Association between hypoglycaemic events and fall-related fractures in Medicare-covered patients with type 2 diabetes

Long-Term Safety and Efficacy of Teneligliptin in Elderly Patients with Type 2 Diabetes: Subgroup Analysis of a 3-Year Post-Marketing Surveillance in Japan

INTRODUCTION

Teneligliptin, a dipeptidyl peptidase 4 inhibitor, was approved for the treatment of type 2 diabetes mellitus (T2DM) in Japan in 2012. However, clinical trials of teneligliptin involved limited numbers of elderly patients. Therefore, we investigated the safety and efficacy of teneligliptin in elderly patients with T2DM.

METHODS

This 3-year follow-up RUBY surveillance registered patients with T2DM who started treatment with teneligliptin between May 2013 and February 2015 in Japan. Collected data included demographics, treatments, adverse drug reactions (ADRs), and laboratory variables. Data were analysed for patients in three age subgroups (< 65, ≥ 65 to < 75, or ≥ 75 years old). Safety was assessed as the incidence of ADRs and efficacy was assessed in terms of glycaemic control, for up to 3 years.

RESULTS

The ADRs and serious ADRs occurred in 3.35% and 0.65% of 4596 patients aged < 65 years, in 4.42% and 1.22% of 3371 patients aged ≥ 65 to < 75 years, and in 3.99% and 1.69% of 2729 patients aged ≥ 75 years. The most common ADRs in patients aged ≥ 65 to < 75 years and ≥ 75 years were gastrointestinal disorders, but the incidence of these ADRs did not show an age-dependent increase. Hypoglycaemia occurred in 0.24%, 0.56%, and 0.29% of patients in each age subgroup, respectively. The least-squares mean changes in glycosylated haemoglobin (HbA1c) adjusted for baseline were - 0.66 ± 0.02% (n = 2177), - 0.72 ± 0.02% (n = 1689), and - 0.77 ± 0.03% (n = 1161) at 3 years.

CONCLUSION

There was no clear difference in the number of ADRs among the three age subgroups, although the incidence of serious ADRs was higher in elderly patients than in patients aged < 65 years. We found no additional safety or efficacy concerns among elderly patients beyond those already described in the package insert. The present results support the use of teneligliptin in elderly patients with T2DM in real-world clinical practice.

TRIAL REGISTRATION

Japic Clinical Trials Information identifier, Japic CTI-153047.

Both hypo- and hyperglycaemia are associated with increased fracture risk in Japanese people with type 2 diabetes: the Fukuoka Diabetes Registry

AIM

The impact of glycaemic control on fracture risk is controversial, which may be due to the possible presence of hypoglycaemia. The aim of this study was to separately investigate the impacts of severe hypoglycaemia and poor glycaemic control on fracture risk in people with type 2 diabetes.

METHODS

Overall, 4706 Japanese participants (2755 men and 1951 postmenopausal women) with type 2 diabetes (mean age 66 years) were followed prospectively (a median of 5.3 years; follow-up rate, 97.6%), and were stratified by severe hypoglycaemia status and glycaemic control. The primary outcome was fractures at any anatomic site.

RESULTS

Fractures occurred in 662 participants (249 men and 413 women). The age- and sex-adjusted incidence rates (expressed per 1000 person-years) were: 71.2 (multiple episodes of severe hypoglycaemia), 43.1 (one episode), 25.2 [HbA_1c < 53 mmol/mol (< 7%) without severe hypoglycaemia], 28.7 [HbA_1c 53 to < 64 mmol/mol (7% to < 8%) without severe hypoglycaemia], 27.7 [HbA_1c 64 to < 75 mmol/mol (8% to < 9%) without severe hypoglycaemia] and 40.5 [HbA_1c ≥ 75 mmol/mol (≥ 9%) without severe hypoglycaemia]. Multivariate-adjusted hazard ratios (95% confidence intervals) for fractures were 2.24 (1.56, 3.21) in those with multiple episodes of severe hypoglycaemia, and 1.42 (1.04, 1.95) in those with HbA_1c ≥ 75 mmol/mol (≥ 9%) without severe hypoglycaemia, compared with those with HbA_1c < 53 mmol/mol (< 7%) without severe hypoglycaemia.

