[Risk-stratified screening for diabetes in adults: results of the first investigation in Hungary]

Prevalence rate of diabetes mellitus, especially of type 2 diabetes, has been increasing worldwide; this is the case in Hungary as well. The early diagnosis of diabetes should be considered as one of the most important factors improving the late prognosis of the disease. Due to cost-effectiveness, screening should primarily be implemented in subjects at high risk to glucose intolerance. A risk-stratified nationwide screening procedure was performed by the Hungarian Diabetes Association in collaboration with general practitioners (GPs) in adult subjects without known diabetes. The screening procedure, which was sponsored by the 77 Elektronika Ltd (Budapest), was performed in a two steps manner. At first step, the Hungarian version of the internationally validated FINDRISC questionnaire (maximal score 26) was filled out by subjects while waiting for GP. At second step, blood glucose value in venous sample was locally measured by standard laboratory methods in subjects with a score value of > or = 12. The further diagnostic steps were carried out by WHO guidelines. As a total, 8921 subjects (59.7% women, 40.3% men) were screened between 01, April 2008 and 31, March 2009. Out of 4286 subjects with a score of > or = 12 (age 53.4 +/- 11.4 years; BMI: 29.9 +/- 4.8 kg/m2; waist circumference: 101.7 +/- 12.7 cm) 3733 (87.1%) had normal fasting blood glucose values, while 283 subjects (6.6%) had IFG, 122 (2.85%) had IGT and 19 participants (0.44%) had isolated IGT. Unknown diabetes was found in 129 subjects (3.01%). If the score value requiring laboratory confirmation was set at higher level (> or = 15 or > or = 20), the proportion of subjects with any degree of glucose intolerance increased. Among anthropometric parameters, BMI had the strongest association with the risk of glucose intolerance: 1 kg/m 2 increase in BMI value increased the risk of abnormal score category (> or = 12) by 24.7% (95% confidence interval: 23.3-26.2%). The risk-stratified screening procedure proved to be simple and effective for detecting early impairment of the carbohydrate metabolism, therefore, its wider implementation should be considered advisable.

Screening for type 2 diabetes and prediabetes – methodological concerns and feasibility in Hungary

A 2-es típusú diabetes kórfejlődése jellemző módon időben elhúzódó és lappangó, olykor a manifeszt betegség kezdeti stádiuma is meglehetősen tünetszegény. Ez megteremti az alapját a szűrővizsgálattal történő betegségfelismerésnek. Szűrővizsgálattal nemcsak a 2-es típusú diabetes, hanem kórmegelőző állapota (összefoglaló néven praediabetes) is felismerhető. A szűrővizsgálat céljára napjainkban az úgynevezett kockázatalapú, kétlépcsős módszer a leginkább elfogadott: az első lépcsőben kérdőív segítségével azonosíthatók a fokozott kockázatú egyének, a második lépcsőben ez utóbbiak körében vércukor-meghatározásra kerül sor. A kérdőívek közül a FINDRISC (Finnish Diabetes Risk Score) használata terjedt el a legtöbb országban, az első hazai tapasztalatok is kedvezőek alkalmazásával kapcsolatban. A szűrővizsgálat megteremti a korai diabetesesetek azonosítását, illetve a primer prevenció lehetőségét. Mindez végül elvezethet a 2-es típusú diabetes előfordulási gyakoriságának csökkenéséhez. Helyes lenne, ha ez az egészségügyi-társadalmi aktivitás hazánkban is – más országokhoz hasonlóan – nemzeti diabetesprogram keretei között valósulna meg.

[Diabetes-specific complications in prediabetes]

According to general belief, diabetes-specific late complications may occur only in overt diabetes mellitus. Nevertheless, several clinical observations recognized that diabetes-specific microangiopathic complications (diabetic retinopathy, nephropathy and neuropathy) might be observed even in subjects with prediabetes. The results of non-pharmacological investigations documented that not only the incidence of newly diagnosed type 2 diabetes but cardiovascular risk factors and microangiopathic late complications could also be decreased by life-style modification in subjects with prediabetes (impaired glucose tolerance).

