Efficacy and safety of different basal and prandial insulin analogues for the treatment of type 2 diabetes: a network meta-analysis of randomized controlled trials

AIM

The aim of the present network meta-analysis is to assess the efficacy and safety across different long and short-acting analogs for the treatment of type 2 diabetes.

METHODS

A PubMed, EMBASE, and Cochrane Central Register of Controlled Trials databases search (20th May, 2020) for all trials with a duration ≥24 weeks comparing an analogue with another or human insulin was performed. Indirect comparisons were performed by NMA choosing glargine U100 and human regular insulin, as the reference for long- and short-acting analogues, respectively. Primary endpoints were HbA1c at 24, 52, and 104 weeks. The weighted difference in means (WDM) and Mantel-Haenzel Odds Ratio [MH-OR] with 95% Confidence Intervals (CI) were calculated for categorical and continuous variables, respectively.

RESULTS

Fifty trials (n = 43) and 7 for basal and prandial analogues, respectively, enrolling 25,554 and 3184 patients with type 2 and 1 diabetes, respectively, were included. At NMA, detemir was less effective than glargine U-100 at 52 weeks. A significant reduction of 24-week HbA1c (WMD [IC]: -0.10 [-0.17, -0.03]%); and risk of total (MH-OR [IC]: 0.80 [0.70, 0.91]), and nocturnal hypoglycemia (MH-OR [IC]: 0.57 [0.45, 0.73]) was observed for basal analogues versus NPH insulin. At NMA, glargine U300 and degludec were associated with a significant reduction in the risk of nocturnal hypoglycemia. No significant differences across different short-acting insulin were observed.

CONCLUSIONS

This paper supports the use of long-acting analogues, rather than NPH insulin, as basal insulin for the treatment of type 2 diabetes, without any preferences for any individual long-acting analogue over the others. The evidence on short acting analogues is limited.

COVID-19 Vaccine Hesitancy and Early Adverse Events Reported in a Cohort of 7,881 Italian Physicians

BACKGROUND

The COVID-19 vaccination campaign began in Italy at the end of December 2020, with the primary aim of immunizing healthcare professionals, using the EMA approved mRNA vaccines (Comirnaty® by Pfizer/BioNTech; mRNA-1273 by Moderna) and recombinant adenoviral vaccine (Vaxzevria® by AstraZeneca). The study aimed at evaluating the prevalence and motivations underlying Vaccine Hesitancy, as well as the incidence and type of adverse events associated with COVID-19 vaccination.

METHODS

Cross-sectional study. Data were collected January 1st to 28th 2021 using a purposely created online self-administered questionnaire from a selected cohort of Italian physicians.

RESULTS

Overall, 7,881 questionnaires were analyzed: 6,612 physicians had received one dose, and 1,670 two doses of Comirnaty®; 30 had received one dose of mRNA-1273. Vaccine Hesitancy rate was 3.6%; it correlated with prior SARS-CoV-2 infection, diabetes, Adverse Eventss at previous vaccinations and refusal of 2020 flu vaccine, and was mainly motivated by concerns about vaccine Adverse Events. Typical Adverse Events were pain/itching/paresthesia at the inoculation site, followed by headache, fever, fatigue and myalgia/arthralgia occurring more frequently after the second dose (77.8 vs 66.9%; p<0.001), and in subjects with a prior SARS-CoV-2 infection.

CONCLUSION

Adherence to COVID-19 vaccination is high among physicians. Adverse Events are typically mild and more frequent in people with a prior SARS-CoV-2 infection.

Sars-CoV2 vaccine hesitancy in Italy: A survey on subjects with diabetes

BACKGROUND AND AIMS

Vaccine Hesitancy (VH) is a relevant obstacle for the COVID-19 vaccination campaign. The aim of this study is to assess the proportion of subjects unwilling to vaccinate among patients with type 1 (T1DM) and 2 (T2DM) diabetes, exploring factors associated with VH.

METHODS AND RESULTS

A purposely created interview was delivered from physicians to a consecutive series of adult (>18 years) subjects with diabetes referring to the Diabetes Outpatient Clinic of Careggi Hospital, Florence, from January 1st to April 30th 2021. Out of 502 subjects enrolled, 92 were vaccine hesitant respondents (18.3%); the corresponding figure for T1DM and T2DM was 13.0% (N = 14), and 19.9% (N = 78), respectively. After adjusting for age, higher HbA1c (1.07 [1.02-1.13], p = 0.008) and triglycerides levels (1.03 [1.01-1.06], p = 0.011) were positively associated with VH, among patients with T1DM. At multivariate analysis, after adjusting for age, creatinine, and statin use, patients with T2DM affected by obesity (9.98 [4.89-9.59], p < 0.01) and with lower levels of creatinine (0.36 [0.21-0.54], p = 0.029) were more likely to refuse COVID vaccination.

CONCLUSIONS

Hesitancy toward COVID-19 vaccination among subjects with diabetes is not negligible and seems to be more prevalent in individuals with lower adherence to medical prescriptions and/or reduced concerns over their health. This suggests the need for specific interventions to increase awareness and counter prejudices on vaccines.

Glucose-lowering therapy in patients undergoing percutaneous coronary intervention

The number of individuals with diabetes and pre-diabetes is constantly increasing. These conditions are overrepresented in patients undergoing percutaneous coronary intervention and are associated with adverse prognosis. Optimal glycaemic control during an acute coronary syndrome is a relevant factor for the improvement of longer-term outcomes. In addition, the implementation of newer glucose-lowering drugs with proven cardiovascular benefits has a remarkable impact on recurrence of events, hospitalisations for heart failure and mortality. In this narrative review, we outline the current state-of-the art recommendations for glucose-lowering therapy in patients with diabetes undergoing coronary intervention. In addition, we discuss the most recent evidence-based indications for revascularisation in patients with diabetes as well as the targets for glycaemic control post revascularisation. Current treatment goals for concomitant risk factor control are also addressed. Lastly, we acknowledge the presence of knowledge gaps in need of future research.

Glucose variability and periodontal disease in type 1 diabetes: a cross-sectional study-The "PAROdontopatia e DIAbete" (PARODIA) project

AIMS

Periodontal disease (PD) is a chronic inflammation of periodontal tissue associated with infection from specific anaerobic pathogens contained in dental plaque. Both type 1 and type 2 diabetes are associated with an increased prevalence of PDs. A two-way relationship between diabetes and periodontitis has been proposed, with diabetes increasing the risk for periodontitis, and periodontal inflammation negatively affecting glycaemic control. To date, the relationship between PD and glucose variability in type 1 diabetes has not been evaluated. To investigate the prevalence of PD in patients with type 1 diabetes and its association with glycemic control and glucose variability.

METHODS

In this cross-sectional study, all enrolled patients were scheduled to attend both a diabetologic and a periodontal visit. HbA1c, glucose coefficient of variation (CV), loss of clinical attachment (CAL), and periodontal probing depth (PPD) were collected.

RESULTS

136 patients were included in the analysis. The prevalence of PD was 63%. A significant correlation was found between mean CAL and glucose CV (r = 0.31, p = 0.002), but not with HbA1c. Mean PPD was also associated with glucose CV (r = 0.27 and 0.044), but not with HbA1c. In a multiple linear regression model, with mean CAL as dependent variable, age, glucose CV, and smoking habit resulted significantly associated (r = 0.23, p = 0.013; r = 0.33, p = 0.001; r = 0.34, p < 0.001, respectively). Assuming mean PPD as dependent variable, multiple linear regression analysis showed a significant association with glucose CV and smoking habits only.

CONCLUSIONS

PD is associated with glucose variability in patients with type 1 diabetes also after adjusting for the main confounders.

Efficacy and effects of bariatric surgery in the treatment of obesity: Network meta-analysis of randomized controlled trials

AIMS

Bariatric surgery (BS) is recommended for subjects with a Body Mass Index (BMI) over of 40 kg/m² or with a BMI between 35 and 40 kg/m² with obesity-related comorbidities. Aim of the study was to compare different types of BS with medical therapy (MT) for the treatment of obesity.

DATA SYNTHESIS

We conducted a network-meta-analysis (NMA) including randomized clinical trials comparing different BS techniques versus MT in people with obesity, with a duration ≥24 weeks (PROSPERO, #CRD42020160359). Primary endpoint was BMI. Indirect comparisons of different types of surgery were performed by NMA. Types of BS included: laparoscopic adjustable gastric banding (LAGB), Roux-en-Y gastric bypass, sleeve gastrectomy (SG), bilio-pancreatic diversion (BPD); greater curvature plication (GCP); one-anastomosis gastric bypass (OAGB); Laparoscopic Vertical Banded Gastroplasty (LVBG) and duodenal switch (DS). 43 trials were retrieved in this metanalysis. BS was associated with a significant reduction in BMI, systolic blood pressure, triglyceride and fasting glucose, and with a significant increase of HDL cholesterol when compared to MT. In direct comparisons, RYGB was more effective than LAGB, LVBG, and GCP, but less effective than DS, whereas LAGB was less effective than LVBG and SG. In the NMA, DS and BPD appeared to be more effective than other procedures.

