Intensive glucose control and macrovascular outcomes in type 2 diabetes

Long-Term Visit-to-Visit Glycemic Variability as a Predictor of Major Adverse Limb and Cardiovascular Events in Patients With Diabetes

Background Peripheral arterial disease (PAD) is a severe complication in patients with type 2 diabetes. Glycemic variability (GV) is associated with increased risks of developing microvascular and macrovascular diseases. However, few studies have focused on the association between GV and PAD. Methods and Results This cohort study used a database maintained by the National Taiwan University Hospital, a tertiary medical center in Taiwan. For each individual, GV parameters were calculated, including fasting glucose coefficient of variability (FGCV) and hemoglobin A1c variability score (HVS). Multivariate Cox regression models were constructed to estimate the relationships between GV parameters and composite scores for major adverse limb events (MALEs) and major adverse cardiovascular events (MACEs). Between 2014 and 2019, a total of 45 436 adult patients with prevalent type 2 diabetes were enrolled for analysis, and GV was assessed during a median follow-up of 64.4 months. The average number of visits and time periods were 13.38 and 157.87 days for the HVS group and 14.27 and 146.59 days for the FGCV group, respectively. The incidence rates for cardiac mortality, PAD, and critical limb ischemia (CLI) were 5.38, 20.11, and 2.41 per 1000 person-years in the FGCV group and 5.35, 20.32, and 2.50 per 1000 person-years in HVS group, respectively. In the Cox regression model with full adjustment, the highest FGCV quartile was associated with significantly increased risks of MALEs (hazard ratio [HR], 1.57 [95% CI, 1.40-1.76]; P<0.001) and MACEs (HR, 1.40 [95% CI, 1.25-1.56]; P<0.001). Similarly, the highest HVS quartile was associated with significantly increased risks of MALEs (HR, 1.44 [95% CI, 1.28-1.62]; P<0.001) and MACEs (HR, 1.28 [95% CI, 1.14-1.43]; P<0.001). The highest FGCV and HVS quartiles were both associated with the development of PAD and CLI (FGCV: PAD [HR, 1.57; P<0.001], CLI [HR, 2.19; P<0.001]; HVS: PAD [HR, 1.44; P<0.001], CLI [HR, 1.67; P=0.003]). The Kaplan-Meier analysis showed significantly higher risks of MALEs and MACEs with increasing GV magnitude (log-rank P<0.001). Conclusions Among individuals with diabetes, increased GV is independently associated with the development of MALEs, including PAD and CLI, and MACEs. The benefit of maintaining stable glycemic levels for improving clinical outcomes warrants further studies.

Effect of dietary patterns on cardiovascular risk factors in people with type 2 diabetes. A systematic review and network meta-analysis

AIMS

To identify the most effective dietary pattern for improving cardiovascular risk factors in people with type 2 diabetes.

METHODS

PubMed, Embase, the Cochrane library, SCOPUS and Web of Science were systematically searched for randomized controlled trials comparing the effects of dietary patterns on body weight, blood pressure, HbA1c and lipids after 6 and 12 months. Treatment effects were synthesized using Bayesian network meta-analysis. Six-month changes in HbA1c, SBP and LDL-C were used to estimate relative risk reductions (RRR) for cardiovascular events.

RESULTS

Seventy-three RCTs on eight different dietary patterns were included. All reduced body weight and HbA1c after 6 months, with the largest effects from the low carbohydrate (body weight -4.8 kg, 95 %credibility interval (95 %CrI) -6.5;-3.2 kg) and Mediterranean diet (HbA1c -1.0 %, 95 %CrI -15;-0.4 % vs usual diet). There were no significant 6-month blood pressure or lipid effects. Dietary patterns had non-statistically significant 12-months effects. The Mediterranean diet resulted in the largest expected RRR for cardiovascular events: -16 % (95 %CI -31;3.0) vs usual diet.

CONCLUSIONS

In patients with type 2 diabetes, all dietary patterns outperformed usual diet in improving body weight and HbA1c after 6 months and clinically relevant cardiovascular risk reduction could be achieved. There was insufficient evidence to select one optimal dietary pattern.

6. Glycemic Targets: Standards of Care in Diabetes-2023

The American Diabetes Association (ADA) "Standards of Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

Efficacy, safety and therapeutic mechanism of Shen-Qi Xiao-Tan formula in the treatment of peripheral atherosclerosis in patients with type 2 diabetes mellitus: a randomized, double-blind, placebo-controlled trial protocol

BACKGROUND

Peripheral atherosclerosis is a common macrovascular complication of diabetes, but the treatment is limited. Chinese herbal medicine is the complementary and alternative therapy to delay the progression of atherosclerosis and reduce blood glucose and lipids. Shen-Qi Xiao-Tan (SQXT) formula is one of the prescriptions commonly used to treat diabetic peripheral atherosclerosis, but there is still a lack of high-quality evidence-based evidence.

METHODS

This is a randomized, double-blind, placebo-controlled add-on trial that is expected to enroll 114 diabetic patients with peripheral atherosclerosis. After a 2-week run-in period, participants will been randomly assigned in a 1:1 ratio and receive 12 weeks of usual treatment and SQXT formula (treatment group) or usual treatment and placebo (control group). The primary outcome is the change in carotid intima-media thickness from baseline to endpoint. The secondary outcomes are the structure and function of peripheral arteries, blood glucose and lipids, traditional Chinese medicine syndrome score, and quality of life, and safety and endpoint events are evaluated. To explore the therapeutic mechanism through oxidative stress, inflammation, and advanced glycation end products, and lipidomics will be used to screen for biomarkers for diagnosis and efficacy evaluation.

DISCUSSION

The objective of this trial is to evaluate the efficacy, safety and therapeutic mechanism of SQXT formula in the treatment of diabetic peripheral atherosclerosis. It will obtain high-quality evidence-based evidence and promote the treatment of diabetic macroangiopathy and the research and development of new drugs.

TRIAL REGISTRATION

This trial is registered on Chinese Clinical Trials.gov with number ChiCTR2100047189 on 10 Jun 2021, and has been approved by the Ethical Review Committee of Hospital of Chengdu University of Traditional Chinese Medicine with number 2020KL-080.

GLP-1 Receptor Agonists for the Reduction of Atherosclerotic Cardiovascular Risk in Patients With Type 2 Diabetes

Patients with type 2 diabetes are at high risk for development of cardiovascular disease, including myocardial infarction, stroke, heart failure, and cardiovascular death. Multiple large cardiovascular outcome trials with novel glucose-lowering agents, namely SGLT2i (SGLT2 inhibitors) and GLP-1 RA (GLP-1 receptor agonists), have demonstrated robust and significant reductions of major adverse cardiovascular events and additional cardiovascular outcomes, such as hospitalizations for heart failure. This evidence has changed the landscape for treatment of patients with type 2 diabetes. Both diabetes and cardiology guidelines and professional societies have responded to this paradigm shift by including strong recommendations to use SGLT2i and/or GLP-1 RA, with evidence-based benefits to reduce cardiovascular risk in high-risk individuals with type 2 diabetes, independent of the need for additional glucose control. GLP-1 RA were initially developed as glucose-lowering drugs because activation of the GLP-1 receptor by these agents leads to a reduction in blood glucose and an improvement in postprandial glucose metabolism. By stimulating GLP-1R in hypothalamic neurons, GLP-1 RA additionally induce satiety and lead to weight loss. Data from cardiovascular outcome trials demonstrated a robust and consistent reduction in atherothrombotic events, particularly in patients with established atherosclerotic cardiovascular disease. Despite the consistent evidence of atherosclerotic cardiovascular disease benefit from these trials, the number of patients receiving these drugs remains low. This overview summarizes the experimental and clinical evidence of cardiovascular risk reduction offered by GLP-1 RA, and provides practical information on how these drugs should be implemented in the treatment of type 2 diabetes in the cardiology community.