How to interpret results of the HEART2D trial?

HEART2D was a multinational, randomized, controlled trial designed to compare the effects of prandial insulin versus basal insulin on risk for subsequent cardiovascular (CV) outcomes in patients with type 2 diabetes (T2D) after acute myocardial infarction (MI). Trial design was based on the hypothesis that 2.5 mmol/L postprandial blood glucose (BG) difference between groups would result in risk reduction of 19 to 23% over the planned follow up period (18-36 mo) in the group with lower postprandial BG. One thousand one hundred and fifteen (1115) patients were randomized [prandial strategy (N = 557), basal strategy (N = 558)]. HEART2D was stopped after futility rule implementation at the fourth interim analysis. The risk of a first combined adjudicated CV events in the prandial group (N = 174, 31.2%) and basal (N = 181, 32.4%) groups was similar (HR = 0.98; 95% CI [0.8, 1.21]). The results of HEART2D left the question of the role of postprandial hyperglycemia in diabetic CV disease unanswered. Here, we discuss possible reasons for this outcome, including characteristics of daily BG profiles in the two treatment groups, event rate, risk factors other than standard CV risk factors and glycemic variables. The main reasons for this outcome of HEART2D study could be smaller than expected on-study differences between the study groups in postprandial hyperglycemia, and low event rate. Further trials with larger patient populations and improved designs, focusing also on diabetic patients with lower cardiovascular risk and lower baseline HbA(1c) levels are needed in order to shed more light on this important clinical problem.

[Hypertension in diabetes mellitus]

Hypertension can be detected very often in patients with diabetes mellitus. In some cases, hypertension develops as a consequence of diabetic nephropathy. Although diabetic nephropathy may occur both in type 1 and in type 2 diabetes, some differences can be observed in the clinical picture according to the type of diabetes. In the majority of patients with type 2 diabetes or prediabetes, the pathomechanism of hypertension can be explained by the concept of the metabolic syndrome. In order to avoid or decrease target organ damage, the goal of antihypertensive treatment in diabetes mellitus is to be set at <130/80 mmHg. The initial antihypertensive therapy is usually based on the evaluation of the global cardiovascular risk. Apart from modifying nutrition and lifestyle, pharmacological treatment with combination of antihypertensive drugs is generally required in order to achieve treatment goal. Diabetic or antidiabetic properties of antihypertensive drugs and antihypertensive characteristics of some antidiabetic drugs should be considered in the everyday clinical practice.

Cardiometabolic risk and educational level in adult patients with type 1 diabetes

A low educational level and a poor socioeconomic status could be associated with increased risk for chronic diseases. The aim of the study was to evaluate the relationship between the educational level and cardiometabolic risk in adult patients with type 1 diabetes (n = 437; age: 38.0 +/- 10.4 years, duration of diabetes: 19.2 +/- 11.1 years; x +/- SD). Educational levels were classified as low [primary school, n = 56 (12.8%)], middle [high school, n = 251 (57.4%)] or high [university, n = 130 (29.7%)]. The prevalence rate of the metabolic syndrome proved to be higher in patients with low versus high educational levels (ATP-III criteria: 42.9 vs. 21.5%, P = 0.0006). Antihypertensive treatment and cardiovascular diseases were more prevalent in patients with low versus high educational level (46.4 vs. 26.2%, P = 0.01; 12.5 vs. 2.3%, P = 0.02; respectively). Overall glycemic control was worse in patients with low versus high educational level (HbA(lc): 8.8 +/- 1.6 vs. 7.9 +/- 1.4%; P = 0.0006). Patients with low versus high educational level differed significantly regarding smoking habits (smokers: 28.6 vs. 11.6%; P = 0.01) and regular physical activity (5.4 vs. 33.1%; P = 0.0001). Higher prevalence rate of certain cardiometabolic risk factors was associated with low educational level in middle-aged type 1 diabetic patients with relatively long duration of diabetes; therefore, these patients should have priority when preventing cardiovascular complications.