CONCLUSIONS

Both severe hypoglycaemia and poor glycaemic control were significantly related to an increased risk of fracture in people with type 2 diabetes, although severe hypoglycaemia conferred a stronger risk.

Is Switching from Oral Antidiabetic Therapy to Insulin Associated with an Increased Fracture Risk?

BACKGROUND

Observational studies showed that exposure to exogenous insulin increases fracture risk. However, it remains unclear whether the observed association is a function of the severity of underlying type 2 diabetes mellitus, complications, therapies, comorbidities, or all these factors combined. That being so, and because of the relative infrequency of these events, it is important to study this further in a large-database setting. QUESTION/PURPOSES: (1) Is switching from oral antidiabetic agents to insulin associated with an increased fracture risk? (2) How soon after switching does the increased risk appear, and for how long does this increased risk persist?

METHODS

Data from healthcare utilization databases of the Italian region of Lombardy were used. These healthcare utilization databases report accurate, complete, and interconnectable information of inpatient and outpatient diagnoses, therapies, and services provided to the almost 10 million residents in the region. The 216,624 patients on treatment with oral antidiabetic therapy from 2005 to 2009 were followed until 2010 to identify those who modified their antidiabetic therapy (step 1 cohort). Among the 63% (136,307 patients) who experienced a therapy modification, 21% (28,420 patients) switched to insulin (active exposure), and the remaining 79% (107,887 patients) changed to another oral medication (referent exposure). A 1:1 high-dimension propensity score matching design was adopted for balancing patients on active and referent exposure. Matching failed for 3% of patients (926 patients), so the cohort of interest was formed by 27,494 insulin-referent couples. The latter were followed until 2012 to identify those who experienced hospital admission for fracture (outcome). A Cox proportional hazard model was fitted to estimate the hazard ratio (HR) for the outcome risk associated with active-exposure (first research question). Between-exposure comparison of daily fracture hazard rates from switching until the 24 successive months was explored through the Kernel-smoothed estimator (second research question).

RESULTS

Compared with patients on referent exposure, those who switched to insulin had an increased risk of experiencing any fracture (HR = 1.5 [95% CI 1.3 to 1.6]; p < 0.001). The same risk was observed for hip and vertebral fractures, with HRs of 1.6 (95% CI 1.4 to 1.8; p < 0.001) and 1.8 (95% 1.5 to 2.3; p < 0.001), respectively. Differences in the daily pattern of outcome rates mainly appeared the first 2 months after switching, when the hazard rate of patients on active exposure (9 cases for every 100,000 person-days) was higher than that of patients on referent exposure (4 cases for every 100,000 person-days). These differences persisted during the remaining follow-up, though with reduced intensity.

CONCLUSIONS

We found quantitative evidence that switching from oral antidiabetic therapy to insulin is associated with an increased fracture risk, mainly in the period immediately after the start of insulin therapy. The observed association may result from higher hypoglycemia risk among patients on insulin, which leads to a greater number of falls and resulting fractures. However, although our study was based on a large sample size and highly accurate data, its observational design and the lack of clinical data suggest that future research will need to replicate or refute our findings and address the issue of causality, if any. Until then, though, prescribers and patients should be aware of this risk. Careful control of insulin dosage should be maintained and measures taken to reduce fall risk in these patients.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Suitable Use of Injectable Agents to Overcome Hypoglycemia Risk, Barriers, and Clinical Inertia in Community-Dwelling Older Adults with Type 2 Diabetes Mellitus

