the treatment of hyperglycaemia in patients with type 2 diabetes: A systematic review. Diabetes Obes Metab 2018; 20:427-437. [PMID: 28834075 PMCID: PMC5813232 DOI: 10.1111/dom.13088] [Citation(s) in RCA: 215] [Impact Index Per Article: 35.8] [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: 06/13/2017] [Revised: 08/08/2017] [Accepted: 08/15/2017] [Indexed: 12/28/2022]
Abstract
AIMS Therapeutic inertia, defined as the failure to initiate or intensify therapy in a timely manner according to evidence-based clinical guidelines, is a key reason for uncontrolled hyperglycaemia in patients with type 2 diabetes. The aims of this systematic review were to identify how therapeutic inertia in the management of hyperglycaemia was measured and to assess its extent over the past decade. MATERIALS AND METHODS Systematic searches for articles published from January 1, 2004 to August 1, 2016 were conducted in MEDLINE and Embase. Two researchers independently screened all of the titles and abstracts, and the full texts of publications deemed relevant. Data were extracted by a single researcher using a standardized data extraction form. RESULTS The final selection for the review included 53 articles. Measurements used to assess therapeutic inertia varied across studies, making comparisons difficult. Data from low- to middle-income countries were scarce. In most studies, the median time to treatment intensification after a glycated haemoglobin (HbA1c) measurement above target was more than 1 year (range 0.3 to >7.2 years). Therapeutic inertia increased as the number of antidiabetic drugs rose and decreased with increasing HbA1c levels. Data were mainly available from Western countries. Diversity of inertia measures precluded meta-analysis. CONCLUSIONS Therapeutic inertia in the management of hyperglycaemia in patients with type 2 diabetes is a major concern. This is well documented in Western countries, but corresponding data are urgently needed in low- and middle-income countries, in view of their high prevalence of type 2 diabetes.
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Affiliation(s)
| | | | - Stuart Pocock
- London School of Hygiene and Tropical MedicineLondonUK
| | - Marina V. Shestakova
- Endocrinology Research CenterMoscowRussian Federation
- I.M. Sechenov First Moscow State Medical UniversityMoscowRussian Federation
| | | | | | - Niklas Hammar
- AstraZenecaMölndalSweden
- Institute of Environmental Medicine, Karolinska InstituteStockholmSweden
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Ji L, Bonnet F, Charbonnel B, Gomes MB, Kosiborod M, Khunti K, Nicolucci A, Pocock S, Rathmann W, Shestakova MV, Shimomura I, Watada H, Fenici P, Hammar N, Hashigami K, Macaraeg G, Surmont F, Medina J. Towards an improved global understanding of treatment and outcomes in people with type 2 diabetes: Rationale and methods of the DISCOVER observational study program. J Diabetes Complications 2017; 31:1188-1196. [PMID: 28499961 DOI: 10.1016/j.jdiacomp.2017.03.011] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [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: 12/22/2016] [Revised: 03/23/2017] [Accepted: 03/25/2017] [Indexed: 01/19/2023]
Abstract
AIM Contemporary global real-world data on the management of type 2 diabetes are scarce. The global DISCOVER study program aims to describe the disease management patterns and a broad range of associated outcomes in patients with type 2 diabetes initiating a second-line glucose-lowering therapy in routine clinical practice. METHODS The DISCOVER program comprises two longitudinal observational studies involving more than 15,000 patients in 38 countries across six continents. Study sites have been selected to be representative of type 2 diabetes management in each country. Data will be collected at baseline (initiation of second-line therapy), at 6months, and yearly during a 3-year follow-up period. RESULTS The DISCOVER program will record patient, healthcare provider, and healthcare system characteristics, treatment patterns, and factors influencing changes in therapy. In addition, disease control (e.g. achievement of glycated hemoglobin target), management of associated risk factors (e.g. hypercholesterolemia and hypertension), and healthcare resource utilization will be recorded. Microvascular and macrovascular complications, incidence of hypoglycemic events, and patient-reported outcomes will also be captured. CONCLUSIONS The DISCOVER program will provide insights into the current management of patients with type 2 diabetes worldwide, which will contribute to informing future clinical guidelines and improving patient care.
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Affiliation(s)
- Linong Ji
- Peking University People's Hospital, Beijing, China.
| | | | | | | | - Mikhail Kosiborod
- Saint Luke's Mid America Heart Institute, Kansas City, MO, USA; University of Missouri, Kansas City, MO, USA
| | | | - Antonio Nicolucci
- Center for Outcomes Research and Clinical Epidemiology, Pescara, Italy
| | - Stuart Pocock
- London School of Hygiene and Tropical Medicine, London, UK
| | - Wolfgang Rathmann
- Institute for Biometrics and Epidemiology, German Diabetes Center, Leibniz Center for Diabetes Research at Heinrich-Heine-University, Düsseldorf, Germany
| | - Marina V Shestakova
- Endocrinology Research Center, Diabetes Institute, Moscow, Russian Federation; I.M. Sechenov First Moscow State Medical University, Moscow, Russian Federation
| | | | - Hirotaka Watada
- Graduate School of Medicine, Juntendo University, Tokyo, Japan
| | | | - Niklas Hammar
- AstraZeneca, Mölndal, Sweden; Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
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Gomes MB, Almeida AP, Santos DC, Leão E, Cunha EF, Negrato CA. Cause-specific mortality in a cohort of Brazilian patients with type 1 diabetes. Acta Diabetol 2017; 54:535-542. [PMID: 28251285 DOI: 10.1007/s00592-017-0975-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [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: 01/18/2017] [Accepted: 02/14/2017] [Indexed: 01/29/2023]
Abstract
AIMS To assess cause-specific mortality in a cohort of patients with type 1 diabetes (T1D) followed at an university hospital (tertiary level, Rio de Janeiro city) and an outpatient clinic (secondary level, Bauru city) both in Brazil's southeast, and associations of survival with gender, age at diagnosis, self-reported ethnicity and diabetes duration. METHODS Our study is based on a cohort of patients with T1D whose vital status was determined as of December 31, 2015. The causes of mortality were determined by death certificates and outpatient clinic records. RESULTS Among 986 patients, (54.4%) females, (74.8%) Caucasians, 886 (89.9%) were alive, 62 (6.3%) had died, and in 38 (3.9%) the vital status was unknown. Median age at death [interquartile range] and diabetes duration until death were 30.0 [13] and 15.6 [10] years, respectively. Considering those who died (n = 62), most patients (about 70%) died from end-stage renal disease, macrovascular disease or acute complications of diabetes, mainly diabetic ketoacidosis. The other causes of mortality were infections, fatal accidents and non-diabetes-related. The standardized mortality ratio was 3.13 [2.35-4.08] in those aged under 40. In a multivariate Cox model, "age < 40 years" and "year of diagnosis" were the only significant variables with hazard ratios of 6.259 [(3.100-12.639), p < 0.001] and 0.915 [(0.880-0.951), p < 0.001], respectively. CONCLUSIONS Our study shows that patients with T1D had a threefold increase in mortality. The specific causes of mortality were mainly diabetes-related chronic complications; however, acute complications, especially diabetic ketoacidosis, persisted as an important cause of mortality.
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Affiliation(s)
- Marilia B Gomes
- Diabetes Unit, Department of Internal Medicine, State University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Ana P Almeida
- Diabetes Unit, Department of Internal Medicine, State University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Deborah C Santos
- Diabetes Unit, Department of Internal Medicine, State University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Eliete Leão
- Diabetes Unit, Department of Internal Medicine, State University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Edna F Cunha
- Diabetes Unit, Department of Internal Medicine, State University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Carlos A Negrato
- Bauru's Diabetics Association, Rua Saint Martin 27-07, Bauru, São Paulo, CEP 17012-433, Brazil.