From the metabolic syndrome to the concept of global cardiometabolic risk

Although the clustering of cardiovascular risk factors is unquestionable, the clinical significance of the metabolic syndrome as a distinct entity has been debated in the past years. Recently, the term ‘metabolic syndrome’ has been replaced by ‘global cardiometabolic risk’ which implies cardiovascular risk factors beyond the metabolic syndrome. The metabolic syndrome can be frequently detected among people in western and developing countries affecting 25-30% of adult population, and its prevalence rate is increasing. Prospective studies show that the metabolic syndrome is a significant predictor of incident diabetes but has a weaker association with cardiovascular morbidity and mortality. At the same time the metabolic syndrome is inferior to established predicting models for either type 2 diabetes or cardiovascular disease.The underlying pathomechanism of the metabolic syndrome is still poorly understood. The role of insulin resistance – although not as a single factor – is still considered as a key component. In the last decade the importance of abdominal obesity has received increased attention but some studies, mainly in the Asian population, showed that central obesity is not an essential component of the syndrome. Regardless of the theoretical debates the practical implications are indisputable. The frequent clustering of hypertension, dyslipidaemia and glucose intolerance, that often accompanies central obesity, can not be ignored. Following the detection of one risk factor, the presence of other, traditional and non-traditional factors should be searched for, as the beneficial effect of intensive, target oriented, continuous treatment of metabolic and cardiovascular risk factors has been proven in both the short and long term.

Late effect of treatment for reducing cardiovascular risk--a hypothesis on cardiometabolic therapeutic memory

Several clinical studies were carried out in order to decrease cardiovascular morbidity and mortality. Occasionally, long-term observational follow-up was performed after terminating the randomized, controlled clinical trials and it was found that the beneficial effect of the active treatment has been maintained in the follow-up period. This prolonged effect was originally observed in patients with type 1 or type 2 diabetes by using intensive versus conventional treatment and called metabolic memory or metabolic legacy. Nevertheless, cardiovascular risk reduction is not restricted to antihyperglycaemic treatment; therefore, it can be hypothesised that other treatment options such as lifestyle changes, antihypertensive or lipid lowering treatment may have similar effects. In fact, a late beneficial effect of lifestyle changes was observed in controlled clinical studies in subjects with impaired glucose tolerance. Moreover, sustained beneficial effect of ACE-inhibitors, statins or fibrates in subjects with high cardiovascular risk was documented in the follow-up period of randomized, controlled clinical trials. Finally, the long-term advantage of intensified versus conventional multifactorial cardiovascular intervention was proven in patients with type 2 diabetes. Taken together, this phenomenon could be called cardiometabolic therapeutic memory. The concept provides further support for initiating proper therapy for patients with moderate or high cardiovascular risks as early as possible. Following this strategy, not only immediate and short-term but, according to the concept of cardiometabolic therapeutic memory, even long-term beneficial effect of the intervention could be expected.

Effects of prandial versus fasting glycemia on cardiovascular outcomes in type 2 diabetes: the HEART2D trial

OBJECTIVE

Hyperglycemia and Its Effect After Acute Myocardial Infarction on Cardiovascular Outcomes in Patients With Type 2 Diabetes Mellitus (HEART2D) is a multinational, randomized, controlled trial designed to compare the effects of prandial versus fasting glycemic control on risk for cardiovascular outcomes in patients with type 2 diabetes after acute myocardial infarction (AMI).

RESEARCH DESIGN AND METHODS

Patients (type 2 diabetes, aged 30-75 years) were randomly assigned within 21 days after AMI to the 1) prandial strategy (PRANDIAL) (three premeal doses of insulin lispro targeting 2-h postprandial blood glucose <7.5 mmol/l) or the 2) basal strategy (BASAL) (NPH twice daily or insulin glargine once daily targeting fasting/premeal blood glucose <6.7 mmol/l).