Machine learning for the prediction of minor amputation in University of Texas grade 3 diabetic foot ulcers

Minor amputations are performed in a large proportion of patients with diabetic foot ulcers (DFU) and early identification of the outcome of minor amputations facilitates medical decision-making and ultimately reduces major amputations and deaths. However, there are currently no clinical predictive tools for minor amputations in patients with DFU. We aim to establish a predictive model based on machine learning to quickly identify patients requiring minor amputation among newly admitted patients with DFU. Overall, 362 cases with University of Texas grade (UT) 3 DFU were screened from tertiary care hospitals in East China. We utilized the synthetic minority oversampling strategy to compensate for the disparity in the initial dataset. A univariable analysis revealed nine variables to be included in the model: random blood glucose, years with diabetes, cardiovascular diseases, peripheral arterial diseases, DFU history, smoking history, albumin, creatinine, and C-reactive protein. Then, risk prediction models based on five machine learning algorithms: decision tree, random forest, logistic regression, support vector machine, and extreme gradient boosting (XGBoost) were independently developed with these variables. After evaluation, XGBoost earned the highest score (accuracy 0.814, precision 0.846, recall 0.767, F1-score 0.805, and AUC 0.881). For convenience, a web-based calculator based on our data and the XGBoost algorithm was established (https://dfuprediction.azurewebsites.net/). These findings imply that XGBoost can be used to develop a reliable prediction model for minor amputations in patients with UT3 DFU, and that our online calculator will make it easier for clinicians to assess the risk of minor amputations and make proactive decisions.

Reconsidering the role of glycaemic control in cardiovascular disease risk in type 2 diabetes: A 21st century assessment

It is well known that the multiple factors contributing to the pathogenesis of type 2 diabetes (T2D) confer an increased risk of developing cardiovascular disease (CVD). Although the relationship between hyperglycaemia and increased microvascular risk is well established, the relative contribution of hyperglycaemia to macrovascular events has been strongly debated, particularly owing to the failure of attempts to reduce CVD risk through normalizing glycaemia with traditional therapies in high-risk populations. The debate has been further fuelled by the relatively recent discovery of the cardioprotective properties of glucagon-like peptide-1 receptor agonists and sodium-glucose cotransporter-2 inhibitors. Further, as guidelines now recommend individualizing glycaemic targets, highlighting the importance of achieving glycated haemoglobin (HbA1c) goals safely, the previously observed negative influences of intensive therapy on CVD risk might not present if trials were repeated using current-day treatments and individualized HbA1c goals. Emerging longitudinal data illuminate the overall effect of excess glucose, the impacts of magnitude and duration of hyperglycaemia on disease progression and risk of CVD complications, and the importance of glycaemic control at or early after diagnosis of T2D for prevention of complications. Herein, we review the role of glucose as a modifiable cardiovascular (CV) risk factor, the role of microvascular disease in predicting macrovascular risk, and the deleterious impact of therapeutic inertia on CVD risk. We reconcile new and old data to offer a current perspective, highlighting the importance of effective, early treatment in reducing latent CV risk, and the timely use of appropriate therapy individualized to each patient's needs.

[The Economic Evaluation of the GLICEMIA 2.0 Study as an Example of a Complex Intervention]

BACKGROUND

A piggyback approach was used to evaluate the cost-effectiveness of the prevention program delivered at the point of care pharmacy in the GLICEMIA 2.0 study that sought to guide participants in the intervention group to improved glycemic control in type 2 diabetes with sustained incentivization of lifestyle changes, therapeutic compliance, and adherence. The control group received passive medication management and monitoring.

METHODS

Primary endpoint of the GLICEMIA 2.0 study was the stabilization of HbA1c values. For health economic evaluation, incremental differences in output changes were examined, defined as the difference in the distribution of the HbA1c values between both groups over time. Direct program costs and anticipated indirect costs of service utilization were used as cost parameters. A net monetary benefit approach was used to validate cost-effectiveness thresholds via the formation of ICER values.

RESULTS

The intervention group had significantly higher reductions in HbA1c-values. Risk stratification of initial HbA1c showed (short-term) cost effectiveness for initially higher HbA1c values. Due to the limited study period, no long-term differences in medical resource utilization could be assessed.

CONCLUSION

The GLICEMIA program indicates considerable effectiveness potentials, especially for high-risk patients. The study design seems to have assisted the intervention group's adherence in contrast to the control group. Detailed impacts within the complex intervention could not be validated due to restrictions of the study design as a complex intervention. Overall, statements about effect sustainability and further utilization rates progressions are limited due to a lack of follow-up.

Revisiting 'intensive' blood glucose control: A causal directed acyclic graph-guided systematic review of randomized controlled trials

AIM

To clarify the importance of HbA1c reduction and antidiabetic drug use in preventing major adverse cardiovascular events (MACE) for patients with type 2 diabetes (T2D).

MATERIALS AND METHODS

We conducted an updated systematic review of contemporary large randomized controlled trials assessing the relative efficacy and safety of antidiabetic drugs with less hypoglycaemia risk in adult T2D patients. Mixed-effects meta-regression was performed to examine the associations of HbA1c reduction with subsequent risk of macrovascular and microvascular events. We evaluated the potential mediating role of HbA1c reduction in the relationship between antidiabetic drugs and MACE.

RESULTS

Eighteen placebo-controlled trials comprising 155 610 participants were included. The effects of treatment differed among antidiabetic drug classes for most adverse outcomes with high heterogeneity (I2 : 63.7%-95.8%). Mean HbA1c reduction was lowest with dipeptidyl peptidase-4 inhibitors (0.30%), followed by sodium-glucose co-transporter-2 inhibitors (0.46%), and was highest with glucagon-like peptide-1 receptor agonists (0.58%) and thiazolidinediones (0.60%). Lower relative risks of MACE were significantly associated with larger reductions in achieved HbA1c (β -0.3182; 95% CI: -0.5366 to -0.0998; P = .0043), even after adjusting for drug classes. When considering HbA1c lowering as a mediator to be controlled, beneficial effects owing to specific antidiabetic treatment for MACE were not observed (χ2  = 1.4494; P = .6940). The proportion mediated by HbA1c reduction was 50.0%-63.5% for these antidiabetic agents.

CONCLUSIONS

The main benefits of antidiabetic agents might result from the reduction in blood sugar levels and are generally independent of drugs used. Risk reduction in MACE was proportional to the magnitude of HbA1c decrease conferred by antidiabetic agents with less hypoglycaemic hazard.

Depot-specific adipose tissue modulation by SGLT2 inhibitors and GLP1 agonists mediates their cardioprotective effects in metabolic disease

Sodium-glucose transporter-2 inhibitors (SGLT-2i) and glucagon-like peptide 1 (GLP-1) receptor agonists are newer antidiabetic drug classes, which were recently shown to decrease cardiovascular (CV) morbidity and mortality in diabetic patients. CV benefits of these drugs could not be directly attributed to their blood glucose lowering capacity possibly implicating a pleotropic effect as a mediator of their impact on cardiovascular disease (CVD). Particularly, preclinical and clinical studies indicate that SGLT-2i(s) and GLP-1 receptor agonists are capable of differentially modulating distinct adipose pools reducing the accumulation of fat in some depots, promoting the healthy expansion of others, and/or enhancing their browning, leading to the suppression of the metabolically induced inflammatory processes. These changes are accompanied with improvements in markers of cardiac structure and injury, coronary and vascular endothelial healing and function, vascular remodeling, as well as reduction of atherogenesis. Here, through a summary of the available evidence, we bring forth our view that the observed CV benefit in response to SGLT-2i or GLP-1 agonists therapy might be driven by their ameliorative impact on adipose tissue inflammation.