The management of type 2 diabetes mellitus in older adults requires a comprehensive understanding of the relationship between the disease (medical) and the functional, psychological/cognitive, and social geriatric domains, to individualize both glycemic targets and therapeutic approaches. Prevention of hypoglycemia is a major priority that should be addressed as soon as its presence or risk is detected, adjusting the target and therapeutics accordingly. Nonetheless, treatment intensification should not be neglected when applicable, consistent with recommendations from organizations such as the American Geriatrics Society and the American Diabetes Association, to reduce not only long-term macrovascular and microvascular complications (individualization), but also short-term complications from hyperglycemia (polyuria, volume depletion, urinary incontinence). Such complications can negatively impact the physical and cognitive function of older adults, worsen their quality of life, and additionally affect their families and society. We emphasize individualization, utilizing the multiple classes of antihyperglycemic agents available. Metformin remains as first-line therapy, and additional agents offer advantages and disadvantages that ought to be considered when developing a patient-centric plan of care. For selected cases, injectable therapies such as long-acting basal insulin analogs and glucagon-like peptide-1 receptor agonists can offer advantages to counter hypoglycemia risk, patient-related barriers, and clinical inertia. Furthermore, some injectable agents could potentially simplify regimens while providing safe and effective glycemic control. In this review, we discuss the use of injectable therapies for selected community-dwelling older adults, barriers to transition to injectable therapy, and measures aimed at removing these barriers and assisting physicians and their teams to transition older patients to injectable therapies when appropriate.

Pathophysiology and Management of Type 2 Diabetes Mellitus Bone Fragility

Individuals with type 2 diabetes mellitus (T2DM) have an increased risk of bone fragility fractures compared to nondiabetic subjects. This increased fracture risk may occur despite normal or even increased values of bone mineral density (BMD), and poor bone quality is suggested to contribute to skeletal fragility in this population. These concepts explain why the only evaluation of BMD could not be considered an adequate tool for evaluating the risk of fracture in the individual T2DM patient. Unfortunately, nowadays, the bone quality could not be reliably evaluated in the routine clinical practice. On the other hand, getting further insight on the pathogenesis of T2DM-related bone fragility could consent to ameliorate both the detection of the patients at risk for fracture and their appropriate treatment. The pathophysiological mechanisms underlying the increased risk of fragility fractures in a T2DM population are complex. Indeed, in T2DM, bone health is negatively affected by several factors, such as inflammatory cytokines, muscle-derived hormones, incretins, hydrogen sulfide (H2S) production and cortisol secretion, peripheral activation, and sensitivity. All these factors may alter bone formation and resorption, collagen formation, and bone marrow adiposity, ultimately leading to reduced bone strength. Additional factors such as hypoglycemia and the consequent increased propensity for falls and the direct effects on bone and mineral metabolism of certain antidiabetic medications may contribute to the increased fracture risk in this population. The purpose of this review is to summarize the literature evidence that faces the pathophysiological mechanisms underlying bone fragility in T2DM patients.

Benefits and harms of intensive glycemic control in patients with type 2 diabetes

Diabetes is a major and costly health concern worldwide, with high morbidity, disability, mortality, and impaired quality of life. The vast majority of people living with diabetes have type 2 diabetes. Historically, the main strategy to reduce complications of type 2 diabetes has been intensive glycemic control. However, the body of evidence shows no meaningful benefit of intensive (compared with moderate) glycemic control for microvascular and macrovascular outcomes important to patients, with the exception of reduced rates of non-fatal myocardial infarction. Intensive glycemic control does, however, increase the risk of severe hypoglycemia and incurs additional burden by way of polypharmacy, side effects, and cost. Additionally, data from cardiovascular outcomes trials showed that cardiovascular, kidney, and mortality outcomes may be improved with use of specific classes of glucose lowering drugs largely independently of their glycemic effects. Therefore, delivering evidence based, patient centered care to people with type 2 diabetes requires a paradigm shift and departure from the predominantly glucocentric view of diabetes management. Instead of prioritizing intensive glycemic control, the focus needs to be on ensuring access to adequate diabetes care, aligning glycemic targets to patients' goals and situations, minimizing short term and long term complications, reducing the burden of treatment, and improving quality of life.