RESULTS

A total of 1,115 patients were randomly assigned (PRANDIAL n = 557; BASAL n = 558), and the mean patient participation after randomization was 963 days (range 1-1,687 days). The trial was stopped for lack of efficacy. Risks of first combined adjudicated primary cardiovascular events in the PRANDIAL (n = 174, 31.2%) and BASAL (n = 181, 32.4%) groups were similar (hazard ratio 0.98 [95% CI 0.8-1.21]). Mean A1C did not differ between the PRANDIAL and BASAL groups (7.7 +/- 0.1 vs. 7.8 +/- 0.1%; P = 0.4) during the study. The PRANDIAL group showed a lower daily mean postprandial blood glucose (7.8 vs. 8.6 mmol/l; P < 0.01) and 2-h postprandial blood glucose excursion (0.1 vs. 1.3 mmol/l; P < 0.001) versus the BASAL group. The BASAL group showed lower mean fasting blood glucose (7.0 vs. 8.1 mmol/l; P < 0.001) and similar daily fasting/premeal blood glucose (7.7 vs. 7.3 mmol/l; P = 0.233) versus the PRANDIAL group.

CONCLUSIONS

Treating diabetic survivors of AMI with prandial versus basal strategies achieved differences in fasting blood glucose, less-than-expected differences in postprandial blood glucose, similar levels of A1C, and no difference in risk for future cardiovascular event rates.

Noninvasive evaluation of neural impairment in subjects with impaired glucose tolerance

OBJECTIVE

To evaluate neural dysfunction in subjects with impaired glucose tolerance (IGT).

RESEARCH DESIGN AND METHODS

For this study, 46 subjects with IGT and 45 healthy volunteers underwent detailed neurological assessment. Cardiovascular autonomic function was assessed by standard cardiovascular reflex tests, and heart rate variability was characterized by the triangle index. Sensory nerve function was assessed using Neurometer (for current perception threshold) and Medoc devices. Peak plantar pressure was measured by dynamic pedobarography, and symptoms were graded using the neuropathy total symptom score.

RESULTS

Subjects with IGT had significantly greater abnormalities detected by four of five cardiovascular reflex tests and greater heart rate variability characterized by the triangle index. They had a higher frequency of both hyperesthesia and hypoesthesia as detected by current perception threshold testing at 5 Hz, as well as increased heat detection thresholds.

CONCLUSIONS

This study provides evidence that subclinical neural dysfunction is present in subjects with IGT and can be detected noninvasively. Cardiovascular autonomic neuropathy may contribute to increased cardiovascular risk in IGT subjects.

Outcomes of adding second hypoglycemic drug after metformin monotherapy failure among type 2 diabetes in Hungary

Aim

The objective of this observational study was to assess the status of glycemic control and associated patient-reported outcomes in ambulatory Hungarian patients with type 2 diabetes mellitus (T2DM) who were prescribed either a sulfonylurea (SU) or a thiazolidinedione (TZD) in addition to the prior metformin (MF) monotherapy.

Methods

Type 2 diabetics aged ≥ 30 years and who had added an SU or TZD to previous MF monotherapy at least 1 year prior to the visit date were identified during January 2006 to March 2007. Information on HbA1c (A1C), medication use and co-morbid conditions was extracted from the medical record up to 6 months prior to the addition of SU or TZD to MF (baseline), and a minimum of one year after the initiation of either SU or TZD. Glycemic control (A1C < 6.5%) was assessed using the last available A1C value in the medical record. Self-reported hypoglycemia, health-related quality of life (HRQoL) and treatment satisfaction were also assessed.