Long-term clinical outcomes of oral antidiabetic drugs as fixed-dose combinations: A nationwide retrospective cohort study

AIM

To compare treatment patterns and clinical outcomes of single-pill fixed-dose combination (FDC) and two-pill combination (TPC) therapies using real-world data.

METHODS

We conducted a nationwide retrospective cohort study using South Korea's healthcare database (2002-2015). We identified two cohorts of incident patients with type 2 diabetes who initiated FDC or TPC therapy within 4 months of their first prescription for metformin or sulphonylurea. We examined persistence and adherence patterns and the clinical outcome of a composite endpoint of death or hospitalization for acute myocardial infarction, heart failure or stroke and compared the differences in treatment patterns and clinical outcomes using Cox models.

RESULTS

Of 5143 and 10 973 patients who initiated FDC and TPC therapy, respectively, we identified 5143 patient pairs after propensity score matching. The FDC group exhibited greater median time to treatment discontinuation (163 vs. 146 days), and proportion of days covered at 12 months (mean 0.60 vs. 0.57, P < .0001) and at 24 months (0.53 vs. 0.51, P = .014) than the TPC group. The FDC group, compared with the TPC group, had reduced risks of the composite clinical outcome (hazard ratio 0.86, 95% confidence intervals 0.77-0.97) and hospitalization for stroke (0.80, 0.67-0.96).

CONCLUSION

FDC therapy may provide favourable cardiovascular benefits, especially reducing the risk of hospitalization for stroke, and has better medication adherence among patients with type 2 diabetes.

[Cardiovascular preventive recommendations. PAPPS 2022 thematic updates. Working groups of the PAPPS]

The recommendations of the semFYC's Program for Preventive Activities and Health Promotion (PAPPS) for the prevention of cardiovascular diseases (CVD) are presented. The following sections are included: epidemiological review, where the current morbidity and mortality of CVD in Spain and its evolution as well as the main risk factors are described; cardiovascular (CV) risk and recommendations for the calculation of CV risk; main risk factors such as arterial hypertension, dyslipidemia and diabetes mellitus, describing the method for their diagnosis, therapeutic objectives and recommendations for lifestyle measures and pharmacological treatment; indications for antiplatelet therapy, and recommendations for screening of atrial fibrillation, and recommendations for management of chronic conditions. The quality of testing and the strength of the recommendation are included in the main recommendations.

Effect of dietary approaches to stop hypertension (DASH) diet, high in animal or plant protein on cardiometabolic risk factors in obese metabolic syndrome patients: A randomized clinical trial

AIMS

This study aimed to investigate the effect of replacing plant proteins with animal proteins in the dietary approaches to stop hypertension (DASH) diet on cardiometabolic risk factors in obese metabolic syndrome participants.

METHODS

In this double-blind randomized controlled clinical trial, 90 obese patients with metabolic syndrome, aged 30-70 years were randomly allocated into the DASH diet based on plant or animal proteins for 8 weeks. Fasting blood samples were collected to assess the biochemical markers. Also, blood pressure, weight, and waist circumference (WC) were measured at the beginning and end of the trial.

RESULTS

The participants in both groups experienced significant reductions in the fasting plasma glucose (FPG), systolic blood pressure (SBP) and diastolic blood pressure (DBP), triglyceride (TG) concentrations, weight and WC. However the reduction in FPG and SBP was higher in the plant-based DASH group, compared to the animal-based DASH group, after adjustment for weight change. No significant changes were found within or between groups with regard to total cholesterol, LDL-C, HDL-C.

CONCLUSIONS

Substituting plant proteins with animal proteins in the DASH diet improves FPG and SBP in obese individuals with metabolic syndrome, independent of weight change. IRCT registration number: IRCT20090203001640N16.

Time to Treatment Intensification to Reduce Diabetes-Related Complications: A Post Hoc Study

Patients with type 2 diabetes mellitus (T2DM) can be affected by clinical inertia, leading to abysmal results. Studies on a suitable timeframe for treatment intensification remain scarce—especially outside of developed countries. This study aimed to explore the association between time to treatment intensification and diabetes-related complications. A database from a tertiary care hospital in Thailand was retrieved in order to conduct a retrospective cohort study for the years 2011–2017. This study comprised outpatients with T2DM presenting an HbA1c of ≥7.0%. Eligible patients were divided into three groups based on the time of treatment intensification: no delayed treatment intensification, treatment intensification within 6 months, and treatment intensification after 6 months. A Cox proportional hazards model was used to investigate the association between time to treatment intensification and diabetes-related complications. A total of 686 patients were included in the final analysis. During 6.5 years of median follow-up, the group with treatment intensification within 6 months was more strongly associated with diabetic nephropathy compared to the group with no delayed treatment intensification (adjusted HR 2.35; 95%CI 1.35–4.09). Our findings reveal that delaying treatment intensification by even 6 months can increase the likelihood of diabetic nephropathy compared to no delayed treatment intensification. We suggest that patients with T2DM whose blood glucose levels are outside the target range promptly receive treatment intensification.

Community Health Workers as Trust Builders and Healers: A Cohort Study in Primary Care

PURPOSE

Improving patients' self-care for chronic disease is often elusive in the context of social deprivation. We evaluated whether a practice-integrated community health worker (CHW) intervention could encourage effective long-term self-management of type 2 diabetes mellitus (T2DM).

METHODS

This cohort study, in a safety-net primary care practice, enrolled patients with uncontrolled T2DM and psychosocial risk factors. Patients were identified through a practice diabetes registry or by clinicians' referrals. The CHWs engaged patients in trust building and sensemaking to understand their social context, identify goals, navigate health care, and connect to community resources. Primary outcome was progress through 3 prospectively defined stages of self-care: outreach (meeting face-to-face); stabilization (collaborating to address patients' life circumstances); and self-care generativity (achieving self-care competencies). Secondary outcomes were change in hemoglobin A_1c (HbA_1c) and need for urgent care, emergency department, or hospital visits.

RESULTS

Of 986 participating patients, 27% remained in outreach, 41% progressed to stabilization, and 33% achieved self-care generativity. Repeated measures ANOVA demonstrates an overall decline in HbA_1c, without group differences, through the 4th HbA_1c measurement (mean follow-up 703 days). Beginning at the 5th HbA_1c measurement (mean 859 days), the self-care generativity group achieved greater declines in HbA_1c, which widened through the 10th measurement (mean 1,365 days) to an average of 8.5% compared with an average of 8.8% in the outreach group and 9.0% in the stabilization group (P = .003). Rates of emergency department and hospital visits were lower in the self-care generativity group.

CONCLUSIONS

Practice-linked CHWs can sustainably engage vulnerable patients, helping them advance self-management goals in the context of formidable social disadvantage.

Impact of SGLT2 inhibitors on the kidney in people with type 2 diabetes and severely increased albuminuria

INTRODUCTION

Diabetes is the most common cause of end stage kidney disease. Therapies such as sodium-glucose co-transporter-2 inhibitors have been identified over the last decade as effective oral hypoglycemic agents that also confer additional cardio and kidney protection. Knowledge of their mechanism of action and impact on patients with diabetes and albuminuria is vital in galvanizing prescriber confidence and increasing clinical uptake.

AREAS COVERED

This manuscript discusses the pathophysiology of diabetic kidney disease, patho-physiological mechanisms for sodium-glucose co-transporter-2 inhibitors, and their impact on patients with Type 2 diabetes mellitus and albuminuric kidney disease.

EXPERT OPINION

Sodium-glucose co-transporter-2 inhibitors reduce albuminuria with consequent benefits on cardiovascular and kidney outcomes in patients with diabetes and severe albuminuria. Whilst they have been incorporated into guidelines, the uptake of these agents into clinical practice has been slow. Increasing the uptake of these agents into clinical practice is necessary to improve outcomes for the large number of patients with diabetic kidney disease globally.