CONCLUSIONS

BS produces a greater weight loss than MT in morbidly obese patients, inducing a greater improvement of obesity-associated metabolic parameters. Available data are insufficient to assess the effect of BS on mortality. Different surgical procedures are heterogeneous for efficacy and safety.

Cardiovascular events and all-cause mortality in patients with type 2 diabetes treated with dipeptidyl peptidase-4 inhibitors: An extensive meta-analysis of randomized controlled trials

AIMS

Meta-analyses of randomized trials on Dipeptidyl Peptidase-4 inhibitors (DPP4i) reported discordant results on major cardiovascular events (MACE), mortality, and heart failure. Aim of this meta-analysis of randomized trials is the assessment of the cardiovascular safety of DPP4i.

DATA SYNTHESIS

A Medline, Embase, Cochrane database search for sitagliptin, vildagliptin, omarigliptin, saxagliptin, alogliptin, trelagliptin, anagliptin, linagliptin, gemigliptin, evogliptin, and teneligliptin was performed up to up January 1st, 2020. All trials with a duration ≥24 weeks and comparing the effects of DPP4i with placebo or active drugs were collected. Mantel-Haenszel odds ratio (MH-OR) with 95% Confidence Interval (95% CI) was calculated for all outcomes defined above. A total of 182 eligible trials were identified. DPP-4i were not associated with an increased risk of MACE (MH-OR 0.99 [0.93, 1.04]), all-cause mortality (MH-OR 0.99 [0.93, 1.06]), and heart failure (MH-OR 1.05 [0.96, 1.15]) with no significant differences across individual molecules, except for saxagliptin, which was associated with an increased risk of heart failure.

CONCLUSIONS

As a class, DPP4i are not associated with any increase or reduction of MACE, all-cause mortality, and heart failure. Saxagliptin seems to be associated with an increased risk of hospitalization for heart failure.

ANMCO POSITION PAPER: on administration of type 2 sodium-glucose co-transporter inhibitors to prevent heart failure in diabetic patients and to treat heart failure patients with and without diabetes

This ANMCO (Associazione Nazionale Medici Cardiologi Ospedalieri) position paper aims to analyse the complex action of sodium-glucose co-transporter 2 inhibitors at the level of the kidney and cardiovascular system, focusing on the effect that these molecules have shown in the prevention and treatment of heart failure in diabetic and non-diabetic subjects. The goal was pursued by comparing the data generated with pathophysiology studies and with multicentre controlled studies in large populations. In accordance with the analysis carried out in the document, the following recommendations are issued: (i) canagliflozin, dapagliflozin, empagliflozin, and ertugliflozin are molecules recommended for the prevention of heart failure hospitalizations in type 2 diabetic subjects; (ii) canagliflozin and dapagliflozin are recommended for the prevention of heart failure hospitalizations in type 2 diabetic subjects with severe chronic kidney disease, dapagliflozin proved to be safe and effective also in diabetic subjects; and (iii) dapagliflozin and empagliflozin are recommended to reduce the combined risk of heart failure and cardiovascular death in diabetic and non-diabetic subjects with heart failure and reduced ejection fraction.

Improvement of glycemic control in type 2 diabetes: A systematic review and meta-analysis of randomized controlled trials

AIM

Different guidelines provide similar, but not identical, therapeutic targets for HbA1c in type 2 diabetes. These targets can also depend from the different pharmacological strategies adopted for intensifying glycemic control.

DATA SYNTHESIS

This meta-analysis includes randomized trials adopting any pharmacological regimen for intensifying glycemic control in T2DM (versus standard of care/placebo), with a trial duration ≥2 years and a between-group HbA1c difference≥0.5%. The primary outcome was to assess the effects of the improvement of glycemic control on major cardiovascular events (MACE), ocular and renal complications, and severe hypoglycemia. Mantel-Haenszel odds ratios (MH-OR) with 95% Confidence Intervals were calculated for all the outcomes considered. We included 13 trials fulfilling the inclusion criteria. The improvement of glycemic control was associated with a lower risk of MACE (MH-OR:0.89 [95%CI 0.85-0.94]) and renal adverse events (MH-OR 0.73 [0.65-0.82]), but not all-cause mortality (MH-OR 0.95 [0.88-1.01]) and ocular adverse complications (MH-OR 0.94 [0.72-1.22]). For glucose-lowering drugs inducing hypoglycemia, a protective effect on the risk of microvascular complications, but not of MACE and all-cause mortality, was observed only for HbA1c ≤ 48 mmol/mol, but with higher risk of severe hypoglycaemia (MH-OR 2.72 [1.79-4.13]). Drugs not inducing hypoglycaemia were associated with a reduction of MACE, renal adverse events, and all-cause mortality, for HbA1c< 7% (no data for lower targets).

CONCLUSIONS

The present meta-analysis show that the improvement of glycemic control with drugs not inducing hypoglycemia is associated with a reduction in the risk of long-term chronic vascular and renal complications, and all-cause mortality.

Trust of Italian healthcare professionals in covid-19 (anti-sars-cov-2) vaccination

Abstract

Background. Vaccination is one of the most effective tools available to Public Health. Its potential usefulness is threatened by the rise of vaccine hesitancy among the general population, which has grown as much as to prompt the World Health Organization to express its concerns on the matter. The risk posed by vaccine hesitancy is even more concerning in the light of the efforts to curb the ongoing COVID-19 pandemic, which focus mainly on mass vaccination campaigns. This holds especially true when applied to healthcare professionals, among whom vaccine hesitancy can be particularly detrimental. For these reasons, our study focuses on potential determinants of vaccine hesitancy among healthcare professionals. Study design. The study is a cross-sectional study. Methods. Data were collected from January 1st to February 16th, by means of a self-administered online questionnaire in a cohort of Italian healthcare professionals. Results. Overall, 10,898 questionnaires were collected. Among the respondents, 1.1% expressed vaccine hesitancy. Hesitancy was less frequent in professionals involved in Primary Care and in the Clinical Sciences/ Public Health group. Among clinicians, paediatricians, oncologists, and geriatrists showed especially accepting attitudes towards vaccination. Lower hesitancy rates were also registered among the respondents who already had received influenza vaccination and who never had any adverse effects following vaccination. Higher hesitancy rates were observed among individuals who had family members aged >65 years and with a history of severe adverse reactions to vaccination. Conclusion. Vaccine hesitancy rates were extremely low among participants in our study. Some medical specialties shown were particularly accepting towards vaccination. The potential predictors and protective factors pointed out by our analysis might allow more refined targets.

[ANMCO Position paper: Sodium-glucose co-transporter 2 inhibitors for the prevention of heart failure in diabetic patients and for the treatment of heart failure patients with and without diabetes]

This ANMCO position paper aims to analyze the complex action of sodium-glucose co-transporter 2 inhibitors at the level of the kidney and cardiovascular system, focusing on the effect that these molecules have shown in the prevention and treatment of heart failure in diabetic and non-diabetic subjects. The goal was pursued by comparing the data generated with pathophysiology studies and with multicenter controlled studies in large populations. In accordance with the analysis carried out in the document, the following recommendations are issued: (i) canagliflozin, dapagliflozin, empagliflozin and ertugliflozin are molecules recommended for the prevention of heart failure hospitalizations in type 2 diabetic subjects; (ii) canagliflozin and dapagliflozin are recommended for the prevention of heart failure hospitalizations in type 2 diabetic subjects with severe chronic kidney disease, dapagliflozin proved to be safe and effective also in diabetic subjects; and (iii) dapagliflozin and empagliflozin are recommended to reduce the combined risk of heart failure and cardiovascular death in diabetic and non-diabetic subjects with heart failure and reduced ejection fraction.

Comparison between different types of exercise training in patients with type 2 diabetes mellitus: A systematic review and network metanalysis of randomized controlled trials

AIM

Aim of the present meta-analysis and network metanalysis (NMA) is the assessment of the effects of physical exercise on glucose control and cardiovascular risk factors in type 2 diabetes.

DATA SYNTHESIS

This metanalysis includes all available trials exploring the effects of different exercise modalities in type 2 diabetes, with a duration of ≥3 months. The standardized difference in means (SDM) with 95% Confidence Intervals were calculated. Data were analyzed using MetaXL and Rev Man 5.0. Primary endpoint was the effect of exercise versus no exercise on HbA1c and fasting plasma glucose (FPG) at endpoint. Secondary endpoints were body weight and fat, waist circumference, and blood pressure. A comparison of different exercise training modalities (aerobic, resistance and combined) for the same endpoints was also performed, choosing 'no exercise' as the reference for indirect comparisons. We included 25 trials fulfilling all inclusion criteria. Physical exercise versus no exercise produced a small, but significant, improvement of HbA1c, body fat, and systolic blood pressure at endpoint (-0.3 [-0.1;-0.4]%, -1.44 [-2.22, -0.66]%, and -5.6 [-9.5, -1.6] mmHg, respectively). Combined, supervised aerobic and resistance exercise were associated with a significantly greater reduction of HbA1c (SDM, -0.4 [-0.6;-0.3], -0.2 [-0.4;-0.1], and -0.2 [-0.3;-0.1]%, respectively), but not of FPG, in comparison with no exercise.