Results

A total of 414 patients (82% SU+MF and 18% TZD+MF) with a mean age of 60.5 years (SD = 9.4 years) participated in the study. About 27% of patients reported hypoglycemic episodes, with about one-third reporting episodes that resulted into interruption of activities or required medical/non-medical assistance. Three quarters of patients were not at glycemic goal and BMI was the only factor significantly associated with failure to have an A1C level < 6.5%. Patients' HRQoL was significantly associated with self-reported hypoglycemic episodes (p = 0.017), and duration of diabetes (p = 0.045).

Conclusion

Nearly 75% of patients were not at A1C goal of < 6.5% despite using two oral anti-hyperglycemic medications. Approximately 9% of patients reporting hypoglycemia required some kind of medical/non-medical assistance. Greater BMI at baseline was associated with an A1C level ≥ 6.5%. Finally, self- reports of hypoglycemia and duration of diabetes were associated with low HRQoL.

Cardiometabolic goal attainment during regular care of adult patients with type 1 diabetes mellitus

A kardiometabolikus kockázati tényezők csökkentésével visszaszoríthatók a cardiovascularis események. A kardiometabolikus kockázati tényezők befolyásolásának eredményességéről 1-es típusú diabetes mellitusban szenvedő felnőtt cukorbetegek körében csak kevés adat áll rendelkezésre. Célkitűzés: Diabetes-szakrendelésen ellenőrzés céljából megjelenő, 1-es típusú diabetes mellitusban szenvedő felnőtt (életkor ≥ 18 év) cukorbetegek körében adatokat gyűjtöttünk a kardiometabolikus kockázati tényezők előfordulásáról és kezelésük eredményességéről. Módszerek: Fél év alatt az ország 11 diabetescentrumában egymást követően megjelent 1-es típusú cukorbetegségben szenvedők (n = 533; 256 férfi, 277 nő; életkor 35,6 ± 11,6 év; diabetestartam 18,0 ± 11,1 év; x ± SD) ellenőrzésekor, az előzményi adatok felvételén túl, antropometriai és laboratóriumi adatokat regisztráltunk. A kardiometabolikus kockázati tényezők kezelési célértékeként a III. Magyar Cardiovascularis Konszenzuskonferencia ajánlásában szereplő adatokat tekintettük mérvadónak. Eredmények: A testtömegindex célértékét (< 25 kg/m 2 ) a betegek 55,3%-a (férfi: 45,7%, nő: 64,3%) érte el. A haskörfogat nők körében megkívánt értékét (< 80 cm) a betegek 50,5%-a, a férfiak esetében mérvadó értéket (< 94 cm) 63,7% érte el. A HbA 1c értéke a betegek 8,4%-ában volt 6,5% alatt (20,5%-ban 7,0% alatt). Lipidcsökkentő kezelésben részesült 130 beteg (24,4%), e csoportban a betegek 53,1%-a érte el a triglicerid, 71,5% a HDL-koleszterin és 27,8% az LDL-koleszterin kezelési célértékét. A lipidek szintjére vonatkozó célérték együttes elérése a betegek 17,7%-ában volt sikeres. Hypertonia miatt kezelésben részesült 173 beteg (32,5%), e betegcsoportban a < 130 Hgmm-es szisztolés vérnyomást a betegek 29,5%-a, a diasztolés célértéket (< 80 Hgmm) pedig 34,7% érte el. A betegek 17,7%-a a vizsgálat időpontjában dohányzónak vallotta magát, 19,2% leszokott a dohányzásról, és 63,2% sohasem dohányzott. Következtetések: Felnőtt, 1-es típusú diabetes mellitusban szenvedők körében a kardiometabolikus kockázati tényezők napjainkban ajánlott kezelési célértékeit a cukorbeteg-gondozás keretein belül nehéz elérni. További erőfeszítéseket kell tenni a cukorbetegek kardiometabolikus kockázati tényezőinek hatékonyabb csökkentése érdekében.

Intraobserver and interobserver variability of measuring waist circumference

BACKGROUND

The measurement of waist circumference for assessing abdominal obesity has become widely accepted.