[Heart and diabetes : What is the importance of GLP-1 receptor agonists in cardiology?]

Patients with diabetes have a high cardiovascular risk, which can be efficiently addressed by the administration of glucagon-like peptide 1 (GLP-1) receptor agonists (GLP-1-RA). Nevertheless, the use of GLP-1-RA has so far been limited in cardiology. This review describes the existing evidence for cardiovascular benefits of GLP-1-RA and presents the available substances with recommendations on administration and titration and taking the side effects into consideration.

Epigenetic modifications in metabolic memory: What are the memories, and can we erase them?

Inherent and acquired abnormalities in gene regulation due to the influence of genetics and epigenetics (traits related to environment rather than genetic factors) underly many diseases including diabetes. Diabetes could lead to multiple complications including retinopathy, nephropathy and cardiovascular disease that greatly increase morbidity and mortality. Epigenetic changes have also been linked to diabetes-related complications. Genes associated with many pathophysiological features of these vascular complications (e.g., inflammation, fibrosis, and oxidative stress) can be regulated by epigenetic mechanisms involving histone posttranslational modifications, DNA methylation, changes in chromatin structure/remodeling and noncoding RNAs. Intriguingly, these epigenetic changes triggered during early periods of hyperglycemic exposure and uncontrolled diabetes are not immediately corrected even after restoration of normoglycemia and metabolic balance. This latency in effect across time and conditions is associated with persistent development of complications in diabetes with prior history of poor glycemic control, termed as metabolic memory or legacy effect. Epigenetic modifications are generally reversible and provide a window of therapeutic opportunity to ameliorate cellular dysfunction and mitigate or 'erase' metabolic memory. Notably, trained immunity and related epigenetic changes transmitted from hematopoietic stem cells to innate immune cells have also been implicated in metabolic memory. Hence, identification of epigenetic variations at candidate genes, or epigenetic signatures genome-wide by epigenome-wide association studies can aid in prompt diagnosis to prevent progression of complications and identification of much-needed new therapeutic targets. Herein, we provide a review of epigenetics and epigenomics in metabolic memory of diabetic complications covering the current basic research, clinical data, and translational implications.

Plaque progression: Where, why, and how fast? A review of what we have learned from the analysis of patient data from the PARADIGM registry

Ischemic heart disease is the most common cause of mortality worldwide. The pathophysiology of myocardial infarction relates to temporal changes of atherosclerotic plaque culminating in plaque rupture, erosion or hemorrhage and the subsequent thrombotic response. Coronary computed tomographic angiography (CCTA) provides the ability to visualize and quantify plaque, and plaque progression can be measured on a per-patient basis by comparing findings of serial CCTA. The Progression of AtheRosclerotic PlAque DetermIned by Computed TomoGraphic Angiography IMaging (PARADIGM) registry was established with the objective of identifying patterns of plaque progression in a large population. The registry comprises over 2000 patients with multiple CCTA scans performed at least two years apart. Unlike previous CCTA registries, a semi-automated plaque quantification technique permitting detailed analysis of plaque progression was performed on all patients with interpretable studies. Since the registry was established, 19 peer-reviewed publications were identified, and all are reviewed and summarized in this article.

Association of hemoglobin A1c time in range with risk for diabetes complications

INTRODUCTION

We assessed the association between hemoglobin A1c time in range (A1c TIR), based on unique patient-level A1c target ranges, with risks of developing microvascular and macrovascular complications in older adults with diabetes.

RESEARCH DESIGN AND METHODS

We used a retrospective observational study design and identified patients with diabetes from the Department of Veterans Affairs (n=397 634). Patients were 65 years and older and enrolled in Medicare during the period 2004-2016. Patients were assigned to individualized A1c target ranges based on estimated life expectancy and the presence or absence of diabetes complications. We computed A1c TIR for patients with at least four A1c tests during a 3-year baseline period. The association between A1c TIR and time to incident microvascular and macrovascular complications was studied in models that included A1c mean and A1c SD.

RESULTS

We identified 74 016 patients to assess for incident microvascular complications and 89 625 patients to assess for macrovascular complications during an average follow-up of 5.5 years. Cox proportional hazards models showed lower A1c TIR was associated with higher risk of microvascular (A1c TIR 0% to <20%; HR=1.04; 95%) and macrovascular complications (A1c TIR 0% to <20%; HR=1.07; 95%). A1c mean was associated with increased risk of microvascular and macrovascular complications but A1c SD was not. The association of A1c TIR with incidence and progression of individual diabetes complications within the microvascular and macrovascular composites showed similar trends.

CONCLUSIONS

Maintaining stability of A1c levels in unique target ranges was associated with lower likelihood of developing microvascular and macrovascular complications in older adults with diabetes.

Effects of insulin on cardiovascular events and all-cause mortality in patients with type 2 diabetes: A meta-analysis of randomized controlled trials

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), all-cause mortality, and hospitalization for heart failure (HHF) as critical outcomes, decided to perform a systematic review and meta-analysis on the effect of insulin with this respect.

DATA SYNTHESIS

A MEDLINE database search was performed to identify all RCTs, up to June 1st, 2021, with duration≥52 weeks, in which insulin was compared with either placebo or active comparators. The principal endpoints were MACE and HHF (restricted for RCT reporting MACEs within their outcomes), 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. Six RCTs (enrolling 8091 patients and 10,139 in the insulin and control group, respectively) were included in the analysis for MACEs and HF, and 18 in that for all-cause mortality (9760 and 11,694 patients in the insulin and control group, respectively). Treatment with insulin neither significantly increased nor reduced the risk of MACE, all-cause mortality, and HHF in comparison with placebo/active comparators (MH-OR: 1.09, 95% CI 0.97-1.23; 0.99, 95% CI 0.91, 1.08; and 0.90, 95% CI 0.78, 1.04, respectively).

CONCLUSIONS

This meta-analysis showed no significant effects of insulin on incident MACE, all-cause mortality, and HHF.

Metformin and the heart: Update on mechanisms of cardiovascular protection with special reference to comorbid type 2 diabetes and heart failure

Metformin has been in clinical use for the management of type 2 diabetes for more than 60 years and is supported by a vast database of clinical experience: this includes evidence for cardioprotection from randomised trials and real-world studies. Recently, the position of metformin as first choice glucose-lowering agent has been supplanted to some extent by the emergence of newer classes of antidiabetic therapy, namely the sodium-glucose co-transporter-2 (SGLT2) inhibitors and glucagon-like peptide-1 (GLP-1) receptor agonists. These agents have benefitted through support from large cardiovascular outcomes trials with more modern trial designs than earlier studies conducted to assess metformin. Nevertheless, clinical research on metformin continues to further assess its many potentially advantageous effects. Here, we review the evidence for improved cardiovascular outcomes with metformin in the context of the current era of diabetes outcomes trials. Focus is directed towards the potentially cardioprotective actions of metformin in patients with type 2 diabetes and heart failure (HF), now recognised as the most common complication of diabetes.

The Evaluation of Cardiovascular Risk in Diabetic Patients

AIM

The aim of the study was to evaluate cardiovascular risk in patients with diabetes mellitus type 2 according to gender.

METHODS

The monitoring was designed as a retrospective analysis of data obtained from the documentation of the diabetic outpatients treated with the dipeptidyl peptidase-4 inhibitors (DPP4is) or sodium–glucose co-transporter-2 (SGLT2). Cardiovascular risk was assessed according to UKPDS risk engine.

RESULTS

The levels of HbA1c decreased throughout the whole study. Sixty per cent of patients achieved an HbA1c level <8% after 18 months. Both men and women had similar glycaemic compensation. Men had a significantly higher risk of fatal coronary heart disease (CHD) (p < 0.001), stroke (p < 0.01) and fatal stroke (p < 0.01) compared to women. We found the risk of fatal CHD to be 38-fold higher in men compared to women (p < 0.01).