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Gomes MB, Negrato CA. Adherence to insulin therapeutic regimens in patients with type 1 diabetes. A nationwide survey in Brazil. Diabetes Res Clin Pract 2016; 120:47-55. [PMID: 27513598 DOI: 10.1016/j.diabres.2016.07.011] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [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: 12/23/2015] [Revised: 03/30/2016] [Accepted: 07/16/2016] [Indexed: 01/22/2023]
Abstract
AIMS Determine the relationship between self-reported adherence to insulin therapeutic regimens in Brazilian patients with type 1 diabetes and demographic, clinical data, glycemic control and cardiovascular risk factors. METHODS This was a cross-sectional, multicenter study conducted between August 2011 and August 2014 in 10 Brazilian cities. Data were obtained from 1698 patients, aged 30.0±11.90years (55.5% females, 53.6% Caucasians) with a diabetes duration of 15.4±1.9years. Adherence was evaluated using an adapted 4-item Morisky Medication Scale (MMAS) questionnaire. RESULTS A total of 166 (9.8%), 717 (42.2%) and 815 (48.0%) of the patients reported maximal (group 0), moderate (group 1) and minimal (group 2) adherence to their insulin therapeutic regimen, respectively. A significant difference in HbA1c was observed in patients from group 2, 9.2±2.2% (77±25mmol/mol) compared to group 1, 8.9±2.0% (74±22mmol/mol) and group 0, 8.6±1.9% (71±21mmol/mol) (p=0.003). A multivariate logistic analysis revealed that the significant independent variables related to higher insulin therapeutic regimen adherence were older age, higher adherence to diet, lower rate of self-reported hypoglycemia in the last month, low economic status and living in the Southeast region. Insulin therapeutic regimens, number of daily insulin injections, self-monitoring of blood glucose, gender, ethnicity and cardiovascular risk factors were not related to adherence. CONCLUSIONS Most Brazilian T1D patients did not adhere to their prescribed insulin therapeutic regimen, according to the MMAS 4-item scale. This tool should be initially used to identify non-adherent patients and help them overcome the barriers to adherence to their prescriptions.
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Affiliation(s)
- M B Gomes
- Department of Internal Medicine, Diabetes Unit, State University Hospital of Rio de Janeiro, Brazil
| | - C A Negrato
- Bauru's Diabetics Association, Department of Internal Medicine, Bauru, São Paulo, Brazil.
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Giuffrida FMA, Bulcão C, Cobas RA, Negrato CA, Gomes MB, Dib SA. Double-diabetes in a real-world sample of 2711 individuals: associated with insulin treatment or part of the heterogeneity of type 1 diabetes? Diabetol Metab Syndr 2016; 8:28. [PMID: 27011769 PMCID: PMC4804538 DOI: 10.1186/s13098-016-0143-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2015] [Accepted: 03/09/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Double diabetes (DD) describes both individuals with obesity upon diagnosis of type 1 diabetes and those who have gained weight during follow-up, although cardiovascular risk factors (CVRF) are not well understood in this group. We aim to evaluate the frequency of DD in a real-world type 1 diabetes sample and the interaction of insulin treatment with CVRF. METHODS Multicentre cross-sectional study of 2711 individuals with clinical diagnosis of type 1 diabetes from secondary diabetes centres in 20 Brazilian cities. RESULTS Patients with diabetes duration <5 and ≥5 years had similar frequency of overweight (20.4 vs. 25 %) and obesity, (9.8 vs. 6.1 %), p 0.28 for trend. Insulin dose (U/kg/day) was lower in obese individuals compared to normal BMI, with mean (95 % CI) 0.72 (0.62-0.83) vs. 0.88 (0.84-0.92) U/kg/day for diabetes duration <5 years and 0.84 (0.77-0.92) vs. 0.99 (0.97-1.01) U/kg/day for duration ≥5 years. Obese individuals had lower HDL (47.5 vs. 54.4 mg/dL) and higher non-HDL-cholesterol (134.5 vs. 115.2 mg/dL) than lean ones only among those with more than 5 years of diabetes. CONCLUSIONS Lower insulin doses in obese individuals point to a role of clinical heterogeneity in insulin deficiency rather than normal progression of type 1 diabetes. Early obesity in type 1 diabetes is associated to lower HDL-cholesterol and higher number of CVRF. These data suggest a broad landscape of pathophysiological phenomena in double diabetes, rather than simple progression of a homogeneous clinical entity.
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Affiliation(s)
- Fernando M. A. Giuffrida
- />Departamento de Ciências da Vida, Universidade do Estado da Bahia (UNEB), Rua Silveira Martins, 2555, Cabula, Salvador, Bahia CEP: 41.150-000 Brazil
- />Centro de Diabetes e Endocrinologia do Estado da Bahia (CEDEBA), Salvador, Brazil
| | - Caroline Bulcão
- />Centro de Diabetes e Endocrinologia do Estado da Bahia (CEDEBA), Salvador, Brazil
| | - Roberta A. Cobas
- />Universidade Estadual do Rio de Janeiro, Rio De Janeiro, Brazil
| | | | - Marilia B. Gomes
- />Universidade Estadual do Rio de Janeiro, Rio De Janeiro, Brazil
| | - Sergio Atala Dib
- />Centro de Diabetes, Universidade Federal de São Paulo, São Paulo, Brazil
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Gomes MB, Negrato CA, Calliari LEP. Early age at menarche: a risk factor for overweight or obesity in patients with type 1 diabetes living in urban areas? Diabetes Res Clin Pract 2015; 107:23-30. [PMID: 25467623 DOI: 10.1016/j.diabres.2014.10.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [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: 06/03/2014] [Revised: 09/13/2014] [Accepted: 10/18/2014] [Indexed: 02/06/2023]
Abstract
AIMS Determine the relationship between age at menarche, glycemic control and cardiovascular risk factors in patients with type 1 diabetes living in urban areas. METHODS This was a multicenter cross-sectional study conducted in 20 cities in four Brazilian geographic regions. Data were obtained from 1527 female patients, 59.3% Caucasians, aged 25.1 ± 10.6 years. Diabetes duration was 11.4 ± 8.1 years. Age at menarche was stratified in four groups: 8-11 (group 1, early menarche), 12 (group 2), 13 (group 3) and 14-18 years (group 4, late menarche). RESULTS The mean age at menarche was 12.7 ± 1.7 years without difference among geographical regions, economic status, level of care and ethnicity. BMI had an inverse correlation with age at menarche (r=-0.14, p<0.001). No significant difference was observed among the four groups for blood pressure, lipid profile and diabetes-related chronic complications. Logistic regression analysis showed that early age at menarche, 8-11 years (odds ratio (ORs) 1.77 [1.30-2.41], p<0.001) and duration of diabetes [ORs 1.01 (1.00-1.03), p=0.02], were related to greater risk of patients' overweight or obesity; adherence to diet [ORs 0.78 (0.60-0.93), p=0.01], physical activity [ORs 0.75 (0.94-0.94), p=0.01], and lower insulin dose (U/kg) [ORs 0.54 (0.59-0.90), p=0.001] were related to lower risk for overweight or obesity. CONCLUSIONS Early menarche occurred in 23.4% of women with type 1 diabetes living in Brazilian urban areas and was strongly associated with overweight/obesity in pubertal/adult life. Further studies are warranted to establish the relationship between early menarche, glycemic control and cardiovascular risk factors.
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Affiliation(s)
- M B Gomes
- Department of Internal Medicine, Diabetes Unit, State University of Rio de Janeiro, Brazil
| | - C A Negrato
- Bauru's Diabetics Association, Bauru, São Paulo, Brazil.
| | - L E P Calliari
- Pediatric Endocrine Unit, Santa Casa School of Medical Sciences, São Paulo, SP, Brazil
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Rodacki M, Zajdenverg L, Dantas JR, de Oliveira JEP, Luiz RR, Cobas RA, Palma CCS, Negrato CA, Gomes MB. Should thyroid-stimulating hormone goals be reviewed in patients with type 1 diabetes mellitus? Results from the Brazilian Type 1 Diabetes Study Group. Diabet Med 2014; 31:1665-72. [PMID: 24961827 DOI: 10.1111/dme.12530] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [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: 11/03/2013] [Revised: 04/15/2014] [Accepted: 06/20/2014] [Indexed: 12/19/2022]
Abstract
AIMS To investigate if thyroid-stimulating hormone (TSH) levels are associated with any differences in glycaemic control or diabetes-related complications in individuals with Type 1 diabetes. METHODS This observational, cross-sectional and multicentre study included patients with Type 1 diabetes for ≥ 5 years, with a recent TSH measurement and without a known previous thyroid disease. Patients were divided into three groups according to TSH levels: 0.4-2.5 mU/l; 2.5-4.4 mU/l; and ≥ 4.5 mU/l. RESULTS We included 1205 individuals with a mean ± sd age of 23.8 ± 11.3 years. Seven patients had TSH levels <0.4 mU/l and were excluded from the comparison between groups. HbA1c levels, systolic and diastolic blood pressure, LDL cholesterol and disease duration were similar in all groups (P = 0.893, P = 0.548, P = 0.461, P = 0.575 and P = 0.764, respectively). The rates of diabetic retinopathy and GFR < 60/mL/min/1.73 m(2) differed between groups (P = 0.006 and P < 0.001, respectively) and were lower in those with lower TSH levels. Multivariate analysis confirmed these associations. The frequencies of retinopathy and GFR < 60 mL/min/1.73 m(2) were higher not only in patients with TSH ≥ 4.5 mU/l (odds ratio 1.878 and 2.271, respectively) but also in those with TSH levels of 2.5-4.4 mU/l (odds ratio 1.493 and 2.286, respectively), when compared with patients with TSH levels of 0.4-2.5 mU/l. CONCLUSIONS TSH levels of 0.4-2.5 mU/l are associated with a lower risk of diabetic retinopathy and renal failure in individuals with Type 1 diabetes, independently of glycaemic control and duration of the disease.