CONCLUSIONS

Physical exercise produces small, but detectable, advantages on glycemic control and cardiovascular risk factors and should be suggested in type 2 diabetes. Combined aerobic/resistance training seems to be superior to aerobic training alone, but differences are small and the reliability of supporting evidence limited.

The Role of testosterone treatment in patients with metabolic disorders

INTRODUCTION

The specific role of testosterone [T] replacement therapy [TRT] on glycometabolic profile and body composition, particularly in patients with metabolic syndrome [MetS] and/or type 2 diabetes mellitus [T2DM], is still the object of an intense debate.

AREAS COVERED

To discuss available evidence on the association between T and metabolic diseases and on the possible effect of T administration on metabolic disorder-associated hypogonadism. Both preclinical and clinical data have been considered. In addition, a meta-analysis of the available placebo and non-placebo-controlled randomized clinical trials [RCTs] investigating the effects of TRT in T2DM or MetS in several outcomes has been also performed.

EXPERT OPINION

Data derived from preclinical and clinical studies suggest that T administration, by reducing fat mass, can improve body composition and ameliorate some aspects of glucose metabolism. The effects of TRT on sexual function in patients with established metabolic derangements are inconsistent, whereas better results were observed in preclinical conditions or in patients with newly diagnosed T2DM.

Efficacy and safety of glucose-lowering agents in patients with type 2 diabetes: A network meta-analysis of randomized, active comparator-controlled trials

AIM

Aim of the present network meta-analysis (NMA) is the comparison across glucose-lowering drugs (GLA) concerning their effects on glucose control, body weight, hypoglycemia, gastrointestinal adverse events, and quality of life.

DATA SYNTHESIS

This NMA includes randomized clinical trials comparing different head-to-head comparison trials with EMA-approved GLA in type 2 diabetes, with a duration of ≥52 weeks. All drugs have to be administered at the maximal approved dose. Primary endpoints were HbA1c at 12, 52, and 104+ weeks. Secondary endpoints were body weight, quality of life, hypoglycemia, and gastrointestinal disorders. Indirect comparisons of different GLA were performed by NMA choosing metformin as reference. The standardized difference in means (SDM) and Mantel-Haenzel Odds Ratio [MH-OR] (using random-effect models) with 95% Confidence Intervals were calculated for categorical and continuous variables, respectively. We included 68 trials fulfilling all inclusion criteria. At 12 weeks, when considering indirect comparisons, insulin secretagogues (IS) were associated with a significantly greater reduction in comparison with metformin (SDM, -0.3 [-0.4;-0.2]%); a significantly lower efficacy was observed for pioglitazone. At 52 weeks, IS were no longer associated with a greater reduction of HbA1c; whereas a significant decrease in HbA1c was observed for GLP-1 RA (SDM, -0.2 [-0.1;-0.3]%). At 104+ weeks, only SGLT-2 inhibitors showed a significantly greater HbA1c reduction (SDM, -0.2 [-0.1;-0.3]%), whereas sulfonylureas and insulin showed a significantly lower efficacy (SDM, 0.1 [0.0; 0.2]%), and 0.4 [0.3; 0.5]%, respectively).

CONCLUSIONS

The results of this meta-analysis should be considered together with evidence on long-term outcomes for selecting the most appropriate drugs for individual patients.

Association between different screening strategies for SARS-CoV-2 and deaths and severe disease in Italy

BACKGROUND

The WHO recommends testing any suspected person with Severe Acute Respiratory Syndrome CoronaVirus-2 (SARS-CoV-2), in order to limit the spread of the epidemic. In Italy, some Regions opted for extensive testing, whereas others limited tests to selected subjects. To assess the influence of different strategies, we examined the incidence of death and severe cases in Italy.

METHODS

Data on new cases of SARS-CoV-2, number of tests, deaths and admissions to Intensive Care Units (ICU) were retrieved in each Italian Region, from 24 February to 18 March 2020. As an index of different screening strategies, the number of tests/positive test results (P/T) ratio as of 7 March 2020, was considered. The cumulative number of deaths and of new severe cases, between March 23 and 25 was recorded. The association of those two outcomes with the number of P/T ratio was assessed using linear regression models.

RESULTS

In the interval between March 23 and 25, recorded deaths (*million inhabitants) were 14 (3-54), whereas severe cases were 31 (10-112). Both the number of deaths and that of severe cases showed a significant correlation (R² .57 and .41, with P < .01) with the P/T ratio. Deaths and severe cases were associated with higher mean personal income and lower density of General Practioners (GPs). The association of P/T with severe cases and deaths retained statistical significance after adjusting for mean personal income (R² .30 and .41, respectively; both P = .04) and GPs density (R² .21 and .19, respectively; both P = .03).

CONCLUSIONS

A more aggressive screening strategy for SARS-Cov-2, was associated with lower rates of death and severe disease in Regions of Italy.

Sodium-glucose co-transporter-2 inhibitors and all-cause mortality: A meta-analysis of randomized controlled trials

The present meta-analysis is aimed at assessing the effects of sodium-glucose co-transporter-2 (SGLT2) inhibitors on all-cause mortality and differences across different trials and molecules of the class. We included all randomized clinical trials with a duration of treatment longer than 52 weeks, enrolling at least 100 patients in each arm, and comparing an SGLT2 inhibitor with any comparator or placebo. Out of 139, 235 and 145 items identified, 21 trials were selected, enrolling 39 593 and 30 771 patients in SGLT2 inhibitor and comparator arms, respectively, with a median duration of 104 weeks, and reporting 2474 and 2298 deaths for SGLT2 inhibitors and comparators, respectively. No relevant heterogeneity was found (I² = 17%). Treatment with SGLT2 inhibitors was associated with a significant reduction in all-cause mortality (MH-OR [95% CI] 0.86 [0.81, 0.91] P < .00001). Meta-regression analyses found a significant direct association of treatment effect only with the proportion of Asian subjects enrolled, and an inverse correlation with the proportion of Caucasian patients. In conclusion, SGLT2 inhibitors reduce all-cause mortality in randomized controlled trials.

Effects of real-time continuous glucose monitoring in type 1 diabetes: a meta-analysis of randomized controlled trials

AIMS

Self-monitoring of blood glucose (SMBG) represented a major breakthrough in the treatment of type 1 diabetes. The aim of the present meta-analysis is to assess the effect of continues glucose monitoring (CGM) and flash glucose monitoring (FGM), on glycemic control in type 1 diabetes.

MATERIALS AND METHODS

The present analysis includes randomized clinical trials comparing CGM or FGM with SMBG, with a duration of at least 12 weeks, identified in Medline or clinicaltrials.gov. The principal endpoint was HbA1c at the end of the trial. A secondary endpoint was severe hypoglycemia. Mean and 95% confidence intervals for HbA1c and Mantel-Haenzel odds ratio [MH-OR] for severe hypoglycemia were calculated, using random effect models. A sensitivity analysis was performed using fixed effect models. In addition, the following secondary endpoints were explored, using the same methods: time in range, health-related quality of life, and treatment satisfaction. Separate analyses were performed for trials comparing CGM with SMBG, and those comparing CGM + CSII and SMBG + MDI and CGM-regulated insulin infusion system (CRIS) and CSII + SMBG.

RESULTS

CGM was associated with a significantly lower HbA1c at endpoint in comparison with SMBG (- 0.24 [- 0.34, - 0.13]%); CGM was associated with a significantly lower risk of severe hypoglycemia than SMBG. Treatment satisfaction and quality of life were not measured, or not reported, in the majority of studies. FGM showed a significant reduction in the incidence of mild hypoglycemia and an increased treatment satisfaction, but no significant results are shown in HbA1c. CGM + CSII in comparison with SMBG + MDI was associated with a significant reduction in HbA1c. Only two trials with a duration of at least 12 weeks compared a CRIS with SMBG + CSII; HbA1c between the two treatment arms was not statistically significant (difference in means: - 0.23 [- 0.91; 0.46]%; p = 0.52).

CONCLUSION

GCM compared to SMBG has showed a reduction in HbA1c and severe hypoglycemia in patient with type 1 diabetes. The comparison between CGM + CSII and SMBG + MDI showed a large reduction in HbA1c; it is conceivable that the effects of CSII + CGM on glycemic control additives. The only comparison available between FGM and SMBG was conducted in patients in good control.

Obesity as a risk factor for hospitalization in COronaVirus Disease-19 (COVID-19) patients: Analysis of the Tuscany regional database

BACKGROUND AND AIMS

Aim of the present study is to determine the role of obesity as a risk factor for COronaVirus Disease-19 (COVID-19) hospitalization.