CONCLUSION

Potential cardiovascular effects of antidiabetic treatment should be clearly defined with possible different effects according to gender. We found a much higher risk in men than women, even when their glycaemic compensation was comparable.

2022 update to the position statement by Primary Care Diabetes Europe: a disease state approach to the pharmacological management of type 2 diabetes in primary care

Type 2 diabetes and its associated comorbidities are growing more prevalent, and the complexity of optimising glycaemic control is increasing, especially on the frontlines of patient care. In many countries, most patients with type 2 diabetes are managed in a primary care setting. However, primary healthcare professionals face the challenge of the growing plethora of available treatment options for managing hyperglycaemia, leading to difficultly in making treatment decisions and contributing to treatment and therapeutic inertia. This position statement offers a simple and patient-centred clinical decision-making model with practical treatment recommendations that can be widely implemented by primary care clinicians worldwide through shared-decision conversations with their patients. It highlights the importance of managing cardiovascular disease and elevated cardiovascular risk in people with type 2 diabetes and aims to provide innovative risk stratification and treatment strategies that connect patients with the most effective care.

The cardiovascular benefits of GLP1-RAs are related to their positive effect on glycemic control: A meta-regression analysis

BACKGROUNDS AND AIMS

Glucagon-like-peptides 1 receptor analogues (GLP1-RAs) have gained primacy in the management of type 2 diabetes (T2D).However, in contrast to the CVOT conducted with sodium glucose cotransporter-2 inhibitors (SGLT-2i)there was a significant reduction in glycated haemoglobin (HbA1c) in some of the CVOT with GLP1-RA. The aim of this analysis is to explore the possible association between cardiovascular outcome benefits with GLP1-RA and HbA1c reduction.

METHODS

A Cochrane library based web search yielded 9 eligible citations for this analysis. The analysis was performed using the comprehensive meta-analysis (CMA) software.A meta-regression analysis was performed using HbA1c, weight, and systolic blood pressure reduction as moderators.

RESULT

The meta-regression analysis was conducted on a pooled population of 64,236 patients. There was a significant heterogeneity associated with the MACE benefits (Q = 16.88, I2: 52.59, df = 7, p = 0.03). Among the moderators selected to explain the variance in true effects, HbA1c reduction was significant (Q = 7.00, P=<0.001, R²:1.0). Additional meta-regression analysis using 0.9% reduction of HbA1c from baseline indicated an association with MACE benefit (95% CI -0.23 to -0.02, P = 0.01, R²: 0.98).

CONCLUSION

The MACE benefits associated with GLP1-RAs are dependent on the reduction of HbA1c levels.

Yiqi Tongluo Fang could preventive and delayed development and formation of diabetic retinopathy through antioxidant and anti-inflammatory effects

BACKGROUND

Yiqi Tongluo Fang (YQTLF) is an effective prescription for the treatment of diabetic retinopathy (DR), but its mechanism of action remains unclear.

METHOD

The content of YQTLF was determined using liquid and gas chromatography-mass spectrometry (LC-MS and GC-MS, respectively). Twenty-five Sprague Dawley (SD) rats were randomly selected as the normal control group. One hundred SD streptozotocin-induced diabetes (type 1) rats were randomly divided into diabetic control, diabetic+insulin+ calcium dobesilate (CaD), and diabetic+insulin+ YQTLF groups, with 25 rats in each group. Bodyweight level was measured every 2 weeks. After 12 weeks of gavage, the glucose levels, lipids, oxidative stress, inflammation, retinal histopathology, and the blood-retinal barrier were assessed in each group. The p38 MAPK pathway was changed to explore its internal mechanism. The measurement data were expressed as mean ± standard deviation, and different statistical methods were used according to a normal distribution, square error, or not.

RESULTS

A total of 1024 valid peaks were identified in YQTLF using GC-MS. YQTLF significantly lowered the fasting blood glucose levels in diabetic rats. YQTLF early inhibited changes in retinal histology, capillaries, cells, and tight junction proteins (such as ZO-1, occludin, claudin-5, and VE-cadherin) before the formation and development of DR. These findings correlated with the alleviation of glucolipid metabolism, inflammation, and oxidative stress. The lncRNA MALAT1 and the PRC 2/p38 MAPK-related pathway, such as the expression of EZH2, SUZ12, EED, p38 MAPK, MMP-9, and VEGFR, were also correlated.

CONCLUSION

We have demonstrated the molecular and cellular mechanisms underlying the preventive and delayed development and formation of DR. YQTLF prevents changes in dyslipidemia, retinal histology, capillaries, cells, and tight junction proteins. These protective effects appear to be linked to its antioxidant and anti-inflammatory effects, which prevent the activation of intracellular signaling pathways, such as the lncRNA MALAT1 and PRC 2/p38 MAPK-related pathway.

Association of Baseline HbA1c With Cardiovascular and Renal Outcomes: Analyses From DECLARE-TIMI 58

OBJECTIVE

Current guidelines recommend prescribing SGLT2 inhibitors to patients with type 2 diabetes and established or at high risk for atherosclerotic cardiovascular disease (ASCVD), irrespective of HbA1c levels. We studied the association of HbA1c with cardiovascular and renal outcomes and whether the benefit of dapagliflozin varies by baseline HbA1c.

RESEARCH DESIGN AND METHODS

In the Dapagliflozin Effect on Cardiovascular Events trial (DECLARE-TIMI 58), 17,160 patients with type 2 diabetes were randomly assigned to dapagliflozin or placebo for a median follow-up of 4.2 years. Cardiovascular and renal outcomes by baseline HbA1c in the overall population and with dapagliflozin versus placebo in HbA1c subgroups were studied by Cox regression models.

RESULTS

In the overall population, higher baseline HbA1c was associated with a higher risk of cardiovascular death or hospitalization for heart failure (HHF); major adverse cardiovascular events (MACE), including cardiovascular death, myocardial infarction, and ischemic stroke; and cardiorenal outcomes (adjusted hazard ratios 1.12 [95% CI 1.06-1.19], 1.08 [1.04-1.13], and 1.17 [1.11-1.24] per 1% higher level, respectively). Elevated HbA1c was associated with a greater increased risk for MACE and cardiorenal outcomes in patients with multiple risk factors (MRF) than in established ASCVD (P-interaction = 0.0064 and 0.0093, respectively). Compared with placebo, dapagliflozin decreased the risk of cardiovascular death/HHF, HHF, and cardiorenal outcomes, with no heterogeneity by baseline HbA1c (P-interaction > 0.05).

CONCLUSIONS

Higher HbA1c levels were associated with greater cardiovascular and renal risk, particularly in the MRF population, yet the benefits of dapagliflozin were observed in all subgroups irrespective of baseline HbA1c, including patients with HbA1c <7%.

Angiogenesis, Metabolism, Endothelial and Platelet Markers in Diabetes and Cardiovascular Disease

Introduction: Diabetes is a leading risk factor for cardiovascular disease (CVD), the pathophysiology of both being linked to metabolic, endothelial, renal, angiogenic and platelet abnormalities. We hypothesised that abnormalities in these systems are more adverse in those whose CVD is compounded by diabetes, compared to those with diabetes or CVD alone.

Materials and methods: Serum or plasma from 66 patients with diabetes alone, 76 with CVD alone, and 70 with both diabetes and CVD i.e. diabetic cardiovascular disease, was probed for markers of angiogenesis [angiopoietin 1 and 2, vascular endothelial growth factor (VEGF) and endoglin], metabolic [soluble receptor for advanced glycation products (sRAGE), leptin, lipocalin-2, interleukin-8, and cystatin-C], the endothelium (von Willebrand factor, endothelial microparticles and soluble E selectin)], and the platelet (platelet microparticles and soluble P selectin) by ELISA, Luminex or flow cytometry.