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Affiliation(s)
- M Rodacki
- Diabetes and Nutrition Section, Department of Internal Medicine, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
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Kaiser SE, Sanjuliani AF, Estato V, Gomes MB, Tibiriçá E. Antihypertensive treatment improves microvascular rarefaction and reactivity in low-risk hypertensive individuals. Microcirculation 2014; 20:703-16. [PMID: 23692260 DOI: 10.1111/micc.12067] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2013] [Accepted: 05/16/2013] [Indexed: 10/26/2022]
Abstract
OBJECTIVE To test whether long-term antihypertensive treatment with metoprolol succinate (a β₁-adrenoceptor blocker) or olmesartan medoxomil (an angiotensin II AT₁-receptor blocker) reverses microvascular dysfunction in hypertensive patients. METHODS This study included 44 hypertensive outpatients and 20 age and sex-matched healthy controls. We used skin capillaroscopy to measure capillary density and recruitment at rest and during PORH. Endothelium-dependent vasodilation of skin microcirculation was evaluated with a LDPM system in combination with ACh iontophoresis, PORH, and LTH. RESULTS Pretreatment capillary density in hypertensive patients was significantly reduced compared with controls (71.3 ± 1.5 vs. 80.6 ± 1.8 cap/mm²; p < 0.001), as was PORH (71.7 ± 1.5 vs. 79.5 ± 2.6 cap/mm²; p < 0.05). After treatment for six months, capillary density increased to 75.4 ± 1.1 cap/mm² (p < 0.01) at rest and 76.8 ± 1.1 cap/mm² during PORH. During LTH, CVC in perfusion units (PU)/mmHg was similar in patients (1.71 [1.31-2.12]) and controls (1.60 [1.12-1.91]) and increased significantly (1.82 [1.30-2.20]) after treatment. Maximal CVC during PORH was reduced in hypertensive patients (0.30 [0.22-0.39]) compared to controls (0.39 [0.31-0.49], p < 0.001) and increased (0.41 [0.29-0.51], p < 0.001) after treatment. CONCLUSIONS Capillary rarefaction and microvascular endothelial dysfunction in hypertensive patients responded favorably to long-term pharmacological treatment.
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Affiliation(s)
- Sérgio E Kaiser
- Clinical and Experimental Pathophysiology Unit, State University of Rio de Janeiro, Rio de Janeiro, Brazil
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Davison KAK, Negrato CA, Cobas R, Matheus A, Tannus L, Palma CS, Japiassu L, Carneiro JRI, Rodacki M, Zajdenverg L, Araújo NBC, Cordeiro MM, Luescher JL, Berardo RS, Nery M, Cani C, do Carmo A Marques M, Calliari LE, Noronha RM, Manna TD, Savoldelli R, Penha FG, Foss MC, Foss-Freitas MC, de Fatima Guedes M, Dib SA, Dualib P, Silva SC, Sepúlveda J, Sampaio E, Rea RR, Faria ACRA, Tschiedel B, Lavigne S, Cardozo GA, Pires AC, Robles FC, Azevedo M, Canani LH, Zucatti AT, Coral MHC, Pereira DA, Araujo LA, Pedrosa HC, Tolentino M, Prado FA, Rassi N, Araujo LB, Fonseca RMC, Guedes AD, Mattos OS, Faria M, Azulay R, Forti AC, Façanha CFS, Montenegro R, Montenegro AP, Melo NH, Rezende KF, Ramos A, Felicio JS, Santos FM, Jezini DL, Gomes MB. Relationship between adherence to diet, glycemic control and cardiovascular risk factors in patients with type 1 diabetes: a nationwide survey in Brazil. Nutr J 2014; 13:19. [PMID: 24607084 PMCID: PMC3995939 DOI: 10.1186/1475-2891-13-19] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2013] [Accepted: 02/25/2014] [Indexed: 11/28/2022] Open
Abstract
Background To determine the relationship between adherence to the diet reported by patients with type 1 diabetes under routine clinical care in Brazil, and demographic, socioeconomic status, glycemic control and cardiovascular risk factors. Methods This was a cross-sectional, multicenter study conducted between December 2008 and December 2010 in 28 public clinics in 20 Brazilian cities. The data was obtained from 3,180 patients, aged 22 ± 11.8 years (56.3% females, 57.4% Caucasians and 43.6% non-Caucasians). The mean time since diabetes diagnosis was 11.7 ± 8.1 years. Results Overall, 1,722 (54.2%) of the patients reported to be adherent to the diet without difference in gender, duration of diabetes and socioeconomic status. Patients who reported adherence to the diet had lower BMI, HbA1c, triglycerides, LDL-cholesterol, non HDL-cholesterol and diastolic blood pressure and had more HbA1c at goal, performed more frequently self-monitoring of blood glucose (p < 0.001), and reported less difficulties to follow specific schedules of diet plans (p < 0.001). Less patients who reported to be adherent were obese or overweight (p = 0.005). The quantity of food and time schedule of the meals were the most frequent complaints. Logistic regression analysis showed that ethnicity, (Caucasians, (OR 1.26 [1.09-1.47]), number of medical clinical visits in the last year (OR 1.10 [1.06-1.15]), carbohydrate counting, (OR 2.22 [1.49-3.30]) and diets recommended by diabetes societies’, (OR 1.57 [1.02-2.41]) were related to greater patients’ adherence (p < 0.05) and age, [adolescents (OR 0.60 [0.50-0.72]), high BMI (OR 0.58 [0.94-0.98]) and smoking (OR 0.58 [0.41-0.84]) with poor patients’ adherence (p < 0.01). Conclusions Our results suggest that it is necessary to rethink medical nutrition therapy in order to help patients to overcome barriers that impair an optimized adherence to the diet.
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Affiliation(s)
- Kariane A K Davison
- Bauru's Diabetics Association, Department of Internal Medicine, Bauru, São Paulo, Brazil.
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de Castro SH, Brito GNO, Gomes MB. Health literacy skills in type 2 diabetes mellitus outpatients from an university-affiliated hospital in Rio de Janeiro, Brazil. Diabetol Metab Syndr 2014; 6:126. [PMID: 25960771 PMCID: PMC4424576 DOI: 10.1186/1758-5996-6-126] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2014] [Accepted: 11/11/2014] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Type 2 diabetes mellitus is the most common metabolic disorder and has considerable impact on quality of life. Treatment of DM2 is complex and adherence to treatment requires sophisticated cognition which includes literacy skills. METHODS Health literacy skills of a cross-sectional nonrandom sample of 164 DM2 outpatients at the Diabetes Unit of the Hospital Universitário Pedro Ernesto at the State University of Rio de Janeiro were evaluated by the short version of the Test of Functional Health Literacy in Adults (s-TOFHLA). Procedures available in the SPSS package were used in data analysis. RESULTS Fourteen out of 164 patients (8.5%) were completely illiterate and therefore were not further assessed. The remaining 150 patients (75 men and 75 women) were the participants of this study. Data showed that 110 (73.3%) participants had adequate health literacy skills, 17 (11.3%) had marginal skills and 23 (15.3%) had inadequate skills. Moreover, older participants performed worse than younger patients. In addition, Caucasian and multiethnic participants performed better than Afro-Brazilians. Furthermore, participants with higher educational and occupational levels outperformed those with lower levels. However, only age and education, but not ethnic group and occupation, contributed significantly and independently to health literacy. CONCLUSION This study showed that almost a quarter of the participants are illiterate or have inadequate health literacy skills. Therefore, our results indicate the need for the development of health care instructions properly calibrated to the health literacy skills of DM2 patients.