METHODS AND RESULTS

This observational study was performed using Istituto Superiore di Sanità (ISS) Tuscany COVID-19 database by the Agenzia Regionale Sanità (ARS), including all COVID-19 cases registered until April 30th, 2020, with reported information on chronic diseases. The principal outcome was hospitalization. An age and gender-adjusted logistic regression model was used to assess the association of clinical and demographic characteristics with hospitalization. Further multivariate models were applied. Of 4481 included subjects (36.9% aged over 70 years), 1907 (42.6%) were admitted to hospital. Obesity was associated with hospitalization after adjusting for age and gender. The association of obesity with hospitalization retained statistical significance in a fully adjusted model, including possible confounders (OR: 2.99 [IC 95% 2.04-4.37]). The effect of obesity was more evident in younger (<70 years) than in older (≥70 years) subjects.

CONCLUSIONS

The present data confirm that obesity is associated with an increased risk of hospitalization in patients with COVID-19. Interestingly, the association of obesity with hospitalization was greater in younger (<70 years) patients.

Effect of metformin on all-cause mortality and major adverse cardiovascular events: An updated meta-analysis of randomized controlled trials

AIMS

The Italian Society of Diabetology and the Italian Association of Clinical Diabetologists are developing new guidelines for drug treatment of type 2 diabetes. The effects of anti-hyperglycaemic drugs on all-cause mortality and major adverse cardiovascular events (MACEs) were included among the critical clinical outcomes. We have therefore carried out an updated meta-analysis on the effects of metformin on these outcomes.

DATA SYNTHESIS

A MEDLINE and EMBASE search was performed to identify all randomized controlled trials (RCTs) with duration ≥52 weeks (published up to August 2020), in which metformin was compared with either placebo/no therapy or active comparators. MACEs (restricted for RCT reporting MACEs within their study endpoints) and all-cause mortality (irrespective of the inclusion of MACEs among the pre-specified endpoints) were considered as the primary endpoints. Mantel-Haenszel odds ratio (MH-OR) with 95% confidence interval was calculated for all endpoints considered. Metformin was associated with a nonsignificant reduction of all-cause mortality (n = 13 RCTs; MH-OR 0.80 [95% CI 0.60, 1.07]). However, this association became statistically significant after excluding RCTs comparing metformin with sulfonylureas, SGLT-2 inhibitors or GLP-1 analogues (MH-OR 0.71 [0.51, 0.99]). Metformin was associated with a lower risk of MACEs compared with comparator treatments (n = 2 RCTs; MH-OR 0.52 [0.37, 0.73]), p < 0.001. Similar results were obtained in a post-hoc analysis including all RCTs fulfilling criteria for inclusion in the analysis (MH-OR: 0.57 [0.42, 0.76]).

CONCLUSIONS

This updated meta-analysis suggests that metfomin is significantly associated with lower risk of MACEs and tendentially lower all-cause mortality compared to placebo or other anti-hyperglycaemic drugs.

Choosing the best algorithm among five thyroid nodule ultrasound scores: from performance to cytology sparing-a single-center retrospective study in a large cohort

OBJECTIVE

Incidental diagnosis of thyroid nodules, and therefore of thyroid cancer, has definitely increased in recent years, but the mortality rate for thyroid malignancies remains very low. Within this landscape of overdiagnosis, several nodule ultrasound scores (NUS) have been proposed to reduce unnecessary diagnostic procedures. Our aim was to verify the suitability of five main NUS.

METHODS

This single-center, retrospective, observational study analyzed a total number of 6474 valid cytologies. A full clinical and US description of the thyroid gland and nodules was performed. We retrospectively applied five available NUS: KTIRADS, ATA, AACE/ACE-AME, EUTIRADS, and ACRTIRADS. Thereafter, we calculated the sensitivity, specificity, PPV, and NPV, along with the number of possible fine-needle aspiration (FNA) sparing, according to each NUS algorithm and to clustering risk classes within three macro-groups (low, intermediate, and high risk).

RESULTS

In a real-life setting of thyroid nodule management, available NUS scoring systems show good accuracy at ROC analysis (AUC up to 0.647) and higher NPV (up to 96%). The ability in FNA sparing ranges from 10 to 38% and reaches 44.2% of potential FNA economization in the low-risk macro-group. Considering our cohort, ACRTIRADS and AACE/ACE-AME scores provide the best compromise in terms of accuracy and spared cytology.

CONCLUSIONS

Despite several limitations, available NUS do appear to assist physicians in clinical practice. In the context of a common disease, such as thyroid nodules, higher accuracy and NPV are desirable NUS features. Further improvements in NUS sensitivity and specificity are attainable future goals to optimize nodule management.

KEY POINTS

• Thyroid nodule ultrasound scores do assist clinicians in real practice. • Ultrasound scores reduce unnecessary diagnostic procedures, containing indolent thyroid microcarcinoma overdiagnosis. • The variable malignancy risk of the "indeterminate" category negatively influences score's performance in real-life management of thyroid lesions.

Are diabetes and its medications risk factors for the development of COVID-19? Data from a population-based study in Sicily

BACKGROUND AND AIMS

Diabetes mellitus (DM) has been associated with higher incidence of severe cases of COVID-19 in hospitalized patients, but it is unknown whether DM is a risk factor for the overall COVID-19 incidence. The aim of present study was to investigate whether there is an association of DM with COVID-19 prevalence and case fatality, and between different DM medications and risk for COVID-19 infection and death.

METHODS AND RESULTS

retrospective observational study on all SARS-CoV-2 positive (SARS-CoV-2⁺) cases and deaths in Sicily up to 2020, May 14th. No difference in COVID-19 prevalence was found between people with and without DM (RR 0.92 [0.79-1.09]). Case fatality was significantly higher in SARS-CoV-2⁺ with DM (RR 4.5 [3.55-5.71]). No diabetes medication was associated with differences in risk for SARS-Cov2 infection.

CONCLUSIONS

in Sicily, DM was not a risk factor for COVID-19 infection, whereas it was associated with a higher case fatality.

Deprescription in elderly patients with type 2 diabetes mellitus

AIMS

The Primary aim is to verify physicians' adherence to the 2016 Italian diabetes guidelines therapeutic targets, and their habits on deprescription in elderly persons with Type 2 Diabetes Mellitus (T2DM). Secondary aims are the assessment of the potential impact of the targets' changes in 2018 Italian guidelines, and the outcomes of deprescription in the management of T2DM.

METHODS

Observational retrospective cohort study, enrolling persons with T2DM, aged > 75 years, who attended a visit throughout 2017, and a second visit 6 months later in our outpatient clinic.

RESULTS

Of the 387 patients included, 336 (87, 8%) were on target, according to 2016 guidelines. Deprescription was advisable in 62% of patients on target. Among those, 22% were deprescribed. In patients undergoing deprescription, during the following 6 months, no severe hypoglycemia occurred (versus 5 cases in the prior 6 months). Glycated Hemoglobin (HbA1c) increased (p < 0.05) from 47.0 [41.7-51.0] to 53.0 [45.4-59.5] mmol/mol). Applying to the sample the 2018 Italian Guidelines targets, 57.2% would have been on target, 18.5% above, and 24.3% below (needing deprescription).

CONCLUSION

In our study, a minority of suitable patients received deprescription. Deprescription led to a significant reduction in severe hypoglycemia rate, whereas HbA1c remained on target in the majority of cases.

Type 1 diabetes and periodontitis: prevalence and periodontal destruction-a systematic review

AIMS

Data about the association between periodontal disease or periodontitis (PD), diabetes and hyperglycemia have been reported mostly in patients with type 2 diabetes. Conversely, information about PD in type 1 diabetes (T1DM) is relatively scarce. The aim of this meta-analysis is therefore: (1) to assess the prevalence and severity of PD in patients affected by T1DM in comparison with the general population and (2) to verify the association between severity of PD and glycemic control in type 1 diabetics.

METHODS

An electronic search was performed on MEDLINE, Cochrane Central Register of Trials and EMBASE, up to October 31, 2019. Estimates of prevalence of PD in T1DM were calculated together with Mantel-Haenszel odds ratios (MH-OR) of the risk of PD associated with T1DM; weighed mean difference in CAL between T1DM and control and weighed mean difference in CAL in patients with T1DM and unsatisfactory glycemic control as compared with those in good glycemic control were also evaluated..

RESULTS

The prevalence of PD in type 1 diabetes was 18.5 [8.0; 37.1] %; the MH-OR for PD is 2.51 (1.32;4.76) in T1DM patients versus general population (p = 0.005). The weighed mean difference in CAL depth between T1DM patients and controls is 0.506 [0.181; 0.832] mm (p < 0.005), and in T1DM patients with good glycemic control CAL depth is - 0.71 [- 1.00; - 0.42] mm less deep than in subjects with HbA1c > 7%.

CONCLUSIONS

The present data confirm that T1DM is a relevant risk factor for the development of PD. The proportion of patients affected by PD is more than doubled in subjects with T1DM in comparison with non-diabetic individual, and among patients with T1DM, PD seems to be more severe and the differences appear very wide between subjects in optimal and suboptimal glycemic control.