Results: VEGF (p = 0.04), von Willebrand factor (p = 0.001) and endothelial microparticles (p = 0.042) were all higher in diabetic cardiovascular disease than in diabetes alone and cardiovascular disease alone. Soluble E selectin was higher in diabetic cardiovascular disease than in diabetes alone (p = 0.045), whilst cystatin-C (p = 0.004) and soluble P selectin (p < 0.001) were higher in diabetes and diabetic cardiovascular disease than in cardiovascular disease alone. There were no differences in angiopoietin 1 or 2, endoglin, sRAGE, leptin, lipocalin-2, or interleukin-8.

Conclusion: Angiopoietin 1 or 2, endoglin, sRAGE, leptin, lipocalin-2, interleukin-8, and cystatin-c cannot differentiate diabetes from cardiovascular disease, or both conditions combined. Our data point to a more adverse endothelial (von Willebrand factor, endothelial microparticles), and angiogenic profile (VEGF) in those with diabetic cardiovascular disease, supporting the view that this group should be targeted more aggressively.

Development and Validation of the Diabetes Pen Experience Measure (DPEM): A New Patient-Reported Outcome Measure

BACKGROUND

Satisfaction with insulin-delivery devices has been shown to improve treatment adherence, translating into better glycemic control. The Diabetes Pen Experience Measure (DPEM) is a new patient-reported outcome measure to evaluate patients' experience when using an injection device.

METHODS

The DPEM was developed using literature review and concept elicitation interviews with clinical experts and patients. This led to a theoretical model and a draft measure of the diabetes pen experience, which was refined following cognitive debriefing. Validation entailed a web-based, noninterventional survey; psychometric analyses conducted according to a statistical analysis plan; and refinement and finalization of the DPEM and theoretical model.

RESULTS

In total, 42 patients participated in concept elicitation interviews. Analysis of the qualitative interviews resulted in a preliminary theoretical model. Based on this model, DPEM items were generated; the preliminary version of the DPEM contained 30 items. Following cognitive debriefing, the validation-ready version comprised 28 items. These were later reduced to 7 higher-order items owing to ceiling/floor effects. In total, 300 patients participated in the web-based validation study. The item statistics were all adequate. Item-to-item correlations were good. Item-to-total correlations displayed acceptable associations between each item against the rest of the items, with correlations of 0.68 to 0.79. The internal consistency was adequate, with a Cronbach's alpha of 0.91. The DPEM is scored by summing the 7 item scores and transforming the sum onto a 100-point scale.

CONCLUSION

The evidence presented supports the use of the DPEM in clinical trials to evaluate the patients' experience with diabetes injection devices.

Benefits of GLP-1 (Glucagon-Like Peptide 1) Receptor Agonists for Stroke Reduction in Type 2 Diabetes: A Call to Action for Neurologists

People living with diabetes are at higher risk for stroke and have a poorer prognosis following a stroke event than those without diabetes. Data from cardiovascular outcome trials and meta-analyses indicate that GLP-1RAs (glucagon-like peptide 1 receptor agonists) reduce the risk of stroke in individuals with type 2 diabetes. Accordingly, many guidelines now recommend the addition of GLP-1RAs to ongoing antihyperglycemic regimens to lower the risk of stroke in type 2 diabetes. The current work summarizes evidence supporting the use of GLP-1RAs for stroke reduction in people with type 2 diabetes and offers 2 new resources for neurologists who are considering GLP-1RAs for their patients-a list of frequently asked questions with evidence-based answers on safely initiating and managing GLP-1RAs, and a practical decision-making algorithm to assist in using GLP-1RAs as part of a stroke reduction strategy.

HbA1c, Coronary atheroma progression and cardiovascular outcomes

Background and aims

We tested the hypothesis that on-treatment HbA1c levels independently associate with coronary atheroma progression and major adverse cardiovascular events (MACE: death, myocardial infarction, cerebrovascular accident, coronary revascularization, or hospitalization for unstable angina) rates.

Methods

We performed a post-hoc pooled analysis of data from seven prospective, randomized trials involving serial coronary intravascular ultrasonography (IVUS). The percent atheroma volume (PAV) was calculated as the proportion of the entire vessel wall occupied by atherosclerotic plaque. Using multivariable mixed modeling, we determined the association of on-treatment HbA1c with annualized change in PAV. Cox proportional hazard models were used to assess the association of HbA1c with incidence of MACE.

Results

Among 3,312 patients (mean age 58.6±9years, 28.4%women) average on-treatment HbA1c was 6.2±1.1%. Overall, there was no net significant annualized change in PAV (0.12±0.19%, p = 0.52). In a fully adjusted multivariable analysis (following adjustment of age, sex, body mass index, systolic blood pressure, smoking, low- and high-density lipoprotein cholesterol, triglyceride levels, peripheral vascular disease, trial, region, and baseline PAV), higher on-treatment HbA1c levels were independently associated with annualized changes in PAV [beta-estimate (95% confidence interval): 0.13(0.08, 0.19), p < 0.001]. On-treatment HbA1c levels were independently associated with MACE [hazard ratio (95% confidence interval): 1.13(1.04, 1.23), p = 0.005].

Conclusions

Independent of achieved cardiovascular risk factor control, greater HbA1c levels significantly associate with coronary atheroma progression rates and clinical outcomes. These results support the notion of a direct, specific effect of glycemic control upon coronary atheroma and atherosclerotic events, supporting the rationale of therapies designed to directly modulate it.

Chronic Renal Failure and Cardiovascular Disease: A Comprehensive Appraisal

Coronary artery disease is highly prevalent in patients with chronic kidney disease. The concomitant renal disease often poses a major challenge in decision making as symptoms, cardiac biomarkers and noninvasive studies for evaluation of myocardial ischemia have different sensitivity and specificity thresholds in this specific population. Moreover, the effectiveness and safety of intervention and medical treatment in those patients is of great doubt as most clinical studies exclude patients with advance CKD. In the present paper, we discuss and review the literature in the diagnosis, treatment and prevention of CAD in the acute and chronic setting, in patients with CKD.

Contemporary Medical Therapies for Patients with Peripheral Artery Disease and Concomitant Type 2 Diabetes Mellitus: a Review of Current Evidence

PURPOSE OF REVIEW

The purpose of this review is to highlight the evidence behind landmark trials involving these two novel drug classes in conjunction with a review of long-standing therapies used to improve cardiovascular (CV) outcomes among patients with peripheral artery disease (PAD) patients and type 2 diabetes mellitus (T2DM).

RECENT FINDINGS

Recently, societal guideline recommendations have expanded the management of T2DM to incorporate therapies with CV risk factor modification. This is due to CV outcome trials (CVOT) uncovering advantageous cardioprotective effects of several novel therapies, including glucagon-like peptide-1 receptor agonists (GLP-1 RA) and sodium-glucose cotransporter-2 inhibitors (SGLT2i). Providers who manage high-risk patients with T2DM, such as those with concomitant PAD, are expected to incorporate these novel medical therapies into routine patient care. The body of evidence surrounding GLP-1 RA demonstrates a strong benefit in mitigating the innate heightened CV risk among patients with T2DM. Furthermore, SGLT2i not only have a favorable CV profile but also reduce the risk of HF hospitalizations and progression of renal disease. Patients with T2DM and PAD are known to be at a heightened risk for major adverse cardiac and lower extremity events, heart failure, and chronic kidney disease. As such, the use of novel therapies such as GLP-RA and SGLT2i should be strongly considered to minimize morbidity and mortality in this vulnerable population.