MATERIAL/METHODS

To evaluate the reliability of measuring waist circumference, anthropometric parameters were measured in 150 adult patients by two diabetes educators on two consecutive days. The intraobserver difference was defined as the difference in the measurements made by the same educator on different days and the interobserver difference as the difference in the measurements made by the two educators on the same days.

RESULTS

The correlation coefficients (r values) of the measurements were >0.99 for the educators and days. The interobserver difference was statistically significant for waist circumference (96.23 cm vs. 97.08 cm, p<0.0001). Although the %Delta values (percent difference in the two means) for waist circumference proved to be 2.5-6.3 times higher and the% absolute Delta values (percent average difference) 1.5-2.8 times higher than those for body mass index, the absolute values of the differences (Delta, the difference of the two means, and absolute delta, the average difference) were small (waist circumference Delta: 0.17 cm and 0.85 cm, absolute Delta: 1.51 cm and 2.15 cm; body mass index Delta: 0.02 kg/m(2) and 0.04 kg/m(2), absolute Delta: 0.292 kg/m(2) and 0.226 kg/m(2); intraobserver and interobserver differences, respectively).

CONCLUSIONS

The intraobserver and interobserver variability for waist circumference were higher than those for body mass index. Nevertheless, the differences in repeated measurements of waist circumference were small when expressed in absolute values. The reliability of waist circumference should be considered in the clinical practice.

[Glycaemic control and macrovascular complications in patients with diabetes mellitus]

According to a recent meta-analysis, proper glycaemic control due to intensive antidiabetic treatment could result in a decrease of cardiovascular complications in patients with diabetes mellitus. In comparison to conventional treatment, the relative risk reduction proved to be higher in type 2 than in type 1 diabetic patients. Although a decrease in incidence rate of cardiovascular complications could be documented in different areas (coronary, carotid and peripheral arteries), the decrease was different in terms of numerical changes. Comparing intensive and conventional treatment, no difference in mortality rate could be observed.

Effect of heat shock protein peptide DiaPep277 on beta-cell function in paediatric and adult patients with recent-onset diabetes mellitus type 1: two prospective, randomized, double-blind phase II trials

BACKGROUND

Aim of this trial was to test whether heat shock protein peptide DiaPep277 treatment in adult and paediatric patients with recent-onset type 1 diabetes (T1D) is safe and whether it can preserve endogenous insulin production.

METHODS

Two studies were performed in a prospective, multicentre, double-blind, placebo-controlled trial. Fifty adult (study p520, aged 16-44 years) and 49 paediatric patients (study p521, 4-15 years) with recent-onset T1D were treated subcutaneously at four different time points with 0.2 mg or 1.0 mg DiaPep277 versus placebo and followed for 18 months. Adult patients were treated with 0.2 mg, 1.0 mg or 2.5 mg DiaPep277 versus placebo. Stimulated C-peptide served as readout for functional beta-cell-mass.

RESULTS

DiaPep277-treatment was not associated with severe side effects. No differences were found in placebo and DiaPep277 treated groups. In adults, a modest trend towards better maintenance of beta-cell function was observed in the 0.2 mg and 1.0 mg group, while there was significant loss of stimulated C-peptide in the placebo and 2.5 mg group. Paediatric patients with low HLA risk showed stable C-peptide levels until 13 months upon treatment with 1 mg DiaPep277. Despite similar stimulated C-peptide levels at baseline, children exhibited a more pronounced loss of beta-cell function over 18 months than adults (p = 0.0003).

CONCLUSION

Administration of DiaPep277 seems safe and may have beneficial effects on C-peptide levels over time in some patients with T1D, but this finding was not accompanied by reduced HbA1c or insulin requirement. Studies with more patients and longer follow-up are needed to further study the effect of DiaPep277.