Retrospective Matched Case-Control Study on the Use of CO2 Laser for the Treatment of Nonhealing Diabetic Foot Ulcers: The DULCIS-2 (Diabetic ULcer, CO2 Laser, and Infections) Study

PURPOSE

Infection, which is one of the possible complications of diabetic foot ulcers (DFUs), makes the treatment of ulcers challenging because of its negative impact on healing processes and the high prevalence of multiresistant germs. This study is aimed at verifying the effect of a surgical CO₂ laser (which reduces the bacterial load and allows a more accurate debridement), as compared with the traditional lancets, on the healing rate of DFU.

METHODS

The present case-control retrospective analysis was performed on patients with chronic (>6 months) DFU with Texas grade >1, treated with 80 W surgical CO₂ laser (DEKA SmartXide2 C80, El.En. Group) and compared with a matched sample of patients with similar characteristics, who were treated with a traditional surgical approach. The debridement was performed trying to achieve the complete removal of nonviable tissues. The principal endpoint was the proportion of patients healed at 6 months. All analyses were carried out with SPSS 25.0. The study protocol was approved by the local ethical committee.

RESULTS

This study included 118 patients (59 cases and 59 controls). At 6 months, the proportion of healing patients was 35% and 18% in cases and controls, respectively (P = .034). The corresponding figure at 1 year was 62% and 38% (P = .009), whereas no difference was observed at 1, 2, and 3 months. No serious adverse event was observed.

CONCLUSIONS

In this article, we show for the first time that CO₂ laser treatment, in comparison with traditional surgical approaches, can be associated with an increased healing rate in patients with DFU.

Low-carbohydrate diets and type 2 diabetes treatment: a meta-analysis of randomized controlled trials

AIM

To assess whether LC diets are associated with long-term improvement in glycemic control and weight loss in people with T2DM, and their cardiovascular and renal safety.

METHODS

Meta-analysis of randomized controlled trials lasting more than 3 months, retrieved through extensive search on PubMed, Embase, ClinicalTrial.gov, Cochrane databases up to March 1st, comparing LC diets and balanced carbohydrate diets in people with T2DM.

RESULTS

We retrieved 37 trials, including 3301 patients. Average carbohydrate intake in LC diets was 36% of total energy. LC diets were associated with significant reduction of HbA1c at 3 months (MD - 0.17%, 95% CI - 0.27, - 0.07), no difference at 6 and 12 months, and significant increase at 24 months (MD 0.23%, 95% CI MD 0.02, 0.44). VLC diets were associated with significant HbA1c reduction at 3 and 6 months (MD - 0.43% - 0.60, - 0.26%, and MD - 0.40% 95% CI - 0.59, - 0.22, respectively), but not at 12 and 24 months. LC diets were associated with significant BMI reduction at 6 months (- 1.35 kg/m² 95% CI, - 2.18, - 0.52), but not at other time points. Only a minority of trials reported data on renal function, so renal safety could not be assessed. No significant differences in body weight, lipid profile, or blood pressure were found in the long term.

CONCLUSION

LC diets may produce small short-term improvements in HbA1c and weight, which are not maintained in the long term. Data on their renal safety are insufficient.

Effect of insulin secretagogues on major cardiovascular events and all-cause mortality: A meta-analysis of randomized controlled trials

BACKGROUND AND AIM

In 2019, the Italian Society of Diabetology and the Italian Association of Clinical Diabetologists nominated an expert panel to develop guidelines for drug treatment of type 2 diabetes. This expert panel, after identifying the effects of glucose-lowering agents on major adverse cardiovascular events (MACEs) and all-cause mortality as critical outcomes, decided to perform a systematic review and meta-analysis on the effect of insulin secretagogues (sulfonylureas and glinides) with this respect.

METHODS AND RESULTS

A MEDLINE database search was performed to identify all RCTs, up to January 1st, 2020, with duration≥52 weeks, in which insulin secretagogues (glibenclamide, gliclazide, glimepiride, glipizide, chlorpropamide, repaglinide, nateglinide) were compared with either placebo or active comparators. The principal endpoints were MACE (restricted for RCT reporting MACEs within their outcomes) and all-cause mortality (irrespective of the inclusion of MACEs among the pre-specified outcomes). Mantel-Haenszel odds ratio (MH-OR) with 95% Confidence Interval (95% CI) was calculated for all the endpoints considered. Fourteen RCTs were included in the analysis for MACEs (919 in insulin secretagogues and 1,087 in control group). Insulin secretagogues were not significantly associated with an increased risk of MACEs in comparison with controls (MH-OR 1.08 [95% CI 0.96, 1.22], p = 0.20). When considering the 48 RCTs fulfilling criteria for inclusion in the analysis on all-cause mortality, insulin secretagogues were associated with a significantly increased risk of all-cause mortality (MH-OR 1.11 [1.00, 1.23], p = 0.04).

CONCLUSIONS

This meta-analysis suggests that insulin secretagogues are associated with an increased risk of all-cause mortality when compared with placebo or other anti-hyperglycaemic drugs.

Bullous pemphigoid and dipeptidyl peptidase-4 inhibitors: a meta-analysis of randomized controlled trials

PURPOSE

An increasing body of evidence suggests that dipeptidyl-peptidase 4 (DPP-4) inhibitors could play a role in the development of bullous pemphigoid. The knowledge regarding this association is based on case reports, pharmacovigilance database analyses, and observational studies. Data from randomized clinical trials are a relevant source of information on adverse events. Since no single trial has a sufficient power to assess the risk of very rare adverse events, such as pemphigoid, metanalyses of RCTs could be a useful tool for exploring this issue.

METHODS

An extensive Medline, Embase and Cochrane Database search for sitagliptin or vildagliptin, omarigliptin or saxagliptin or alogliptin or trelagliptin or anagliptin or linagliptin or gemigliptin or evogliptin or teneligliptin was performed up to September 30th, 2019. All trials performed on type 2 diabetes, with duration ≥24 weeks, and comparing DPP4i with placebo or active drugs were collected. The study has been registered on PROSPERO (#153344). Mantel-Haenszel odds ratio (MH-OR) with 95% Confidence Interval (95% CI) was calculated for pemphigoid.

RESULTS

A total of 138 eligible trials were identified (61,514 patients in DPP-4 inhibitors and 59,661 patients in the control group). Only six trials reported at least one case of pemphigoid (17 and 1 cases in DPP4i and control groups, respectively). DPP-4 inhibitors were associated with an increased risk of pemphigoid (MH-OR 4.44 [1.31, 15.00], p = 0.020). A separate analysis for trials with linagliptin showed a significant increase of BP with the active drug (MH-OR 4.69 [1.09, 20.22]; p = 0.04).

CONCLUSIONS

In conclusion, available data from randomized controlled trials seem to confirm the association between DPP-4 inhibitors and bullous pemphigoid. This association could be limited to one molecule of the class (i.e., linagliptin), although data on other DPP4-i (e.g., vildagliptin) are insufficient to rule out similar detrimental effects.

Pharmacological treatment of acute-phase anorexia nervosa: Evidence from randomized controlled trials

BACKGROUND

Anorexia nervosa (AN) is the psychiatric disorder with the highest mortality rate, with a standard mortality ratio of 5.86. Despite the large use of psychotropic drugs in the clinical setting, Food and Drug Administration has not approved any psychoactive treatment for AN.

AIMS

The aim of this study was to perform an updated systematic review and meta-analysis of published randomized controlled trials (RCTs) investigating psychopharmacological treatment in acute-phase AN.

METHODS

The present paper follows the preferred reporting items for systematic reviews and meta-analyses (PRISMA) statement. An extensive literature search was performed. All RCTs enrolling patients with acute-phase AN, comparing at least one psychotropic drug with another drug, placebo, treatment-as-usual or no treatment were included. The main outcome was the effect of psychoactive drugs on body mass index (BMI); data on psychopathological outcomes were also collected when available.

RESULTS

A total of 19 RCTs met all specified criteria. Of these, 11 were excluded from quantitative analyses. Of the eight studies included in the meta-analyses, five reported data on BMI, showing no significant difference between olanzapine and placebo for weight recovery. No significant result was found for AN psychopathology, depressive and anxious symptoms for any of the molecules studied.

CONCLUSIONS

RCTs published in this field display methodological biases, low sample sizes and short follow-up periods. Further research efforts are needed in this field as no evidence has been demonstrated for the use of any psychotropic drug in acute-phase AN neither for weight recovery, nor for comorbid psychiatric symptoms.

Combined continuous glucose monitoring and subcutaneous insulin infusion versus self-monitoring of blood glucose with optimized multiple injections in people with type 1 diabetes: A randomized crossover trial

AIM

To investigate the efficacy of a combination of continuous glucose monitoring (CGM) and continuous subcutaneous insulin infusion (CSII) versus an optimized degludec-based multiple daily injections (MDI) regimen + self-monitoring of blood glucose (SMBG) in people with type 1 diabetes with regard to optimizing glucose control.

MATERIAL AND METHODS

The trial included 28 individuals who underwent a 4-week run-in phase, and were then randomized 1:1 to: (a) CSII + CGM followed by MDI + SMBG or (b) an MDI basal-bolus regimen followed by CSII + CGM.