Long-term clinical and cost-effectiveness of collaborative care in people with uncontrolled type 2 diabetes mellitus and polypharmacy: A multicenter randomized controlled trial

AIMS

This study examined the effectiveness of a collaborative care model on clinical and humanistic outcomes, medical cost, productivity loss, and its cost-effectiveness in managing uncontrolled Type 2 Diabetes Mellitus (T2DM).

METHODS

A randomized controlled study was conducted in two outpatient health institutions in Singapore. Patients aged above 21 years with HbA1c > 7% and polypharmacy were included. Eligible patients were randomized into the intervention (collaborative care) and control (usual care) arms.

RESULTS

A total of 255 patients were included in the analysis. Compared to the control arm, the intervention arm achieved significantly greater glycated hemoglobin (HbA1c) reduction (mean difference: 0.25, 95%CI: [0.001, 0.50], p = 0.049) and quality-adjusted life year (QALY) (+0.011, 95%CI: [0.003, 0.019], p = 0.011) at 12 months. The costs per additional HbA1c and QALY improvements over one year were $40.52 and $920.91 respectively. Activity impairment was lower in the intervention group both at 6 months (12.7% vs 19.0%; p = 0.022) and at 12 months (6.7% vs 14.0%; p = 0.008).

CONCLUSIONS

The collaborative care model achieved earlier HbA1c reduction and reduced patients' activity impairment without decreasing work productivity or increasing medical costs. This intervention is cost-effective for improving glycemic control and quality of life in patients with T2DM.

Differential effects of treatment targets on risks of adverse outcomes according to diabetes duration, age and complications: Can these characteristics be used to individualize diabetes treatment? The Rio de Janeiro type 2 diabetes cohort

AIMS

To investigate interactions between more/less strict treatment targets (HbA_1c, systolic blood pressure, LDL-cholesterol) and clinical characteristics (age, diabetes duration and presence of complications) for occurrence of cardiovascular/microvascular complications and mortality in type 2diabetes.

METHODS

690 individuals were followed-up for 10 years (median). Interactions between treatment targets, estimated as mean values during the first 2-years, and clinical characteristics were tested in multivariable Cox regressions adjusted for other risk factors. Hazard ratios (HRs) were estimated in stratified analyses for cardiovascular/microvascular outcomes and mortality.

RESULTS

During follow-up, 214 patients had a cardiovascular event (175 MACEs); and 265 died (132 cardiovascular deaths); there were 206 renal, 161 retinopathy and 181 peripheral neuropathy events. There were interactions between treatment parameters and clinical characteristics, in most of them the HRs were higher in older individuals, in those with longer diabetes durations and with complications, particularly for the cardiovascular outcomes and mortality. For microvascular outcomes the opposite was observed. For cardiovascular mortality, the HRs of higher HbA_1c were 1.31 (1.08-1.58) and 1.09 (0.88-1.34), respectively with longer/shorter diabetes duration (p-for-interaction 0.11); and 1.43 (1.14-1.79) and 1.02 (0.85-1.23) in older/younger individuals (p-for-interaction 0.019).

CONCLUSIONS

Our findings do not support less strict treatment targets for older individuals, with longer diabetes duration or with complications, particularly for cardiovascular and mortality prevention.

Short-term effects of lifestyle intervention in the reversion to normoglycemia in people with prediabetes

AIMS

To evaluate the short-term effect of lifestyle intervention in people with prediabetes.

METHODS

A stratified multistage sampling method was used in the recruitment of residents of the Jiangsu Province, China in 2017, who had no previous diagnosis of diabetes. Physical examination and laboratory tests were performed, and questionnaires were completed. Those with a prediabetes diagnosis at baseline were included in the cohort and participants were randomized to the intervention group or the control group. The intervention group received a lifestyle intervention strategy, which included exercise, diet and peer educations. The control group received general health education. Participants were followed up in 2018.

RESULTS

A total of 2005 individuals were included in the analysis. At follow-up, there were 516 (36.7%) individuals in the intervention group and 207 (34.5%) individuals in the control group with normal blood glucose levels. The decline in waist circumference and fasting plasma glucose levels was significantly higher in the intervention group than in the control group. This was still observed after adjusting for variables (odds ratio 1.32, P = 0.02). Females or younger individuals who had lower body mass index and plasma glucose levels at baseline were more likely to reverse to normoglycemia at follow-up.

CONCLUSIONS

Compared with a strategy of general health education, a lifestyle intervention strategy could reverse glucose levels to normoglycemia in individuals with prediabetes.

Associations between body composition, fat distribution and metabolic consequences of excess adiposity with severe COVID-19 outcomes: observational study and Mendelian randomisation analysis

Background

Higher body mass index (BMI) and metabolic consequences of excess weight are associated with increased risk of severe COVID-19, though their mediating pathway is unclear.

Methods

A prospective cohort study included 435,504 UK Biobank participants. A two-sample Mendelian randomisation (MR) study used the COVID-19 Host Genetics Initiative in 1.6 million participants. We examined associations of total adiposity, body composition, fat distribution and metabolic consequences of excess weight, particularly type 2 diabetes, with incidence and severity of COVID-19, assessed by test positivity, hospital admission, intensive care unit (ICU) admission and death.

Results

BMI and body fat were associated with COVID-19 in the observational and MR analyses but muscle mass was not. The observational study suggested the association with central fat distribution was stronger than for BMI, but there was little evidence from the MR analyses than this was causal. There was evidence that strong associations of metabolic consequences with COVID-19 outcomes in observational but not MR analyses. Type 2 diabetes was strongly associated with COVID-19 in observational but not MR analyses. In adjusted models, the observational analysis showed that the association of BMI with COVID-19 diminished, while central fat distribution and metabolic consequences of excess weight remained strongly associated. In contrast, MR showed the reverse, with only BMI retaining a direct effect on COVID-19.

Conclusions

Excess total adiposity is probably casually associated with severe COVID-19. Mendelian randomisation data do not support causality for the observed associations of central fat distribution or metabolic consequences of excess adiposity with COVID-19.

Comparative Cardio-Renal Outcomes of Type 2 Diabetes Patients Administered Glucagon-Like Peptide-1 Receptor Agonists: A Network Meta-Analysis

Background: Cardio-renal profiles are available from cardiovascular outcome trials of glucagon-like peptide-1 receptor agonists (GLP-1 RAs).

Methods: A comprehensive systematic review of Embase, Medline, Web of Knowledge, and CENTRAL databases was conducted. Randomized controlled cardiovascular outcome trials of type 2 diabetes mellitus (T2DM) patients administered GLP-1 RAs were included. The following primary outcomes were examined: cardiovascular death, major adverse cardiovascular events (MACE), myocardial infarction, stroke, mortality, heart failure, hypoglycemia, pancreatitis, and thyroid carcinoma. Secondary outcomes included: composite kidney outcome, worsening kidney function, macroalbuminuria, and retinopathy.

Results: Seven trials involving 56,004 patients and eight interventions were identified. Albiglutide was associated with fewer MACE and myocardial infarction events compared with lixisenatide. Lixisenatide was related to a greater number of stroke events and cardiovascular deaths compared to once-weekly semaglutide and oral semaglutide, respectively. Improved mortality was associated with oral semaglutide compared with once-weekly semaglutide, albiglutide, dulaglutide, exenatide, or lixisenatide. Risks of heart failure, thyroid carcinoma, and pancreatitis were similar among all the treatments. Weighting of the nine primary outcomes identified oral semaglutide as first among the eight treatments examined. Among three of the secondary outcomes, once-weekly semaglutide ranked first. Better composite kidney outcome was observed with once-weekly semaglutide than with dulaglutide or exenatide; once-weekly semaglutide improved macroalbuminuria compared with exenatide or lixisenatide; and albiglutide, exenatide, and placebo was associated with fewer cases of retinopathy compared with once-weekly semaglutide. Meanwhile, kidney function was less likely to worsen with dulaglutide than with lixisenatide or placebo.