Preventing microalbuminuria in patients with type 2 diabetes

The public health burden of type 2 diabetes mellitus has been dramatically increasing world-wide. The chronic complications of type 2 diabetes play an important role in decreasing life expectancy and adversely affecting quality of life. Diabetic nephropathy, which is originally microvascular in nature, is widely considered an important complication of diabetes. In prospective clinical investigations, increased urinary albumin excretion proved to be associated not only with subsequent renal outcomes but also with cardiovascular morbidity/mortality independently of other risk factors. Therefore, microalbuminuria as an early sign of increased urinary albumin excretion should be considered important for both treatment and even for prevention. Preventing microalbuminuria might diminish progression to overt nephropathy and, hopefully, might limit cardiovascular events. Regarding primary prevention of diabetic nephropathy, therapeutic intervention should optimally be initiated at the stage of normoalbuminuria. Although additional factors such as smoking cessation, reduction of protein intake, and treatment of lipid abnormalities are important, providing optimal diabetic control as well as targeting optimal blood pressure are the key elements of a prevention strategy in diabetic patients. Recently, the Bergamo Nephrologic Diabetes Complications Trial (BENEDICT) documented that a significant decrease of the development of persistent microalbuminuria could be achieved by using an ACE-inhibitor, trandolapril alone or in combination with verapamil SR, a non-dihydropyridine calcium-channel blocker in hypertensive type 2 diabetic patients with normoalbuminuria. The results of this primary-prevention strategy should be corroborated by further investigations to determine whether these beneficial changes could later result in improvement of renal clinical outcomes, macrovascular complications, or both.

Efficacy of indapamide SR compared with enalapril in elderly hypertensive patients with type 2 diabetes

BACKGROUND

Blood pressure control is the main influential variable in reducing microalbuminuria in patients with type 2 diabetes. In this subanalysis of the Natrilix SR versus Enalapril Study in hypertensive Type 2 diabetics with micrOalbuminuRia (NESTOR) study, we have compared the effectiveness of indapamide sustained release (SR) and enalapril in reducing blood pressure and microalbuminuria in patients > or =65 years of age.

METHODS

Of the 570 hypertensive patients with type 2 diabetes and persistent microalbuminuria in the NESTOR study, 187 (33%) individuals > or =65 years of age were included in this analysis. Of these, 95 patients received indapamide SR 1.5 mg and 92 patients received enalapril 10 mg, taken once daily in both cases. Adjunctive amlodipine and/or atenolol was added if required.

RESULTS

The urinary albumin-to-creatinine ratio decreased by 46% in the indapamide SR group and 47% in the enalapril group. Noninferiority of indapamide SR over enalapril was demonstrated (P = .0236; 35% limit of noninferiority) with a ratio of 0.95 (95% CI: 0.68, 1.34). Mean arterial pressure decreased by 18 mm Hg and 15 mm Hg in the indapamide SR and the enalapril groups, respectively (P = .1136). The effects of both treatments seen in these elderly patients were similar to those observed in the main population, although the extent of the reduction in microalbuminuria was slightly higher. Both treatments were well tolerated, and no difference between groups was observed regarding glucose or lipid profiles.

CONCLUSION

Indapamide SR is not less effective than enalapril in reducing microalbuminuria and blood pressure in patients aged >65 years of age with type 2 diabetes and hypertension.

[Short acting insulin analogues for treating diabetic patients with CSII (continuous subcutaneous insulin infusion)]

The use of insulin pump treatment (CSII: continuous subcutaneous insulin infusion) became widely accepted in the last couple of years. A growing body of experiences accumulated in paediatric practice because CSII is preferable for treating young patients with type 1 diabetes. Nevertheless, CSII can be used, if indicated, for treating type 2 diabetic patients as well. Recently, fast acting insulin analogues are exclusively used for CSII. At moment, clinical observations with insulin lispro and insulin aspart are available but experiences with glulisine are still limited. Although some inconsistencies could be observed in the literature, it is widely accepted, that higher reduction in HbA(1c) values could be achieved by CSII as compared to intensive conservative insulin treatment; this could be more pronounced in cases with high initial HbA(1c) values. CSII with short acting insulin analogues could lead to a higher reduction of HbA(1c) values than CSII with human regular insulin. Moreover, the decrease of hypoglycaemic events could be expected in some cases.