RESULTS

In patients randomized to the CSII + CGM → MDI + SMBG arm, a significant reduction in glycated haemoglobin (HbA1c) versus baseline was found at the end of the first phase (CSII + CGM) without significant variation in the following MDI + SMBG phase. In the arm randomized to the MDI + SMBG → CSII + CGM sequence, a significant improvement in HbA1c was observed in the first phase (MDI + SMBG), together with a further decrease in the following CSII + CGM phase. In the comparison of the two treatments using a mixed linear model, CSII + CGM was superior to MDI + SMBG with respect to change in HbA1c (P = 0.001).

CONCLUSIONS

This study suggests that CSII + CGM improves glycaemic control without relevant safety issues in type 1 diabetes, in comparison with MDI + SMBG.

Metabolic surgery for the treatment of type 2 diabetes: A network meta-analysis of randomized controlled trials

AIM

To compare different types of metabolic surgery (MS) with medical therapy (MT) for the treatment of type 2 diabetes (T2D).

MATERIALS AND METHODS

We conducted a network-meta-analysis (NMA) including randomized clinical trials comparing different MS techniques versus MT in people with T2D, with a duration of ≥24 weeks. Primary endpoints were glycated haemoglobin (HbA1c), fasting plasma glucose (FPG) and diabetes remission. Indirect comparisons of different types of surgery were performed by NMA. Mean and 95% confidence intervals for continuous variables, and Mantel-Haenzel odds ratios for categorial variables, were calculated using random effect models. Types of MS included: laparoscopic adjustable gastric banding (LAGB), Roux-en-Y gastric bypass, sleeve gastrectomy (SG), bilio-pancreatic diversion (BPD); greater curvature plication (GCP); one-anastomosis gastric bypass (OAGB); and duodenojejunal bypass.

RESULTS

The 24 retrieved trials included 1351 patients (1014 with MS and 337 with MT). The mean baseline BMI was 36.8 kg/m² . MS was associated with significantly greater reductions in HbA1c and FPG and greater diabetes remission when compared to MT. In the NMA, a significant reduction in HbA1c was observed with OAGB and SG. All surgical procedures were associated with a significant increase in diabetes remission, except GCP and LAGB. All procedures were associated with a reduction of body mass index (BMI).

CONCLUSIONS

Metabolic surgery is an interesting option for the treatment of T2D, although further data are needed to demonstrate its long-term efficacy and safety. Present data are not sufficient to modify current recommendations, which consider MS a possible treatment for T2D in those with a BMI >35 kg/m² .

Pancreatitis and pancreatic cancer in patients with type 2 diabetes treated with glucagon-like peptide-1 receptor agonists: an updated meta-analysis of randomized controlled trials

AIM

An association between Glucagon-Like Peptide-1 Receptor Agonists (GLP1-RA) and risk of pancreatitis and pancreatic cancer has been suggested. Since its first description, several new trials (including three cardiovascular outcome trials) have been published, substantially increasing the available data set. This suggests the need for an update of the previous meta analysis.

MATERIALS AND METHODS

A Medline search for GLP-1 receptor agonists (exenatide, liraglutide, lixisenatide, albiglutide, dulaglutide, or semaglutide) was performed, collecting all randomized clinical trials, with duration ≥52 weeks, enrolling patients with type 2 diabetes, and comparing a GLP-1 receptor agonist with placebo or any other non-GLP-1 receptor agonist drug. The endpoints were pancreatitis, pancreatic cancer reported as serious adverse events. Mantel-Haenszel odds ratio (MH-OR) with 95% Confidence Interval (95% CI) was calculated for all outcomes defined above, on an intention-to-treat basis.

RESULTS

A total of 43 trials fulfilling inclusion criteria (all reporting data on pancreatitis and pancreatic cancer) was identified. GLP-1 RA showed no association with pancreatitis (MH-OR 1.24 [0.94, 1.64]; p=0,13) and pancreatic cancer (MH-OR 1.28 [0.87, 1.89]; p=0,20).

CONCLUSIONS

No clear evidence of risk for pancreatitis was observed, whereas data on pancreatic cancer are too scarce to draw any conclusion.

Factors associated with increased all-cause mortality during the COVID-19 pandemic in Italy

Background

The number of excess deaths during February–March 2020 in Italy, in comparison with previous years, was considerably higher than the recorded COVID19-related deaths. The present study aimed to explore the association of excess mortality with some indices related to the COVID-19 pandemic and its management.

Methods

Data on all-cause mortality from 20 February–31 March in the years 2015–2020, and demographic, socioeconomic and healthcare organisation data of each Italian region were obtained from the Italian Institute of Statistics. Non-COVID-19-Imputed Excess Mortality (NCIEM) was calculated as the difference between the excess 2020 mortality and reported COVID-19 mortality. The association of NCIEM with the rate of COVID-19 cases, COVID-19 mortality and other potential moderators was assessed using linear regression models.

Results

The nationwide number of excess deaths and COVID-19 deaths was 26,701 and 13,710, respectively, with a difference of 12,991. The NCIEM in different regions showed a direct correlation with COVID-19 mortality (r² = 0.61, p < 0.001) and total cases (r² = 0.30, p = 0.012), and an inverse correlation with cases/total tests ratio (r² = 0.49, p = 0.001). Direct correlations were also found with the proportion of institutionalised elderly, whereas inverse correlations were observed with prevalence of diabetes, cardiovascular mortality and density of general practitioners.

Conclusions

The impact of the COVID-19 pandemic on all-cause mortality was considerably greater than that indicated by official counts of victims. Limited testing capacity and causes of death other than COVID-19 could have contributed to the increase in overall mortality rates.

Major cardiovascular events, heart failure, and atrial fibrillation in patients treated with glucagon-like peptide-1 receptor agonists: An updated meta-analysis of randomized controlled trials

BACKGROUND AND AIMS

Glucagon-like Peptide 1 Receptor Agonists (GLP1-RA) has been associated with a reduction of major cardiovascular events (MACE) and mortality on the basis of the results of cardiovascular outcome trials (CVOT). Several meta-analyses on this issue have been recently published; however, they were all restricted to CVOT, with the exclusion of all studies designed for other endpoints; moreover, other cardiovascular endpoints, such as atrial fibrillation and heart failure have not been fully explored.

METHODS AND RESULTS

A Medline search for GLP-1 receptor agonists (exenatide, liraglutide, lixisenatide, albiglutide, dulaglutide, or semaglutide) was performed, collecting all randomized clinical trials with a duration ≥52 weeks, enrolling patients with type 2 diabetes, and comparing a GLP-1 receptor agonist with placebo or any other non-GLP-1 receptor agonist drug. We included 43 trials, enrolling 63,134 patients. A significant reduction of MACE (MH-OR 0.87 [0.83, 0.92]), all-cause mortality (MH-OR 0.89 [0.83, 0.96]), and a nonstatistical trend toward reduction of heart failure (MH-OR 0.93 [0.85, 1.01]) was observed - GLP1-RA did not increase the risk of atrial fibrillation (MH-OR 0.94 [0.84, 1.04]).

CONCLUSION

The present meta-analysis confirms the favorable effects of glucagon-like peptide-1 receptor agonists on major cardiovascular events, cardiovascular and all-cause mortality, stroke, and possibly myocardial infarction. Conversely, the effects on heart failure remain uncertain. Available data on atrial fibrillation seems to exclude any major safety issues in this respect.

REGISTRATION NUMBER (PROSPERO)

CRD42018115577.

Risk of cancer in patients treated with dipeptidyl peptidase-4 inhibitors: an extensive meta-analysis of randomized controlled trials

AIMS

Observational studies and meta-analyses of randomized trials on dipeptidyl peptidase-4 inhibitors (DPP4i) reported discordant results on the risk of malignancies with this class of drugs. Aim of the present meta-analysis is the assessment of the effect of DPP4i treatment on the incidence of different types of cancer, collecting all available evidence from randomized controlled trials.

METHODS

An extensive MEDLINE, EMBASE, and Cochrane database search for sitagliptin or vildagliptin or omarigliptin or saxagliptin or alogliptin or trelagliptin or anagliptin or linagliptin or gemigliptin or evogliptin or teneligliptin was performed up to September 30th, 2019. All trials performed on type 2 diabetes, with duration ≥ 24 weeks, and comparing of DPP4i with placebo or active drugs were collected. The study has been registered on PROSPERO (#153344). Mantel-Haenszel odds ratio (MH-OR) with 95% confidence interval (95% CI) was calculated for all outcomes.

RESULTS

A total of 157 eligible trials were identified. DPP-4i were not associated with an increased risk of overall cancer (MH-OR 0.93 [0.86, 1.00]; p = 0.07), with no significant differences across individual molecules of the class. When compared with placebo/none, a lower risk of cancer with DPP-4i was observed in placebo-controlled trials (MH-OR 0.90 [0.82, 0.99], p = 0.030), whereas no significant differences have been detected with any other comparators. DPP-4i was associated with a significant reduction in colorectal cancer (MH-OR 0.70 [0.53, 0.94], p = 0.020).