Conclusion: Semaglutide should be considered when GLP-1 RAs are indicated for T2DM patients.

Diabetes, hypertension, and cardiovascular disease development

Background

We aimed to compare cardiovascular risks among participants with T2DM with and without subsequent HTN and participants with HTN with and without subsequent T2DM.

Methods

From January 1, 2000, to December 31, 2018, we identified 16,236 matched pairs of T2DM participants with and without HTN (T2DM cohorts), 53,509 pairs of HTN participants with and without T2DM (HTN cohorts), and 21,158 pairs of comorbid HTN and T2DM participants with T2DM history or HTN history (comorbid cohorts) from Taiwan’s National Health Insurance Research Database. Cox proportional-hazard models were used to calculate the risk of cardiovascular disease.

Results

The mean follow-up time of this study was 6.75 years. Mean incident rates of coronary artery disease for T2DM cohorts, HTN cohorts, and comorbid cohorts were 16.80, 23.18, and 31.53 per 1000 person-years, respectively. The adjusted hazard ratios (HRs) (95% confidence intervals [95% CIs]) for incident coronary artery disease, stroke, and heart failure in T2DM participants with versus without HTN were 2.22 (2.07–2.37), 1.19 (1.16–1.23), and 0.92 (0.82–1.02), respectively; the adjusted HRs for HTN participants with versus without T2DM were 1.69 (1.55–1.84), 1.25 (1.21–1.30), and 0.98 (0.93–1.05), respectively; the adjusted HRs for comorbid T2DM and HTN participants with previous T2DM versus previous HTN were 2.78 (2.37–3.27), 1.20 (1.13–1.28), and 0.95 (0.88–1.03), respectively.

Conclusions

This nationwide cohort study demonstrated that both T2DM with subsequent HTN and HTN with subsequent diabetes were associated with higher cardiovascular disease risks.

6. Glycemic Targets: Standards of Medical Care in Diabetes-2022

The American Diabetes Association (ADA) "Standards of Medical Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee (https://doi.org/10.2337/dc22-SPPC), are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations, please refer to the Standards of Care Introduction (https://doi.org/10.2337/dc22-SINT). Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

Medical Management of Patients With Heart Failure and Reduced Ejection Fraction

The options for treating heart failure with reduced ejection fraction (HFrEF) have expanded considerably over the past decade. While neurohormonal modulation using angiotensin converting enzyme inhibitors and angiotensin receptor blockers, beta blockers and mineralocorticoid receptor antagonists remain the cornerstone of therapy, additional novel approaches including angiotensin receptor neprilysin inhibitors, sodium glucose cotransporter 2 inhibitors, ivrabradine, vericiguat and omecamtiv mecarbil have been shown to improve outcomes in patients with HFrEF. This reviews summarizes currently available approaches as well as promising additional strategies that may be used in the future.

Treatment options for patients with heart failure (HF) with reduced ejection fraction (HFrEF) have expanded considerably over the past few decades. Whereas neurohormonal modulation remains central to the management of patients with HFrEF, other pathways have been targeted with drugs that have novel mechanisms of action. The angiotensin receptor-neprilysin inhibitors (ARNIs) which enhance levels of compensatory molecules such as the natriuretic peptides while simultaneously providing angiotensin receptor blockade have emerged as the preferred strategy for inhibiting the renin angiotensin system. Sodium glucose cotransporter 2 (SGLT2) inhibitors which were developed as hypoglycemic agents have been shown to improve outcomes in patients with HF regardless of their diabetic status. These agents along with beta blockers and mineralocorticoid receptor antagonists are the core medical therapies for patients with HFrEF. Additional approaches using ivabradine to slow heart rate in patients with sinus rhythm, the hydralazine/isosorbide dinitrate combination to unload the heart, digoxin to provide inotropic support and vericiguat to augment cyclic guanosine monophosphate production have been shown in well-designed trials to have beneficial effects in the HFrEF population and are used as adjuncts to the core therapies in selected patients. This review provides an overview of the medical management of patients with HFrEF with focus on the major developments that have taken place in the field. It offers prospective of how these drugs should be employed in clinical practice and also a glimpse into some strategies that may prove to be useful in the future.

Lifetime cost-effectiveness simulation of once-weekly exenatide in type 2 diabetes: A cost-utility analysis based on the EXSCEL trial

AIMS

The Exenatide Study of Cardiovascular Event Lowering (EXSCEL) trial assessed once-weekly exenatide (EQW) vs. placebo, added to usual care in 14,752 patients with type 2 diabetes mellitus (Clinicaltrials.gov: NCT01144338). We assessed the lifetime cost-effectiveness of adding EQW vs. usual care alone from a healthcare perspective.

METHODS

Medical resource use and EQ-5D utilities were collected throughout the study. Within-trial results were extrapolated to a lifetime horizon using the UK Prospective Diabetes Study Outcomes Model version 2 (UKPDS-OM2), predicting predict cardiovascular and microvascular events. Cost-effectiveness was evaluated separately for US and UK settings, with outcomes measured in quality-adjusted life-years (QALYs).

RESULTS

EQW plus usual care gained 0.162 QALYs at an additional cost of $41,545/patient, compared with usual care in a US setting. The incremental cost-effectiveness ratio (ICER) was $259,223/QALY. In a UK setting, the QALY gain was 0.151 at an additional cost of £6357: an ICER of £42,589/QALY. Sensitivity analyses ranged between $34,369-$269,571 and £3430-£46,560 per QALY gained.

CONCLUSIONS

In a lifetime extrapolation, adding EQW to usual care increased QALYs and costs compared with usual care alone. The base-case ICERs exceeded the commonly-cited cost-effectiveness thresholds of $100,000/QALY and £20,000/QALY. However, ICERs were considerably lower in some subgroups, and in sensitivity analyses.

Effect of Clinical Inertia on Diabetes Complications among Individuals with Type 2 Diabetes: A Retrospective Cohort Study

Background and Objectives: Clinical inertia is a key obstacle that leads to suboptimal care in patients with type 2 diabetes mellitus (T2DM). It can occur at any stage of T2DM treatment. However, the effect of clinical inertia on diabetes complications has not been studied sufficiently. This study aimed to evaluate the effect of clinical inertia on the risk of diabetes complications among patients with T2DM. Materials and Methods: A retrospective cohort study was conducted at a tertiary teaching hospital in Thailand between 2011 and 2017. Outpatients with T2DM, aged 40–65 years, presenting an HbA1c greater than 7% were included in this study. Clinical inertia was identified when patients did not get treatment intensification at the index date and a subsequent prescription. The association between clinical inertia and diabetes complications, including a composite of macrovascular complications and a composite of microvascular complications, was determined using a Cox proportional hazard model. Propensity score methods were applied, to control confounding by indication. Results: Of 686 patients with T2DM, 165 (24.0%) experienced clinical inertia. Baseline low-density lipoprotein cholesterol, blood pressure, body mass index, the estimated glomerular filtration rate, and medication between the two groups did not differ significantly. Our study found that clinical inertia was associated with a significantly increased risk of diabetic nephropathy (adjusted HR 1.51, 95% CI 1.01–2.27). The results remained the same as when using propensity score methods. According to the post hoc analysis, lowering the HbA1c levels by 1% results in a significant decrease in the rate of diabetic complications (adjusted HR 0.92, 95% CI 0.86–0.99), the composite of microvascular complications (adjusted HR 0.91, 95% CI 0.84–0.98) and diabetic nephropathy (adjusted HR 0.89, 95% CI 0.80–0.98). Conclusions: Our results demonstrated a significant effect of clinical inertia on diabetic nephropathy. Patients with an HbA1c level over the target range should have their medication intensified to reduce the risk of diabetic nephropathy.