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Affiliation(s)
- Simone H de Castro
- />Departamento de Medicina Interna, Disciplina de Diabetes, Universidade do Estado do Rio de Janeiro, Rio de Janeiro, RJ Brasil
- />Serviço de Diabetes e Metabologia, Hospital Universitário Pedro Ernesto, Universidade do Estado do Rio de Janeiro, Av 28 setembro 77, 3 andar, 20551-030 Rio de Janeiro, RJ Brasil
| | - Gilberto N O Brito
- />Departamento de Psiquiatria e Saúde Mental, Instituto de Saúde da Comunidade, Universidade Federal Fluminense, Niterói, RJ Brasil
- />Departamento de Pesquisa, Instituto Fernandes Figueira, FIOCRUZ, Rio de Janeiro, RJ Brasil
| | - Marilia B Gomes
- />Departamento de Medicina Interna, Disciplina de Diabetes, Universidade do Estado do Rio de Janeiro, Rio de Janeiro, RJ Brasil
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Gomes MB, Tannus LRM, Cobas RA, Matheus ASM, Dualib P, Zucatti AT, Cani C, Guedes AD, Santos FM, Sepulveda J, Tolentino M, Façanha MC, Faria ACRA, Lavigne S, Montenegro AP, Rodacki M, de Fatima Guedes M, Szundy R, Cordeiro MM, Santos PTS, Negrato CA. Determinants of self-monitoring of blood glucose in patients with Type 1 diabetes: a multi-centre study in Brazil. Diabet Med 2013; 30:1255-62. [PMID: 23721292 DOI: 10.1111/dme.12236] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [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: 12/17/2012] [Revised: 03/26/2013] [Accepted: 05/15/2013] [Indexed: 11/27/2022]
Abstract
AIM The aim of this study was to determine the relationship between the daily frequency of self-monitoring of blood glucose and glycaemic control, demographic and socio-economic status in patients with Type 1 diabetes under routine clinical care in Brazil. METHODS This was a cross-sectional, multi-centre study conducted between December 2008 and December 2010 in 28 public clinics in 20 Brazilian cities. The data were obtained from 3176 patients, aged 22 ± 11.8 years, of whom 56.3% were female and 57.4% were Caucasian. The mean time since diabetes diagnosis was 11.7 ± 8.1 years. RESULTS The prevalence of self-monitoring of blood glucose was 88.5%. There was a significant increase in self-monitoring frequency associated with female gender, lower ages, more intensive diabetes management and higher socio-economic status. A correlation between HbA(1c) levels and the daily frequency of self-monitoring was observed (r(s) = -0.13; P = 0.001). The mean HbA1c levels were related to the daily frequency of self-monitoring (P < 0.001) without additional benefit to patients who performed self-monitoring more than four times daily (9.2, 11.2, 10.2,15.2 and 15% for one, two, three, four, five or more self-monitoring tests daily, respectively; P < 0.0001). CONCLUSIONS The majority of our patients (88.5%) performed three or more self-monitoring tests daily, with more frequent testing reported by females, younger patients, those on intensive insulin regimens and of higher socio-economic status. No additional benefit was found in patients who performed self-monitoring more than four times daily. The diabetes care team must improve patients' education regarding self-monitoring of blood glucose and its benefits.
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Affiliation(s)
- M B Gomes
- Department of Internal Medicine, Diabetes Unit, State University Hospital of Rio de Janeiro, São Paulo, Brazil
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Gomes MB, de Mattos Matheus AS, Calliari LE, Luescher JL, Manna TD, Savoldelli RD, Cobas RA, Coelho WS, Tschiedel B, Ramos AJ, Fonseca RM, Araujo NBC, Almeida HG, Melo NH, Jezini DL, Negrato CA. Economic status and clinical care in young type 1 diabetes patients: a nationwide multicenter study in Brazil. Acta Diabetol 2013; 50:743-52. [PMID: 22688518 DOI: 10.1007/s00592-012-0404-3] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [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: 03/13/2012] [Accepted: 05/17/2012] [Indexed: 10/28/2022]
Abstract
The aim of this study is to evaluate the influence of economic status on clinical care provided to Brazilian youths with type 1 diabetes in daily practice, according to the American Diabetes Association's guidelines. This was a cross-sectional, multicenter study conducted between 2008 and 2010 in 28 public clinics in Brazil. Data were obtained from 1,692 patients (55.3 % female, 56.4 % Caucasian), with a mean age of 13 years (range, 1-18), a mean age at diagnosis of 7.1 ± 4 years and diabetes duration of 5 ± 3.7 years. Overall, 75 % of the patients were of a low or very low economic status. HbA1c goals were reached by 23.2 %, LDL cholesterol by 57.9 %, systolic blood pressure by 83.9 % and diastolic blood pressure by 73.9 % of the patients. In total, 20.2 % of the patients were overweight and 9.2 % were obese. Patients from very low economic status were less likely to attend tertiary care level when compared with those from low, medium and high economic status, 64.2 % versus 75.5 % versus 78.3 % and 74.0 %; p < 0.001, respectively. The rate of annual screening for retinopathy, nephropathy and for foot alterations was 66.2, 69.7 and 62.7 %, respectively. Insulin dose, age, very low economic status, daily frequency of self-blood glucose monitoring and female gender were independently associated with poor glycemic control. Screening for diabetic complications and attaining glucose, lipid and blood pressure goals present a challenge for young Brazilian type 1 diabetes patients. The low economic status of the majority of our patients may represent a barrier to reaching these goals.
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Affiliation(s)
- Marilia B Gomes
- Diabetes Unit, Department of Internal Medicine, State University Hospital of Rio de Janeiro, Avenida 28 de Setembro, 77, 3° andar, Rio de Janeiro, Rio de Janeiro, 20.551-030, Brazil,
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Negrato CA, Montenegro Junior RM, Von Kostrisch LM, Guedes MF, Mattar R, Gomes MB. Insulin analogues in the treatment of diabetes in pregnancy. ACTA ACUST UNITED AC 2013; 56:405-14. [PMID: 23108744 DOI: 10.1590/s0004-27302012000700001] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2012] [Accepted: 08/09/2012] [Indexed: 11/22/2022]
Abstract
Pregnancy affects both maternal and fetal metabolism, and even in non-diabetic women, it exerts a diabetogenic effect. Among pregnant women, 2% to 14% develop gestational diabetes. Pregnancy can also occur in women with preexisting diabetes, which may predispose the fetus to many alterations in organogenesis, restrict growth, and the mother, to some diabetes-related complications, such as retinopathy and nephropathy, or to acceleration of the course of these complications, if they are already present. Women with gestational diabetes generally start their treatment with diet and lifestyle changes; when these changes are not enough for optimal glycemic control, insulin therapy must then be considered. Women with type 2 diabetes using oral hypoglycemic agents are advised to change to insulin therapy. Those with preexisting type 1 diabetes should start intensive glycemic control. As basal insulin analogues have frequently been used off-label in pregnant women, there is a need to evaluate their safety and efficacy. The aim of this review is to report the use of both short- and long-acting insulin analogues during pregnancy and to enable clinicians, obstetricians, and endocrinologists to choose the best insulin treatment for their patients.
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Gomes MB, Tannus LRM, Matheus ASDM, Cobas RA, Palma CCS, Silva ATK, Negrato CA, Dib SA, Rodacki M, Felício JS, Canani LH. Prevalence, awareness, and treatment of hypertension in patients with type 1 diabetes: a nationwide multicenter study in Brazil. Int J Hypertens 2013; 2013:565263. [PMID: 23533714 PMCID: PMC3603155 DOI: 10.1155/2013/565263] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2012] [Accepted: 01/24/2013] [Indexed: 11/17/2022] Open
Abstract
Objective. This study evaluated the prevalence, awareness, and type of treatment for hypertension in Brazil in patients with type 1 diabetes (T1D). Methods. This was a cross-sectional, multicenter study that was conducted from December 2008 to December 2010 in 28 public clinics located in 20 Brazilian cities. Results. A total of 3,591 patients were studied, 56% female, average age 21.2 ± 11.7 years, with a median duration of diabetes 9.6 ± 8.1 years. Blood pressure levels were available for a total of 3,323 patients and 689 (19.2%) patients were hypertensive. Hypertensive patients were older, exhibited longer duration of diabetes, and had higher body mass index (BMI), total cholesterol, triglycerides, and LDL-C values (P < 0.001, for all comparisons), but only 370 (53.7%) received treatment. Patient awareness of hypertension was documented in 453 (65.5%) patients. However, only 76 (22.9%) of the treated patients attained the target systolic (sBP) and diastolic blood pressures (dBP). Conclusions. Our results demonstrate that a large number of T1D patients with hypertension do not receive appropriate treatment; few of the treated T1D patients achieved the target sBP and dBP values. Greater attention should be paid to blood pressure evaluation, hypertension diagnosis, and treatment of T1D patients in Brazil.