The use of metformin, insulin, sulphonylureas, and thiazolidinediones and the risk of fracture: Systematic review and meta-analysis of observational studies

Certain glucose-lowering medications have been implicated in the risk of fracture. While there is convincing evidence from randomized controlled trials (RCTs) that thiazolidinedione use is associated with a higher risk of fracture, the effects of metformin, insulin, and sulphonylureas on the risk of fracture remain equivocal because these medications are not generally investigated in RCTs. A meta-analysis of observational studies to provide further insights into the association between the use of metformin, insulin, sulphonylureas, or thiazolidinediones and the risk of fracture was performed. PubMed and Web of Science databases were searched to identify relevant observational studies. A random effects model was used to estimate the summary relative risks (RRs) with 95% confidence intervals (CIs). The use of insulin (RR 1.49, 95% CI 1.29, 1.73; n = 23 studies), sulphonylureas (RR 1.30, 95% CI 1.18, 1.43; n = 10), and thiazolidinediones (RR 1.24, 95% CI 1.13, 1.35; n = 14) was associated with an increased risk of fracture, whereas the use of metformin was associated with a reduced risk of fracture (RR 0.86, 95% CI 0.75, 0.99; n = 12). Regarding types of thiazolidinediones, both pioglitazone (RR 1.38, 95% CI 1.23, 1.54; n = 5) and rosiglitazone (RR 1.34, 95% CI 1.14, 1.58; n = 5) were positively associated with the risk of fracture. In summary, there is compelling evidence to discourage the use of thiazolidinediones in individuals with an increased risk of fracture, whereas metformin appears to have a good safety profile for the risk of fracture. The reduced risk of fracture with metformin could possibly be due to the reduced overall risk of fracture among metformin users, as this medication is typically prescribed in the early stages of type 2 diabetes mellitus. The use of insulin or sulphonylureas may increase fracture risk; this risk is most likely attributed to an increased risk of hypoglycaemia-induced falls. Further confirmation by additional RCTs is required to determine whether the observed association between the use of metformin, insulin, or sulphonylureas and the risk of fracture is due to treatment with these medications or confounding factors.

Effect of Dipeptidyl Peptidase-4 Inhibitors on the Risk of Bone Fractures in a Korean Population

BACKGROUND

There have been equivocal results in studies of the effects of dipeptidyl peptidase-4 inhibitors (DPP-4i) on fractures. In this study, we analyzed the effect of DPP-4i on bone fracture risk in a Korean population.

METHODS

We extracted subjects (n = 11,164) aged 50 years or older from the National Health Insurance Service-National Sample Cohort 2.0 from 2009 to 2014. Our control group included subjects without diabetes (n = 5,582), and our treatment groups with diabetes included DPP-4i users (n = 1,410) and DPP-4i non-users (n = 4,172). The primary endpoint was the incidence of a composite outcome consisting of osteoporosis diagnosis, osteoporotic fractures, vertebral fractures, non-vertebral fractures, and femoral fractures. The secondary endpoint was the incidence of each individual component of the composite outcome. Survival analysis was performed with adjustment for age, gender, diabetes complications severity index, Charlson comorbidity index, hypertension medication, and dyslipidemia treatment.

RESULTS

The incidence of the composite outcome per 1,000 person-years was 0.089 in DPP-4i users, 0.099 in DPP-4i non-users, and 0.095 in controls. There was no significant difference in fracture risk between DPP-4i users and DPP-4i non-users or controls after the adjustments (P > 0.05). The incidences of osteoporosis diagnosis, osteoporotic fractures, vertebral fractures, non-vertebral fractures, and femoral fractures were not significantly different between DPP-4i users and non-users. The results of subgroup analyses by gender and age were consistent.

CONCLUSION

DPP-4i had no significant effect on the risk of fractures in a Korean population.

Assessing hypoglycemia frequency using flash glucose monitoring in older Japanese patients with type 2 diabetes receiving oral hypoglycemic agents

AIM

It is important to consider hypoglycemia for glycemic control in elderly patients with type 2 diabetes. Continuous blood glucose monitoring system is an effective method to investigate blood glucose fluctuation. This study examined hypoglycemia frequency using continuous blood glucose monitoring system in older patients with type 2 diabetes.