CONCLUSIONS

Available data do not support the hypothesis of an association of DPP4i treatment with malignancies, with a possible beneficial effect for colon-rectal cancer.

Impact of Influenza Vaccination on All-Cause Mortality and Hospitalization for Pneumonia in Adults and the Elderly with Diabetes: A Meta-Analysis of Observational Studies

Diabetes is a chronic condition that can be worsened by complications such as seasonal influenza virus infections. The aim of the present meta-analysis is the systematic retrieval and analysis of all available evidence on the effects of an influenza vaccine on diabetic patients. We conducted a systematic review and meta-analysis by searching MEDLINE, Embase and the Cochrane databases from inception until April 2019. We included all types of studies reporting on the effectiveness of influenza vaccination in adult and elderly patients with type 1 and type 2 diabetes. The Newcastle-Ottawa scale was used to assess risk of bias, the GRADE methodology was used to assess the evidence for each outcome. A total of 2261 studies were identified, of those, 6 studies completely fulfilled the inclusion criteria. In the 6 studies included in the analysis, influenza vaccination was associated with a lower mortality rate (Mantel Haenszel Odds Ratio (MH-OR), 95% CI: 0.54 (0.40; 0.74), p < 0.001). Patients who received influenza vaccination showed a lower risk of hospitalization for pneumonia (MH-OR, 95% CI: 0.89; (0.80; 0.98), p = 0.18). A sensitivity analysis using fixed effect model confirmed the results (MH-OR, 95% CI: 0.91; (0.87; 0.96); p = 0.001). The results of this meta-analysis are clinically relevant and support the recommendation for all persons with diabetes to receive influenza vaccination.

Immune checkpoints inhibitors and hyperglycemia: A Meta-analysis of randomized controlled trials

BACKGROUND

Immune checkpoint inhibitors (ICI) exert their therapeutic effect by modulating the immune system and potentiating antitumor immunity. ICI have been associated with several immune-related adverse events, such as diabetes. However, no formal metaanalysis with this respect has been conducted so far. Aim of the present metaanalysis of randomized trials is to assess the effects of ICI on incident diabetes and hyperglycemia.

METHODS

A MEDLINE, Scopus, ISI-WOS, and Cochrane database search was performed to identify trials, enrolling patients with any form of cancer, up to April 23rd, 2019 in which ICI have been compared either with placebo or active comparators. Data were extracted from published reports or, if not available, from clinicaltrials.gov. The principal endpoints were the incidence of diabetes and cases of hyperglycemia, reported as adverse events. Mantel-Haenszel Odds Ratio with 95% Confidence Interval (MH-OR) was calculated for all outcomes. The study has been registered on PROSPERO website (CDR133927).

FINDINGS

Out of 42 trials retrieved, 40 reported information on incident diabetes or hyperglycemia. No association of ICI with incident diabetes (MH-OR 1.27 [0.66, 2.43], p = 0.47) was observed; whereas there was a trend toward an increased risk of hyperglycemia (MH-OR 1.45 [0.99, 2.13], p = 0.060), which reached statistical significance in sensitivity analyses and when analyzing separately placebo-controlled trials (MH-OR 1.95 [1.10, 3.49], p = 0.020). I² statistics did not suggest any relevant heterogeneity for all the principal analyses performed.

INTERPRETATION

ICI treatment is associated with an increased risk of hyperglycemia, and an increase in the risk of diabetes cannot be excluded.

Effects of probiotic supplementation during pregnancy on metabolic outcomes: A systematic review and meta-analysis of randomized controlled trials

AIM

To perform a systematic review and meta-analysis of randomized controlled trials (RCTs) to evaluate the effect of probiotics in pregnancy on the incidence of gestational diabetes (GDM) and fasting plasma glucose (FPG).

METHODS

A MEDLINE, EMBASE, Scopus and Cochrane search (up to May 30th, 2019) was performed to identify RCTs of comparison of probiotics with placebo/active comparators in pregnant women. Principal endpoints were the incidence of GDM and the change of FPG. Other maternal and fetal outcomes were secondary endpoints. Mantel-Haenszel Odds Ratio with 95% CI (MH-OR) was calculated for dichotomous outcomes, whereas standardized differences in means was calculated for continuous variables. (PROSPERO registration CRD42019139889).

FINDINGS

A total of 17 RCTs, all versus placebo, was identified. The overall quality of the trials was satisfactory. No effect of probiotics on incidence of GDM (MH-OR: 0.77[0.51,1.16], p = 0.21,I2:62%) was observed, with a small but significant reduction of FPG (mean difference -1.01 [-1.96, -0.06]mg/dl, p = 0.02, I²:46%). Among secondary endpoints, a significant reduction of maternal insulin (both in women with or without diabetes) was observed in the probiotics group.

INTERPRETATION

Probiotics during pregnancy do not reduce the incidence of GDM, with a very little (statistically but not clinically significant) reduction of fasting plasma glucose.

Cholelithiasis in patients treated with Glucagon-Like Peptide-1 Receptor: An updated meta-analysis of randomized controlled trials

Glucagon-Like Peptide-1 Receptor Agonists (GLP1-RA) has been associated with cholelithiasis in a previous meta-analysis. The publication of new trials suggests the need for an update. We collected trials with GLP1-RA vs. other therapies, calculating Mantel-Haenszel odds ratio (MH-OR, 95%CI). GLP1-RA significantly increased the risk of cholelithiasis (MH-OR 1.28 [1.11, 1.48]).

Long-term metabolic and cardiovascular effects of antipsychotic drugs. A meta-analysis of randomized controlled trials

Most of the randomized controlled trials (RCTs) on antipsychotics (APs) have efficacy as their primary endpoint, leading to a lack of evidence on long-term metabolic effects of APs. The aim of the present meta-analysis is to compare different APs for the long-term modification of risk of major adverse cardiovascular events (MACE) and related mortality, in patients with schizophrenia and bipolar disorder. All RCTs found on Medline/Embase of at least 52 weeks up to 19 December 2017, enrolling patients with bipolar disorder or schizophrenia and comparing an AP with another AP or placebo were included. The primary outcome of this analysis was the association of APs with the incidence of cardiovascular death, myocardial infarction (MI), and stroke. 3013 studies were screened, 92 met the selection criteria. MI, stroke and cardiovascular death were reported in 11, 6 and 24 studies, respectively. No significant difference was observed with respect to MI and Stroke; a significantly higher cardiovascular mortality was observed for sertindole when compared to risperidone (Mantel-Haenszel Odds Ratio: 2.56, 95% CI: 1.33 - 5). Long-term cardiovascular effects of APs deserve to be studied more extensively. The request by regulatory authorities of cardiovascular safety data from specifically designed trials would be useful.

Fournier's gangrene and sodium-glucose co-transporter-2 inhibitors: A meta-analysis of randomized controlled trials

Fournier's gangrene (FG) is a rare, life-threatening necrotizing fasciitis of the perineum. The US Food and Drug Administration (FDA) released a Drug Safety Communication regarding the risk of FG associated with sodium-glucose co-transporter-2 inhibitors (SGLT2i), relying on the FDA Adverse Event Reporting System. To verify this association, we performed a meta-analysis of all randomized controlled trials enrolling patients with type 2 diabetes, comparing SGLT2i with placebo or different therapies, collecting cases of FG reported as a serious adverse event. Risk of abscess, cellulitis and erysipela were secondary outcomes. We retrieved 84 trials enrolling 42 415 patients in the SGLT2i group and 27 158 patients in comparator groups. No difference was observed between SGLT2i and comparators in the risk of FG (Mantel-Haenzel odds ratio [MH-OR] 0.41 [0.09, 1.82]), abscess (MH-OR 0.94 [0.54, 1.65]), cellulitis (MH-OR 0.90 [0.71, 1.13] or erysipela (MH-OR 0.89 [0.45, 1.77]). The number of events was small, leading to a wide confidence interval that does not allow ruling out an increase in FG or skin and subcutaneous tissue infections.

Glucagon-like peptide-1 receptor agonists and cardiovascular outcomes in patients with and without prior cardiovascular events: An updated meta-analysis and subgroup analysis of randomized controlled trials

AIM

To conduct a meta-analysis of cardiovascular outcome trials on the effects of glucagon-like peptide-1 receptor agonists (GLP-1RAs) on major adverse cardiovascular events (MACE).

METHODS

A search of MEDLINE, EMBASE, Cochrane database and clinicaltrials.gov was performed to identify controlled trials (up to 15 June 2019) of GLP-1RAs with a cardiovascular endpoint. The principal endpoint of the present meta-analysis was MACE; secondary endpoints included myocardial infarction, stroke, cardiovascular and all-cause mortality, and hospitalization for heart failure. Mantel-Haenszel odds ratios (MH-ORs) with 95% confidence intervals (CIs) were calculated for all outcomes.