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Affiliation(s)
- Marilia B. Gomes
- Department of Internal Medicine, Diabetes Unit, State University of Rio de Janeiro, 20551-030 Rio de Janeiro, RJ, Brazil
| | | | | | - Roberta Arnoldi Cobas
- Department of Internal Medicine, Diabetes Unit, State University of Rio de Janeiro, 20551-030 Rio de Janeiro, RJ, Brazil
| | - Catia C. Sousa Palma
- Department of Internal Medicine, Diabetes Unit, State University of Rio de Janeiro, 20551-030 Rio de Janeiro, RJ, Brazil
| | - Aline Tiemi Kano Silva
- Department of Internal Medicine, Diabetes Unit, State University of Rio de Janeiro, 20551-030 Rio de Janeiro, RJ, Brazil
| | | | - Sergio Atala Dib
- Diabetes Unit, Federal University of São Paulo State, 04021-001 São Paulo, SP, Brazil
| | - Melanie Rodacki
- Federal University of Rio de Janeiro, 21941-901 Rio de Janeiro, RJ, Brazil
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Giuffrida FMA, Guedes AD, Rocco ER, Mory DB, Dualib P, Matos OS, Chaves-Fonseca RM, Cobas RA, Negrato CA, Gomes MB, Dib SA. Heterogeneous behavior of lipids according to HbA1c levels undermines the plausibility of metabolic syndrome in type 1 diabetes: data from a nationwide multicenter survey. Cardiovasc Diabetol 2012; 11:156. [PMID: 23270560 PMCID: PMC3547761 DOI: 10.1186/1475-2840-11-156] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2012] [Accepted: 12/25/2012] [Indexed: 12/21/2022] Open
Abstract
Background Cardiovascular risk factors (CVRF) may cluster in type 1 diabetes, analogously to the metabolic syndrome described in type 2 diabetes. The threshold of HbA1c above which lipid variables start changing behavior is unclear. This study aims to 1) assess the behavior of dyslipidemia according to HbA1c values; 2) detect a threshold of HbA1c beyond which lipids start to change and 3) compare the clustering of lipids and other non-lipid CVRF among strata of HbA1c individuals with type 1 diabetes. Methods Effects of HbA1c quintiles (1st: ≤7.4%; 2nd: 7.5-8.5%; 3rd: 8.6-9.6%; 4th: 9.7-11.3%; and 5th: >11.5%) and covariates (gender, BMI, blood pressure, insulin daily dose, lipids, statin use, diabetes duration) on dyslipidemia were studied in 1275 individuals from the Brazilian multi-centre type 1 diabetes study and 171 normal controls. Results Body size and blood pressure were not correlated to lipids and glycemic control. OR (99% CI) for high-LDL were 2.07 (1.21-3.54) and 2.51 (1.46-4.31), in the 4th and 5th HbA1c quintiles, respectively. Hypertriglyceridemia increased in the 5th quintile of HbA1c, OR 2.76 (1.20-6.37). OR of low-HDL-cholesterol were 0.48 (0.24-0.98) and 0.41 (0.19-0.85) in the 3rd and 4th HbA1c quintiles, respectively. HDL-cholesterol correlated positively (0.437) with HbA1c in the 3rd quintile. HDL-cholesterol and insulin dose correlated inversely in all levels of glycemic control. Conclusions Correlation of serum lipids with HbA1c is heterogeneous across the spectrum of glycemic control in type 1 diabetes individuals. LDL-cholesterol and triglycerides worsened alongside HbA1c with distinct thresholds. Association of lower HDL-cholesterol with higher daily insulin dose is consistent and it points out to a role of exogenous hyperinsulinemia in the pathophysiology of the CVRF clustering. These data suggest diverse pathophysiological processes depending on HbA1c, refuting a unified explanation for cardiovascular risk in type 1 diabetes.
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Malerbi FEK, Negrato CA, Gomes MB. Assessment of psychosocial variables by parents of youth with type 1 diabetes mellitus. Diabetol Metab Syndr 2012; 4:48. [PMID: 23174044 PMCID: PMC3538713 DOI: 10.1186/1758-5996-4-48] [Citation(s) in RCA: 36] [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] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2012] [Accepted: 11/16/2012] [Indexed: 01/10/2023] Open
Abstract
UNLABELLED PURPOSE To evaluate the impact of type 1 diabetes (T1D) on family functioning and child-rearing practices from parents' point of view, to assess parents' health-related quality of life and to explore the relations between psychosocial variables and diabetes care outcomes in youth with diabetes. METHODS This research was part of the cross-sectional multicenter Brazilian Type 1 Diabetes Study, conducted between December 2008 and December 2010 in 28 public clinics of 20 cities across four Brazilian geographical regions. Psychosocial questions were addressed to 1,079 parents of patients with T1D through an interview (89.3% mothers, 52.5% Caucasians, 38.6 ± 7.6 years old). Overall, 72.5% of the families were from low or very low socioeconomic levels. Parents were also submitted to health-related quality of life instruments (EQ-5D+EQ-VAS). Clinical data from the last medical appointment were collected by a physician using standardized chart review forms. The demographic, educational and socioeconomic profiles were also obtained and HbA1c levels registered. RESULTS Discomfort and anxiety/depression were the main complaints in EQ-5D, and were significantly more frequent in mothers (37.3% and 53.4%, respectively) than in fathers (25.7% and 32.7%, respectively). The mother was the only parent involved in diabetes care in 50.5% of the cases. The majority of parents (78.5%) mentioned changes in family functioning after the diagnosis, although they neither treated their diabetic children differently from the others (76.3%), nor set prohibitions (69.1%) due to diabetes. The majority was worried about diabetes complications (96.4%) and felt overwhelmed by diabetes care (62.8%). Parents report of overwhelming was significantly associated with anxiety/depression, as measured by the EQ-5D questionnaire. Less than half of the patients had already slept over, and the permission to do it increased as a function of children's age. Nearly half of the parents (52%) admitted to experiencing difficulties in setting limits for their children/adolescents. HbA1c levels in patients from this group (9.7 ± 2.5%) were significantly higher than those of children/adolescents whose parents reported no difficulties towards limit-setting (8.8 ± 2.1%). Parents whose children/adolescents reported the occurrence of hypoglycemic episodes in the last month complained significantly more about anxiety/depression (55.1%) than parents from patients who did not report it (45.7%). Also a significantly greater proportion of parents whose children/adolescents had been hospitalized due to hyperglycemia reported anxiety /depression (58.7%) than those whose children/adolescents had not been hospitalized (49.8%). CONCLUSIONS After the diagnosis of T1D, the lifestyle of all family members changes, what interferes with their quality of life. Mothers are still the primary caregivers for children/adolescents with diabetes. Difficulty to set limits for children/adolescents may be a risk for poor metabolic control. The study demonstrates the importance of family context in the adjustment of young patients to T1D. The specific needs of T1D patients and their impact on a family routine must be considered for future improvement on therapy elements and strategies.
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Affiliation(s)
- Fani Eta Korn Malerbi
- School of Psychology, Pontifícia Universidade Católica de São Paulo, Rua Monte Alegre 984, 05014 001, São Paulo, SP, Brazil
| | | | - Marilia B Gomes
- Department of Internal Medicine, Diabetes Unit, State University Hospital of Rio de Janeiro, Rio de Janeiro, RJ, Brazil
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Abstract
Pregnancy affects both the maternal and fetal metabolism and even in nondiabetic women exerts a diabetogenic effect. Among pregnant women, 2 to 17.8% develop gestational diabetes. Pregnancy can also occur in women with preexisting diabetes, that can predispose the fetus to many alterations in organogenesis, growth restriction and the mother to some diabetes-related complications like retinopathy and nephropathy or accelerate the course of these complications if they are already present. Women with gestational diabetes generally start their treatment with diet and lifestyle modification; when these changes fail in keeping an optimal glycemic control, then insulin therapy must be considered. Women with type 2 diabetes in use of oral hypoglycemic agents are advised to change to insulin therapy. Those with preexisting type 1 diabetes must start an intensive glycemic control, preferably before conception. All these procedures are performed aiming to keep glycemic levels normal or near-normal as possible to avoid the occurrence of adverse perinatal outcomes to the mother and to the fetus. The aim of this review is to reinforce the need to improve the knowledge on reproductive health of women with diabetes during gestation and to understand what are the reasons for them failing to attend for prepregnancy care programs, and to understand the underlying mechanisms of adverse fetal and maternal outcomes, which in turn may lead to strategies for its prevention.