METHODS

A total of 70 patients with type 2 diabetes aged >65 years, receiving oral treatment only and having a glycated hemoglobin (HbA1c) level of <8% were enrolled. Flash glucose monitoring system was used for the device. Patients were classified into three groups according to the type of medicine administered, in addition to other oral hypoglycemics, and were compared: (i) those taking sulfonylureas (SU); (ii) those taking glinides; and (iii) those who did not take either SU or glinides.

RESULTS

There was a significant positive correlation between the coefficient of variation and hypoglycemic frequency in all the patients, and a significant negative correlation between HbA1c and hypoglycemia in those receiving SU. When hypoglycemia was defined as glucose levels <54 mg/dL and <70 mg/dL, the cut-off HbA1c values for developing hypoglycemia were 6.3% and 6.7%, sensitivity was 75.0% and 76.2%, and specificity was 90.9% and 77.6%, respectively.

CONCLUSIONS

In older patients with type 2 diabetes receiving SU, hypoglycemic frequency increases with decreases in HbA1c level. In particular, in patients with HbA1c levels of <6.3% receiving SU, it is necessary to consider medication modification. Geriatr Gerontol Int 2019; 19: 1030-1035.

Ensuring continuity of care for patients with diabetes mellitus

Diabetes mellitus is a common long-term condition that requires careful monitoring and management. Patients with long-term conditions are often transferred between healthcare settings, for example: during admission to hospital from the community; transfer between hospital wards or inpatient departments; discharge from hospital into the community; and possible readmission to hospital. During the healthcare pathway of a patient with diabetes, there are frequent opportunities for treatment errors or miscommunication to occur, particularly related to medicines such as insulin. Therefore, it is important for nurses to develop effective communication skills to provide continuity of care as patients with diabetes navigate the healthcare pathway. This article examines the potential transfer points in the patient's healthcare pathway and discusses how effective diabetes care can be maintained throughout these transitions.

[Successful treatment of severe sulfonylurea-induced hypoglycemia by the subcutaneous administration of octreotide in an elderly patient with diabetes: A case report]

Sulfonylureas, a potent stimulator of insulin release from pancreatic β cells, can cause hypoglycemia, which is apt to recur with a prolonged duration in elderly patients. Octreotide acetate, a long-acting somatostatin analogue, suppresses the secretion of insulin and is recognized as a possible treatment for sulfonylurea-induced hypoglycemia. However, there are few reports on its use in an actual clinical setting, especially in the elderly. We herein report a case in which subcutaneous injection of octreotide was effective for treating prolonged and recurrent hypoglycemia caused by sulfonylureas in an elderly man. An 89-year-old man was transported to the emergency department of our hospital for disturbance of consciousness in the morning. He had been treated for type 2 diabetes with 0.5 mg glimepiride, with the most recent HbA1c measurement being 5.7%. His plasma glucose level was low (22 mg/dL), and he was in a coma (Japan Coma Scale: 300). Under a diagnosis of hypoglycemic coma caused by sulfonylurea, we dripped 10% glucose solution and administered 50% glucose solution every 1 to 2 h through a peripheral vein, but his hypoglycemia recurred several times. Finally, 50 μg octreotide was subcutaneously injected. Thereafter, hypoglycemia did not recur, and additional injections of 50% glucose solution were not required. The same dose of octreotide was additionally administered after 8 h. In conclusion, the subcutaneous injection of octreotide can be an effective and safe method of treating prolonged hypoglycemia caused by sulfonylureas in the elderly.

Hypoglycemia and hyperglycemia are risk factors for falls in the hospital population

OBJECTIVE

To determine the role of hypoglycemia, hyperglycemia or the combination of both as independent risk factors for falls in a hospital population. Secondary objectives included evaluation of other risk factors for falling and their relationships with glucose levels.