RESULTS

In the seven trials included, all placebo-controlled, GLP-1RA treatment was associated with a reduction in MACE (MH-OR 0.87 [95% CI 0.81, 0.93]). Cardiovascular and all-cause mortality, myocardial infarction and stroke were also reduced (MH-OR 0.88 [95% CI 0.80, 0.96], MH-OR 0.90 [95% CI 0.82, 0.98], MH-OR 0.91 [95% CI 0.84, 0.98] and MH-OR 0.86 [95% CI 0.77, 0.97], respectively). Results for hospitalization for heart failure were not statistically significant (MH-OR 0.93 [95% CI 0.83, 1.04]). The meta-analyses of patient subgroups showed a significant reduction in MACE with GLP-1RAs, irrespective of gender, advanced age and obesity.

CONCLUSIONS

GLP-1RAs are associated with a reduction in cardiovascular morbidity and mortality in high-risk patients with diabetes. This effect does not appear to be moderated by gender or body mass index. The possibility of different effects of GLP-1RAs between patients in primary and secondary prevention merits further investigation.

Exploring the heterogeneity of the effects of SGLT-2 inhibitors in cardiovascular outcome trials

BACKGROUND AND AIM

The interpretation of discrepancies across cardiovascular safety trials (CVOT) with SGLT-2 inhibitors in the incidence of major cardiovascular events (MACE) and mortality is complex, because of heterogeneity in trial protocols and baseline characteristics of patients enrolled. Aim of this analysis is the exploration of possible determinants of heterogeneity of relative risk reduction for major cardiovascular events (MACE) and all-cause mortality.

METHODS AND RESULTS

Incidence of events (MACE and mortality) in intervention and control groups and baseline characteristics of patients were extracted for each trial (EMPAREG, CANVAS, and DECLARE). For studies including both primary and secondary prevention cohorts, those two subgroups were considered separately. Metaregression analysis was used to assess the association of relative risk reduction with baseline characteristics of patients, including observed incidence of events with placebo. The estimated reduction in the incidence of MACE associated with SGLT-2 inhibitors showed a significant association with the incidence of MACE in the control group, suggesting that a greater effect was observed in trials enrolling patients at higher risk (Slope -0.008 [-0.023; 0.007], p = 0.31). A higher proportion of patients treated with statins, β-blockers and insulin at baseline was associated with a greater reduction of MACE, but not of mortality.

CONCLUSIONS

In CVOT trials, the magnitude of the effect of SGLT-2 inhibitors on MACE is driven by absolute risk of enrolled patients; as a consequence, the estimated risk reduction is lower in primary prevention cohorts, which have a lower risk. This result supports the hypothesis of a class effect of SGLT-2 inhibitors on MACE.

Pancreatitis and pancreatic cancer in patientes treated with Dipeptidyl Peptidase-4 inhibitors: An extensive and updated meta-analysis of randomized controlled trials

AIM

Observational studies and metanalyses of randomized trials on Dipeptidyl Peptidase-4 inhibitors (DPP4i) reported discordant results on the risk of pancreatitis and pancreatic cancer with this class of drugs. Aim of the present meta-analysis is the assessment of the effect of DPP4i treatment on the incidence of pancreatitis and pancreatic cancer, collecting all available evidence from randomized controlled trials. Methods Data Sources: an extensive Medline, Embase and Cochrane Database search for sitagliptin or vildagliptin or omarigliptin or saxagliptin or alogliptin or trelagliptin or anagliptin or linagliptin or gemigliptin or evogliptin or teneligliptin was performed up to up to September 30th, 2019. All trials performed on type 2 diabetes, with duration ≥24 weeks, and comparing of DPP4i with placebo or active drugs were collected. The study has been registered on PROSPERO (#153344). Mantel-Haenszel odds ratio (MH-OR) with 95% Confidence Interval (95% CI) was calculated for all outcomes defined above. Results A total of 165 eligible trials were identified. DPP-4 inhibitors were not associated with an increased risk of pancreatitis (MH-OR 1.13 [0.86, 1.47]) or pancreatic cancer (MH-OR 0.86 [0.60, 1.24]) with no significant differences across individual molecules of the class.

CONCLUSIONS

available data do not support the hypothesis of an association of DPP4i treatment with pancreatitis. Present data do not suggest any association of DPP4i with pancreatic cancer, although they are insufficient to draw definitive conclusions.

Antimicrobial Photodynamic Therapy in Infected Diabetic Foot Ulcers: A Multicenter Preliminary Experience

BACKGROUND

The increasing resistance of bacteria to antibiotics and the frequency of comorbid conditions of patients make the treatment of diabetic foot infections problematic. In this context, photodynamic therapy could be a useful tool to treat infected wounds. The aim of this study was to evaluate the effect of repeated applications of a phthalocyanine derivative (RLP068) on the bacterial load and on the healing process.

METHODS

The present analysis was performed on patients with clinically infected ulcers who had been treated with RLP068. A sample for microbiological culture was collected at the first visit before and immediately after the application of RLP068 on the ulcer surface, and the area was illuminated for 8 minutes with a red light. The whole procedure was repeated three times per week at two centers (Florence and Arezzo, Italy) (sample A), and two times per week at the third center (Stuttgart, Germany) (sample B) for 2 weeks.

RESULTS

Sample A and sample B were composed of 55 and nine patients, respectively. In sample A, bacterial load decreased significantly after a single treatment, and the benefit persisted for 2 weeks. Similar effects of the first treatment were observed in sample B. In both samples, the ulcer area showed a significant reduction during follow-up, even in patients with ulcers infected with gram-negative germs or with exposed bone.

CONCLUSIONS

RLP068 seems to be a promising topical wound management procedure for the treatment of infected diabetic foot ulcers.

Impact of technology on glycaemic control in type 2 diabetes: A meta-analysis of randomized trials on continuous glucose monitoring and continuous subcutaneous insulin infusion

AIM

To conduct a meta-analysis to assess the effect of continuous subcutaneous insulin infusion (CSII), continuous glucose monitoring (CGM), and the combination of the two, on glycaemic control in type 2 diabetes.

MATERIALS AND METHODS

The analysis included randomized clinical trials comparing CSII with multiple daily injections (MDI) in people with type 2 diabetes, as well as studies comparing CGM or flash glucose monitoring (FGM) with self-monitoring of blood glucose (SMBG), with a duration of at least 12 weeks, identified in Medline or clinicaltrials.gov. The principal endpoint was glycated haemoglobin (HbA1c) at the end of the trial. Mean and 95% confidence intervals (CIs) for HbA1c and Mantel-Haenzel odds ratios for severe hypoglycaemia were calculated, using random-effect models.

RESULTS

The retrieved trials showed a significant heterogeneity (I² = 90%). The difference in HbA1c between CSII and MDI was not statistically significant (-0.26% [95% CI -0.74;0.22]; P = .29). The difference in endpoint HbA1c between CGM and SMBG was marginally significant (-0.24 [95% CI -0.49;0.00]; P = .05), and CGM was possibly associated with a lower hypoglycaemic risk. Only one trial explored the effect of FGM, as compared with SMBG, on HbA1c in type 2 diabetes, finding no difference across groups (at study end: 8.4% ± 0.8% vs 8.3% ± 1.1% with FGM and SMBG, respectively). Conversely, FGM was associated with an improvement in quality of life and with a lower incidence of hypoglycaemic events. The small number of retrieved trials indicates that the results should be interpreted with caution.

CONCLUSIONS

The analysis showed that CSII, CGM and FGM provide only small benefits compared with MDI (on either HbA1c, hypoglycaemic risk or quality of life) in insulin-treated people with type 2 diabetes.

Direct-acting antivirals for HCV treatment in older patients: A systematic review and meta-analysis

The advent of highly effective and well-tolerated direct antiviral antivirals (DAAs) has dramatically changed the landscape of chronic hepatitis C. The effect of DAAs in older adults is difficult to determine since patients aged ≥ 65 years were too few in most clinical trials and data mainly come from observational studies. We performed a systematic review and meta-analysis to evaluate the efficacy and safety of DAAs in patients aged 65 and older. PubMed, Scopus, Web of Science, Cochrane Central Register of Controlled Trials, ClinicalTrials.gov, HCV-Trials.com databases were searched for literature published until 1 December 2017. English language articles reporting results of phase 2 or 3 randomized controlled trials (RCTs), single-arm clinical trials (SATs) and observational studies were included in the final analysis. All studies included subgroups of older patients and compared their outcomes with younger individuals. By using a random-effects or fixed-effects model, odds ratio (OR) was calculated for the efficacy and safety. Heterogeneity was tested using I² statistics. Thirty-seven studies reported data on the DAA efficacy. The OR was 1.66 (95%CI: 1.00-2.75; P = 0.06) in meta-analysis of RCTs, and similar results were found in SATs and observational studies. HCV genotype, stage of fibrosis or HIV co-infection did not affect the rate of SVR in older persons. Prevalence of anaemia (OR 0.26 95%CI: 0.09-0.69; P = 0.007) (OR 0.25 95%CI: 0.09-0.69; P = 0.007) and skin complaints (OR 0.61 95%CI: 0.45-0.83; P = 0.001) was higher in older adults. Finally, geriatric patients affected by chronic HCV infection can be safely treated with DAAs with the same efficacy reported in younger adults.