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Affiliation(s)
- Carlos Antonio Negrato
- Bauru's Diabetics Association, Department of Internal Medicine, Rua Saint Martin 27-07 CEP 17.012-433, Bauru, São Paulo, Brazil
| | - Rosiane Mattar
- Department of Gynecology and Obstetrics, São Paulo Federal University, São Paulo, Brazil
| | - Marilia B Gomes
- Department of Internal Medicine, Diabetes Unit, State University Hospital of Rio de Janeiro, Rio de Janeiro, Brazil
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Abstract
AIMS To examine the temporal trends in the frequency of diabetic ketoacidosis at onset compared to other modalities of diagnosis of Type 1 diabetes in Brazil. METHODS This was a retrospective, cross-sectional and multicenter study conducted between December 2008 and December 2010 in 28 public clinics at secondary and tertiary levels of care, located in 20 cities in four geographic regions of Brazil. Each clinic provided data extracted from at least 50 outpatients with Type 1 diabetes diagnosed between 1960 and 2010, using standardized chart review forms. Data were obtained from 3591 patients (56.0% females, 57.1% Caucasians). Median values (range) for age, age at diagnosis and duration of diabetes were, respectively, 19 years (1-66 years), 10 years (< 1-44 years) and 7 years (< 1-50 years). Logistic regression was performed with diabetic ketoacidosis (Yes/No) as the dependent variable and other clinical features as independent variables. RESULTS Type 1 diabetes diagnosis was made by diabetic ketoacidosis in 1,520 (42.3%), by fasting plasma glucose in 1413 (39.4%), by random blood glucose in 516 (14.4%), by oral glucose tolerance test in 66 (1.8%) and by other methods in 76 (2.1%) cases, respectively. Diagnosis made before the year 2000 had a greater odds to occur by diabetic ketoacidosis (Odds ratio 1.26, 95% confidence intervals (CI) 1.09-1.48). Since then, a decrease has occurred. Economic status, geographic region and age were significantly related to diabetic ketoacidosis at diagnosis. CONCLUSIONS Although high prevalence of diabetic ketoacidosis at diagnosis of Type 1 diabetes in Brazil is observed, recently, more patients have been diagnosed by other methods.
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Affiliation(s)
- C A Negrato
- Department of Internal Medicine, Bauru's Diabetics Association, Rua Saint Martin 27-07, Bauru, São Paulo State, Brazil.
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Gomes MB, Coral M, Cobas RA, Dib SA, Canani LH, Nery M, de Freitas MCF, Faria M, Felício JS, da Silva SC, Pedrosa H, Costa e Forti A, Rea RR, Pires AC, Montenegro Junior R, Oliveira JE, Rassi N, Negrato CA. Prevalence of adults with type 1 diabetes who meet the goals of care in daily clinical practice: a nationwide multicenter study in Brazil. Diabetes Res Clin Pract 2012; 97:63-70. [PMID: 22397904 DOI: 10.1016/j.diabres.2012.02.008] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.8] [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] [Received: 11/25/2011] [Revised: 02/02/2012] [Accepted: 02/12/2012] [Indexed: 12/21/2022]
Abstract
OBJECTIVE To determine the prevalence of patients with type 1 diabetes mellitus who meet the glycemic and cardiovascular (CV) risk factors goals and the frequency of screening for diabetic complications in Brazil according to the American Diabetes Association guidelines. RESEARCH DESIGN AND METHODS This was a cross-sectional, multicenter study conducted between December 2008 and December 2010 in 28 public clinics in 20 Brazilian cities. Data were obtained from 1774 adult patients (56.8% females, 57.2% Caucasians) aged 30.3 ± 9.8 years with diabetes duration of 14.3 ± 8.8 years. RESULTS Systolic blood pressure was at goal in 40.3% and diastolic blood pressure was at goal in 26.6% of hypertensive patients. LDL cholesterol and HbA1c were at the goal in 45.2% and 13.2% of the patients, respectively. Overweight was presented in 25.6% and obesity in 6.9%. Among those with more than 5 years of disease, screening for retinopathy was performed in the preceding year in 70.1%. Nephropathy and feet complications were screened in 63.1% and 65.1%, respectively. CONCLUSIONS The majority of patients did not meet metabolic control goals and a substantial proportion was not screened for diabetic complications. These issues may increase the risk of chronic complications and negatively impact public health.
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Affiliation(s)
- Marilia B Gomes
- Department of Internal Medicine, Diabetes Unit, State University Hospital of Rio de Janeiro, Brazil.
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Matheus ASDM, Tibiriçá E, da Silva PB, de Fátima Bevilácqua da Matta M, Gomes MB. Uric acid levels are associated with microvascular endothelial dysfunction in patients with Type 1 diabetes. Diabet Med 2011; 28:1188-93. [PMID: 21658123 DOI: 10.1111/j.1464-5491.2011.03349.x] [Citation(s) in RCA: 27] [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: 12/21/2022]
Abstract
AIMS Recent data identified uric acid as an independent risk factor for cardiovascular disease. The aim of the present study was to assess the association between uric acid and endothelial dysfunction in 57 patients with Type 1 diabetes and 53 healthy control subjects. METHODS Microvascular endothelial function was evaluated using laser Doppler perfusion monitoring coupled with pharmacological (iontophoretic administration of acetylcholine and sodium nitroprusside) and physiological (post-occlusive reactive hyperaemia and thermal hyperaemia) stimuli. RESULTS Uric acid was higher in subjects without diabetes than in those with diabetes (P = 0.03). Microvascular vasodilator response to acetylcholine was significantly reduced in Type 1 diabetes (P = 0.002) and was correlated to disease duration (r = -0.3, P = 0.01), triglyceride (r = -0.37, P = 0.005), insulin dose (r = -0.28, P = 0.03), fasting plasma glucose levels (r = -0.3, P = 0.02), HbA(1c) (r = -0.34, P = 0.001) and uric acid (r = -0.3, P = 0.005). On stepwise multivariate analysis, age, HbA(1c) and uric acid were the most important independent variables that were associated with the endothelium-dependent response in Type 1 diabetes (P = 0.02). CONCLUSIONS Glycaemic control and uric acid in the normal range were the most important contributing factors to the decreasing endothelium-dependent responses associated with Type 1 diabetes. Consequently, uric acid could be a new potential marker of microvascular endothelial dysfunction in these patients. Further studies are required to explore the clinical relevance of the relationship between uric acid levels, oxidative stress and endothelial dysfunction in patients with Type 1 diabetes, as well as whether treatment with uric acid-lowering drugs for slight elevations in uric acid would benefit these patients.
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Affiliation(s)
- A S de M Matheus
- Diabetes Unit, State University of Rio de Janeiro, Rio de Janeiro, Brazil.
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Cobas RA, Santos B, da Silva PCB, Neves R, Gomes MB. Progression to microalbuminuria in patients with type 1 diabetes: a seven-year prospective study. Diabetol Metab Syndr 2011; 3:21. [PMID: 21871097 PMCID: PMC3177769 DOI: 10.1186/1758-5996-3-21] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2011] [Accepted: 08/26/2011] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND The presence of microalbuminuria can be associated with overt nephropathy and cardiovascular disease in patients with type 1 diabetes (T1D). We aimed to determine the incidence and evaluate the baseline predictors for the development of microalbuminuria in patients with T1D. METHODS This study is a longitudinal cohort study of 122 normoalbuminuric patients with T1D who were receiving routine clinical care at baseline. A detailed medical history was taken, and a physical examination was performed at baseline. All of the patients were regularly examined for diabetes-associated complications. An analysis of predictors was performed using the Cox regression. RESULTS Over 6.81 (3.59-9.75) years of follow-up, 50 (41%) of the patients developed microalbuminuria. The incidence density was 6.79/100 people per year (95% CI 5.04-8.95), and the microalbuminuria developed after 5.9 (2.44-7.76) and 11 (5-15) years of follow-up and diabetes duration, respectively. After an individual Cox regression, the baseline variables associated with the development of microalbuminuria were age, age at diagnosis, duration of diabetes, systolic and diastolic blood pressure, fasting glycemia, body mass index (BMI), total cholesterol and triglycerides levels, cholesterol/HDL ratio and a family history of type 2 diabetes.After a multivariate Cox regression, the only independent factors associated with the development of microalbuminuria were BMI [HR 1.12 (1.03-1.21)] and cholesterol/HDL ratio [HR 1.32 (1.05-1.67)]. CONCLUSIONS A higher BMI and cholesterol/HDL ratio increased the risk of developing microalbuminuria in young patients with T1D after a short follow-up. Both risk factors are modifiable and should be identified early and followed closely.