RESEARCH DESIGN AND METHODS

Retrospective cohort study over 2 years on hospitalized subjects (N = 57411) analyzing in-hospital-falls and capillary glucose values. Bivariate analysis (χ² test) and multivariate analysis (logistic regression) were performed to test for correlation of glucose values, age, sex, Charlson index, service of care, diagnosis at discharge and diabetes treatment with risk of in-hospital-falls.

RESULTS

The comparison of patients who experienced a fall (fall population) with the non-fall population suggested that: glucose determinations were significantly more frequent in the fall population (OR 3.45; CI 2.98-3.99; p < 0.0001); values of glucose below 70 mg/dl and over 200 mg/dl were significantly associated to falls during hospitalization (OR 1.76; CI 1.42-2.19; p < 0.001) as compared to glycemic values between 70 and 200 mg/dl; diabetes treatment was significantly correlated to risk of fall (OR 2.97; CI 2.54-3.49; p < 0.001); the frequency of glycemia measurements below 70 mg/dl and over 200 mg/dl in the same subject was significantly associated to falls during hospitalization (OR 1.01; CI 1.01-1.02; p < 0.001).

CONCLUSION

Hypoglycemia and hyperglycemia during hospital stays are correlated with an increased risk for falls in the hospitalized population. Presence of diabetes, use of insulin or glucose variability could potentially constitute risk factors for falls inside the hospital as well.

Glycemic control and 10-year odds of all-cause fractures in elderly veterans with type 2 diabetes

AIMS

To investigate the relationship of average level of glycemic control and fractures in elderly Veterans.

METHODS

Retrospective cohort of Veterans (age ≥65) grouped as follows: no diabetes, HbA1c ≤7.0% [≤53 mmol/mol], HbA1c 7.1-8.0% [54-64 mmol/mol], HbA1c 8.1-9.0% [65-75 mmol/mol], and HbA1c >9% [>75 mmol/mol]. Data from January 1, 2010 - January 1, 2017 from the Veteran's Affairs Corporate Data Warehouse was analyzed using Chi-square and Cox regression analysis.

RESULTS

3434 fractures occurred from the 36,744 Veterans included. The fracture incidences were 14.4, 11.7, 7.9, 8.2, and 10.8 events per 1000 patient years and the hazard ratios were 1.233 (1.130-1.345); p < 0.0001, 0.718 (0.626-0.825); p < 0.0001, 0.682 (0.545-0.854); p = 0.0009, and 0.887 (0.633-1.245); p = 0.4915 in the no diabetes, HA1c ≤7% [≤53 mmol/mol], 7.1-8% [54-64 mmol/mol], 8.1-9% [65-75 mmol/mol], and >9% [>75 mmol/mol] groups after accounting for covariates in the final model.

CONCLUSION

In elderly Veterans with type 2 diabetes the average HbA1c 7.1-8.0% [54-64 mmol/mol], and 8.1-9% [65-75 mmol/mol] have the lowest fracture incidence and those without diabetes showing the highest incidence rate; however, due to the overall low rate of fracture, the absolute difference in incidence of fracture was very small at 2-5 per 1000 patient years. Beyond limiting the risk factors identified these results don't support altering diabetes treatment goals to reduce fracture risk.

Treatment of Diabetes in Older Adults: An Endocrine Society* Clinical Practice Guideline

OBJECTIVE

The objective is to formulate clinical practice guidelines for the treatment of diabetes in older adults.

CONCLUSIONS

Diabetes, particularly type 2, is becoming more prevalent in the general population, especially in individuals over the age of 65 years. The underlying pathophysiology of the disease in these patients is exacerbated by the direct effects of aging on metabolic regulation. Similarly, aging effects interact with diabetes to accelerate the progression of many common diabetes complications. Each section in this guideline covers all aspects of the etiology and available evidence, primarily from controlled trials, on therapeutic options and outcomes in this population. The goal is to give guidance to practicing health care providers that will benefit patients with diabetes (both type 1 and type 2), paying particular attention to avoiding unnecessary and/or harmful adverse effects.