[The effectiveness of carvedilol in heart failure]

BACKGROUND

The third generation beta-blocker (carvedilol) is effective in reduction of hypertension, and of mortality and morbidity as a supplement to conventional drugs of heart failure therapies (diuretics, ACE inhibitors), based on randomized controlled trials and retrospective analysis.

OBJECTIVE

To analyse the efficacy of carvedilol in the treatment of heart failure with special focused on morbidity, mortality endpoints.

METHODS

We assessed the multicenter, randomised, double-blind studies involving more than 150 patients (1995-2005) from MEDLINE database, in which carvedilol was used in the case of moderate to severe heart failure. We also present the results of health-economic publications (2000-2005).

RESULTS

In U.S. Carvedilol Heart Failure Study (n 1096) the mortality declined by 65% (3.2% vs. 7.8%; p <0.001) with carvedilol vs. placebo, while the cardiovascular hospitalization decline was 27% (14.1% vs. 19.6%; p = 0.036) in heart failure (LVEF < or = 5%) applied together with the basic therapy (diuretic and ACE-inhibitor). In the COPERNICUS trial the efficacy of carvedilol was compared to placebo in the case of severe HF patients (LVEF < 25%, n = 2889). The annual mortality risk declined by 35% (19.7% vs. 12.8%, 95% CI 19-48%, p = 0.00013) while the risk of mortality or any risk of hospitalisation by 24% (p = 0.00004) in the active group. The CAPRICORN study (LVEF < or = 0%, n=1959) showed that carvedilol is efficacious in reduction of total (HR: 0.77; 95% CI 0.60-0.98; p = 0.031) and cardiovascular mortality (HR: 0.75; 95% CI 0.58-0.96; p = 0.024) as far as high-risk patients are concerned.

CONCLUSION

The effectiveness of carvedilol is certified in reduction of mortality and hospitalization in the treatment of moderate-severe heart-failure as part of the combination therapy. The benefits of use of the drug are well measurable not only on the level of patients but on the suppliers and the financer as well, thanks to the decline of resource utilization.

[New features in the recommendations of the Second Hungarian Therapeutic Consensus Conference]

The First Hungarian Therapeutic Consensus Conference took place on 3rd Nov. 2003 with the participation of 9 medical societies. Over the past 2 years the results of new major studies have been published and the American ATP III has also updated its guidelines issued in 2004. Based on the above proposals, the Second Hungarian Therapeutic Consensus Conference held on 3rd Nov. 2005 partly confirmed its earlier suggestions, but made some changes as well. Within the high risk category the Conference optionally created a very high risk group from those patients who - in addition to their cardiovascular disease--have either diabetes or metabolic syndrome or acut coronaria syndrome or who are chain smokers. We have included - as a complement - into the asymptomatic high risk category such newly emerging risk factors, one of which already in itself means high risk: ankle/arm index < or = 0.9, GFR <60 ml/min, microalbuminuria (30-300 mg), preclinical atherosclerosis (plaque). Besides, 4 other risk factors were also categorised such as Lp/a (> or = 30 mg/dl), CRP (> or = 3mg/l), homocysteine (> or = 12 micromol), familiarity--atherogenic gene constellation, but only the presence of at least two of these verify high risk. In very high risk group the goals of 3.5 mmol/l and 1.8 mmol/l were determined as therapeutic option. The goal in obese patients--expressed earlier only in BMI--can now be equally determined by the abdominal circumference (94 cm for men, 80 cm for women respectively). ACE inhibitors were recommended earlier as a preventive therapy in case of dysfunction of the left ventricle, while at present they are suggested for all patients with cardiovascular disease. In the recent recommendations guidelines related to nutrition, smoking, exercise have also been included.