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Affiliation(s)
- Roberta A Cobas
- Division of Diabetes, Department of Medicine, State University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Bráulio Santos
- Biostatistics and Bioinformatics Unit, National Institute of Cardiology, Rio de Janeiro, Brazil
| | - Pedro CB da Silva
- Division of Diabetes, Department of Medicine, State University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Ricardo Neves
- Division of Ophthalmology, Department of Medicine, State University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Marilia B Gomes
- Division of Diabetes, Department of Medicine, State University of Rio de Janeiro, Rio de Janeiro, Brazil
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Tibiriçá E, Matheus ASM, Nunes B, Sperandei S, Gomes MB. Repeatability of the evaluation of systemic microvascular endothelial function using laser doppler perfusion monitoring: clinical and statistical implications. Clinics (Sao Paulo) 2011; 66:599-605. [PMID: 21655753 PMCID: PMC3152722 DOI: 10.1590/s1807-59322011000400013] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2010] [Accepted: 11/01/2011] [Indexed: 01/08/2023] Open
Abstract
OBJECTIVE An awareness of the repeatability of biological measures is required to properly design and calculate sample sizes for longitudinal interventional studies. We investigated the day-to-day repeatability of measures of systemic microvascular reactivity using laser Doppler perfusion monitoring. METHODS We performed laser Doppler perfusion monitoring in combination with skin iontophoresis using acetylcholine and sodium nitroprusside as well as post-occlusive reactive and thermal hyperemia twice within two weeks. The repeatability was assessed by calculating the within-subject standard deviations, limits of agreement, typical errors and intra-class correlation coefficients between days 1 and 2. The ratio of the within-subject standard deviation to the mean values obtained on days 1 and 2 (within-subject standard deviation/GM) was used to determine the condition with the best repeatability. RESULTS Twenty-four healthy subjects, aged 24.6 ± 3.8 years, were recruited. The area under the curve of the vasodilatory response to post-occlusive reactivity showed marked variability (within-subject standard deviation/GM = 0.83), while the area under the curve for acetylcholine exhibited less variability (within-subject standard deviation/ GM = 0.52) and was comparable to the responses to sodium nitroprusside and thermal treatment (within-subject standard deviations/GM of 0.67 and 0.56, respectively). The area under the blood flow/time curve for vasodilation during acetylcholine administration required the smallest sample sizes, the area under the blood flow/time curve during post-occlusive reactivity required the largest sample sizes, and the area under the blood flow/time curves of vasodilation induced by sodium nitroprusside and thermal treatment required intermediate sizes. CONCLUSIONS In view of the importance of random error related to the day-to-day repeatability of laser Doppler perfusion monitoring, we propose an original and robust statistical methodology for use in designing prospective clinical studies.
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Negrato CA, Rafacho A, Negrato G, Teixeira MF, Araújo CAR, Vieira L, Silva CA, Date SK, Demarchi AC, Gomes MB. Glargine vs. NPH insulin therapy in pregnancies complicated by diabetes: an observational cohort study. Diabetes Res Clin Pract 2010; 89:46-51. [PMID: 20378197 DOI: 10.1016/j.diabres.2010.03.015] [Citation(s) in RCA: 29] [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] [Received: 01/27/2010] [Revised: 03/07/2010] [Accepted: 03/14/2010] [Indexed: 12/28/2022]
Abstract
AIMS The effects of glargine insulin therapy in pregnancies are not well established. We compared maternal and neonatal outcomes of women with pregestational and gestational diabetes treated with glargine or NPH insulin. METHODS A prospective cohort study was conducted analyzing outcomes from 56 women with pregestational and 82 with gestational diabetes treated with either insulin regimen. RESULTS Comparisons were performed among 138 women: 56 with pregestational and 82 with gestational diabetes. In relation to maternal complications, worsening of retinopathy and nephropathy, preeclampsia, micro and macroalbuminuria, and all kinds of hypoglycemia were found higher in women with pregestational diabetes NPH-treated vs. glargine-treated. In women with gestational diabetes NPH-treated, it was observed increased incidence of prepregnancy and new-onset pregnancy hypertension, micro and macroalbuminuria, as well as mild and frequent hypoglycemia, compared to glargine-treated. Among the neonatal outcomes, 1-min Apgar score <7, necessity of intensive care unit and fetal death in pregestational, while jaundice and congenital malformations in gestational diabetes, respectively, were more frequently observed in infants born to NPH-treated, compared to glargine-treated. CONCLUSIONS Glargine use during pregnancy from preconception through delivery, showed to be safe since it is associated with decreased maternal and neonatal adverse outcomes compared with NPH insulin-treated patients.
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Lerario AC, Chacra AR, Pimazoni-Netto A, Malerbi D, Gross JL, Oliveira JEP, Gomes MB, Santos RD, Fonseca RMC, Betti R, Raduan R. Algorithm for the treatment of type 2 diabetes: a position statement of Brazilian Diabetes Society. Diabetol Metab Syndr 2010; 2:35. [PMID: 20529311 PMCID: PMC2904721 DOI: 10.1186/1758-5996-2-35] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2009] [Accepted: 06/08/2010] [Indexed: 12/29/2022] Open
Abstract
The Brazilian Diabetes Society is starting an innovative project of quantitative assessment of medical arguments of and implementing a new way of elaborating SBD Position Statements. The final aim of this particular project is to propose a new Brazilian algorithm for the treatment of type 2 diabetes, based on the opinions of endocrinologists surveyed from a poll conducted on the Brazilian Diabetes Society website regarding the latest algorithm proposed by American Diabetes Association /European Association for the Study of Diabetes, published in January 2009.An additional source used, as a basis for the new algorithm, was to assess the acceptability of controversial arguments published in international literature, through a panel of renowned Brazilian specialists. Thirty controversial arguments in diabetes have been selected with their respective references, where each argument was assessed and scored according to its acceptability level and personal conviction of each member of the evaluation panel.This methodology was adapted using a similar approach to the one adopted in the recent position statement by the American College of Cardiology on coronary revascularization, of which not only cardiologists took part, but also specialists of other related areas.
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Affiliation(s)
- Antonio C Lerario
- Medicine School of Universidade São Paulo, InCor - HCFMUSP Diabetes Core. Sao Paulo, Brazil
| | - Antonio R Chacra
- Paulista Medicine School at Universidade Federal São Paulo - UNIFESP, Sao Paulo, Brazil
| | - Augusto Pimazoni-Netto
- Integrated Center of Cardiovascular Hypertension and Metabology at the Kidney and Hypertension Hospital at Universidade Federal de São Paulo, São Paulo, Brazil
- Diabetes Center of Hospital Alemão Oswaldo Cruz, in Sao Paulo, Brazil
| | | | - Jorge L Gross
- Medical School at Universidade Federal Rio Grande do Sul and Hospital Clínicas in Porto Alegre, Porto Alegre, Brazil
| | - José EP Oliveira
- Medicine School of Universidade Federal Rio de Janeiro and Division of Nutrology and Diabetes Service at UFRJ Hospital Universitário Clementino Fraga Filho, Rio de Janeiro, Brazil
| | - Marilia B Gomes
- Medicine School of State University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Raul D Santos
- InCor Lipid Clinical InCor - HCFMUSP, Sao Paulo, Brazil
| | | | - Roberto Betti
- Diabetes Core. InCor- HCFMUSP and Diabetes Center of Hospital Alemão Oswaldo Cruz, Sao Paulo, Brazil
| | - Roberto Raduan
- Internal Medicine Service at Beneficencia Portuguesa, Sao Paulo, Brazil
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Giuffrida FM, Sallum CF, Gabbay MA, Gomes MB, Pires AC, Dib SA. Relationship between glycated hemoglobin and metabolic syndrome of type 1 and type 2 diabetes: a factor analysis study. Diabetes Care 2010; 33:e80. [PMID: 20508225 DOI: 10.2337/dc09-2280] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
| | | | | | | | - Antonio C. Pires
- São José do Rio Preto School of Medicine, São José do Rio Preto, Brazil
| | - Sergio A. Dib
- Diabetes Center, Federal University of São Paulo, São Paulo, Brazil
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Negrato CA, Dias JPL, Teixeira MF, Dias A, Salgado MH, Lauris JR, Montenegro RM, Gomes MB, Jovanovic L. Temporal trends in incidence of Type 1 diabetes between 1986 and 2006 in Brazil. J Endocrinol Invest 2010; 33:373-7. [PMID: 19620822 DOI: 10.1007/bf03346606] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.7] [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: 10/25/2022]
Abstract
BACKGROUND Scarce information is available about the variation in the incidence of Type 1 diabetes in the Brazilian population in the last decades. AIM The objective of this study was to assess the long-term trends (1986-2006) in the incidence of Type 1 diabetes in Bauru, São Paulo State, Brazil. SUBJECTS AND METHODS The annual incidence of Type 1 diabetes (per 100,000 per yr) from 1986 to 2006 was determined in children <or=14 yr of age, using the capture and recapture method. RESULTS A total of 176 cases were diagnosed in the study population. The overall incidence was 10.4/100,000 with a range of 2.82/100,000 in 1987 to 18.49/100,000 in 2002 representing a 6.56-fold increase within the same population. The estimated incidence, using the capture and recapture method varied from 2.82/100,000 per yr in 1987 to 27.20/100,000 per yr in 2002, representing a 9.6-fold variation. The global pattern of incidence variation was categorized as high (10-19.99/100,000 per yr), and very high (>or=20/100,000 per yr) in 71.43% of the study-years. Incidence was slightly higher among females, Caucasians, children in the 5-9 yr of age range and belonging to lower socio-economic classes. Most diagnoses were established during the colder months and/or with higher pluviometric indexes. CONCLUSIONS The incidence of Type 1 diabetes in children is increasing in Bauru, São Paulo State, Brazil, and the global pattern of incidence was classified as high or very high, mainly in the last 10 yr. All Brazilian regions should be involved in the study.
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Affiliation(s)
- C A Negrato
- Division of Diabetes, Department of Epidemiology, Bauru's Diabetics Association, Bauru, Brazil.
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Negrato CA, Montenegro RM, Mattar R, Zajdenverg L, Francisco RPV, Pereira BG, Sancovski M, Torloni MR, Dib SA, Viggiano CE, Golbert A, Moisés ECD, Favaro MI, Calderon IMP, Fusaro S, Piliakas VDD, Dias JPL, Gomes MB, Jovanovic L. Dysglycemias in pregnancy: from diagnosis to treatment. Brazilian consensus statement. Diabetol Metab Syndr 2010; 2:27. [PMID: 20416099 PMCID: PMC2867808 DOI: 10.1186/1758-5996-2-27] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2009] [Accepted: 04/24/2010] [Indexed: 12/16/2022] Open
Abstract
There is an urgent need to find consensus on screening, diagnosing and treating all degrees of dysglycemia that may occur during pregnancies in Brazil, considering that many cases of dysglycemia in pregnant women are currently not diagnosed, leading to maternal and fetal complications. For this reason the Brazilian Diabetes Society (SBD) and the Brazilian Federation of Gynecology and Obstetrics Societies (FEBRASGO), got together to introduce this proposal. We present here a joint consensus regarding the standardization of clinical management for pregnant women with any degree of dysglycemia, on the basis of current information, to improve medical assistance and to avoid related complications of dysglycemia in pregnancy to the mother and the fetus. This consensus aims to standardize the diagnosis among general practitioners, endocrinologists and obstetricians allowing the dissemination of information in basic health units, public and private services, that are responsible for screening, diagnosing and treating disglycemic pregnant patients.
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Affiliation(s)
| | - Renan M Montenegro
- School of Medicine of the Federal University of Ceará, Fortaleza-Ce, Brazil
| | - Rosiane Mattar
- Federal School of Medicine of São Paulo State (UNIFESP), São Paulo-SP, Brazil
| | | | | | | | | | | | - Sergio A Dib
- Federal School of Medicine of São Paulo State (UNIFESP), São Paulo-SP, Brazil
| | - Celeste E Viggiano
- Nutrition Department of the Brazilian Diabetes Society, São Paulo-SP, Brazil
| | - Airton Golbert
- Federal University of Health Sciences of Porto Alegre (UFRGS), Porto Alegre-RS, Brazil
| | - Elaine CD Moisés
- School of Medicine of Ribeirão Preto (USP), Ribeirão Preto-SP, Brazil
| | | | - Iracema MP Calderon
- Botucatu Medical School, São Paulo State University (UNESP), Botucatu-SP, Brazil
| | - Sonia Fusaro
- Federal School of Medicine of São Paulo State (UNIFESP), São Paulo-SP, Brazil
| | - Valeria DD Piliakas
- Hospital and Maternity Leonor Mendes de Barros, and UNICASTELO, São Paulo-SP, Brazil
| | | | - Marilia B Gomes
- Endocrine and Diabetes Unit, State University of Rio de Janeiro, Rio de Janeiro-RJ, Brazil
| | - Lois Jovanovic
- Sansum Diabetes Research Institute, Santa Barbara, California, USA
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Dib SA, Gomes MB. Etiopathogenesis of type 1 diabetes mellitus: prognostic factors for the evolution of residual beta cell function. Diabetol Metab Syndr 2009; 1:25. [PMID: 19961609 PMCID: PMC2797766 DOI: 10.1186/1758-5996-1-25] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2009] [Accepted: 12/04/2009] [Indexed: 01/07/2023] Open
Abstract
Type 1A diabetes mellitus (T1ADM) is a progressive autoimmune disease mediated by T lymphocytes with destruction of beta cells. Up to now, we do not have precise methods to assess the beta cell mass, "in vivo" or "ex-vivo". The studies about its genetic susceptibility show strong association with class II antigens of the HLA system (particularly DQ). Others genetics associations are weaker and depend on the population studied. A combination of precipitating events may occur at the beginning of the disease. There is a silent loss of immune-mediated beta cells mass which velocity has an inverse relation with the age, but it is influenced by genetic and metabolic factors. We can predict the development of the disease primarily through the determination of four biochemically islet auto antibodies against antigens like insulin, GAD65, IA2 and Znt8. Beta cell destruction is chronically progressive but at clinical diagnosis of the disease a reserve of these cells still functioning. The goal of secondary disease prevention is halt the autoimmune attack on beta cells by redirecting or dampening the immune system. It is remains one of the foremost therapeutic goals in the T1ADM. Glycemic intensive control and immunotherapeutic agents may preserve beta-cell function in newly diagnosed patients with T1ADM. It may be assessed through C-peptide values, which are important for glycemic stability and for the prevention of chronic complications of this disease. This article will summarize the etiopathogenesis mechanisms of this disease and the factors can influence on residual C-peptide and the strategies to it preservation.
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Affiliation(s)
- Sergio A Dib
- Endocrinology Division, Department of Medicine of Federal University of São Paulo, SP, Brazil
| | - Marilia B Gomes
- Diabetes Division, Department of Medicine of State University of Rio de Janeiro, GB, Brazil
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Tibiriçá E, Rodrigues E, Cobas R, Gomes MB. Increased functional and structural skin capillary density in type 1 diabetes patients with vascular complications. Diabetol Metab Syndr 2009; 1:24. [PMID: 19958533 PMCID: PMC2794258 DOI: 10.1186/1758-5996-1-24] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2009] [Accepted: 12/03/2009] [Indexed: 01/13/2023] Open
Abstract
The present study was designed to study skin capillary density and recruitment of the upper and lower extremities in patients with type 1 diabetes with vascular complications, when compared to patients without complications and healthy subjects. We used intravital video-microscopy to measure basal and maximal (during venous congestion) skin capillary densities as well as capillary recruitment using post-occlusive reactive hyperemia (PORH) in the dorsum of the fingers and toes.Our results showed that besides microvascular vasodilation and loss of autoregulatory capacity, patients with type 1 diabetes with vascular complications present increased skin capillary density in both extremities.
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Affiliation(s)
- Eduardo Tibiriçá
- Department of Medicine, Diabetes Unit, State University of Rio de Janeiro, Rio de Janeiro, Brazil
- Laboratory of Cardiovascular Investigation, Oswaldo Cruz Institute, Rio de Janeiro, Rio de Janeiro, Brazil
| | - Elba Rodrigues
- Laboratory of Cardiovascular Investigation, Oswaldo Cruz Institute, Rio de Janeiro, Rio de Janeiro, Brazil
| | - Roberta Cobas
- Department of Medicine, Diabetes Unit, State University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Marilia B Gomes
- Department of Medicine, Diabetes Unit, State University of Rio de Janeiro, Rio de Janeiro, Brazil
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