Seasonal Variation in Severe Glucose-lowering Drug-induced Hypoglycemia in Patients with Type 2 Diabetes

Objective Glucose-lowering drug-induced hypoglycemia is a serious complication and there have been a few reports of seasonal variations in hypoglycemia in patients with type 2 diabetes. The aim of the present study was to examine the association between severe drug-induced hypoglycemia and seasonal variations, and to elucidate the contributing factors. Methods This retrospective, single center clinical study, analyzed the cases of 125 patients who required emergency hospitalization for severe drug-induced hypoglycemia between January 1, 2001 and December 31, 2014. The period from November to April was defined as the cold season. Results Severe hypoglycemia occurred more often in the cold season than in the warm season. In the cold season, 62 of 9,981 (0.6%) emergency department visits involved patients who required hospitalization for drug-induced hypoglycemia. In contrast, in the warm season, 27 of 8,649 (0.3%) visits involved patients who required hospitalization for drug-induced hypoglycemia (p=0.002). The proportion of patients treated with sulfonylurea (SU) in the cold season was higher than that in the warm season. Even the use of low-dose SU caused hypoglycemia in the cold season. In the SU-treated group, the proportion of patients with white blood cell and/or C-reactive protein elevation was higher in the cold season than in the warm season (p=0.04). Conclusion Severe glucose-lowering drug-induced hypoglycemia occured more frequently in the cold season than in the warm season, and was associated with an inflammatory state in patients treated with SU.

Inhibition of the sodium-glucose co-transporter 2 in the elderly: clinical and mechanistic insights into safety and efficacy

The prevalence of type 2 diabetes mellitus (T2DM) in the elderly grew sharply over the last decade. Reduced insulin sensitivity and secretory capacity, weight gain, sarcopenia, and elevated adiposity are all common metabolic and body changes in the aging population that favor an increased risk of hypoglycemia, frailty syndrome, falls, and cognitive dysfunction. First line antidiabetic therapy is frequently not safe in older individuals because of its high risk of hypoglycemia and prevalent co-morbid diseases, such as chronic kidney disease, osteoporosis, cardiovascular disease, and obesity. Sodium-glucose cotransporter 2 inhibitor (SGLT2i) is a new class of antidiabetic therapy that inhibits glucose and sodium reabsorption on renal proximal convoluted tubule. Its effect is well demonstrated in various clinical scenarios in the younger population. This review and metanalysis describe particularities of the SGLT2i on the elderly, with mechanistic insights of the potential benefit and remaining challenges about the use of these drugs in this important age group. Further, we will present a meta-analysis of the main effects of SGLT2i reported in post-hoc studies in which the median age of the subgroups analyzed was over 60 years. Despite the absence of specific clinical trials for this population, our findings suggest that SGLT2i therapy on older individuals is effective to lower glucose and maintain its effect on systolic blood pressure and body weight.

Diabetes pharmacotherapy and effects on the musculoskeletal system

Persons with type 1 or type 2 diabetes have a significantly higher fracture risk than age-matched persons without diabetes, attributed to disease-specific deficits in the microarchitecture and material properties of bone tissue. Therefore, independent effects of diabetes drugs on skeletal integrity are vitally important. Studies of incretin-based therapies have shown divergent effects of different agents on fracture risk, including detrimental, beneficial, and neutral effects. The sulfonylurea class of drugs, owing to its hypoglycemic potential, is thought to amplify the risk of fall-related fractures, particularly in the elderly. Other agents such as the biguanides may, in fact, be osteo-anabolic. In contrast, despite similarly expected anabolic properties of insulin, data suggests that insulin pharmacotherapy itself, particularly in type 2 diabetes, may be a risk factor for fracture, negatively associated with determinants of bone quality and bone strength. Finally, sodium-dependent glucose co-transporter 2 inhibitors have been associated with an increased risk of atypical fractures in select populations, and possibly with an increase in lower extremity amputation with specific SGLT2I drugs. The role of skeletal muscle, as a potential mediator and determinant of bone quality, is also a relevant area of exploration. Currently, data regarding the impact of glucose lowering medications on diabetes-related muscle atrophy is more limited, although preclinical studies suggest that various hypoglycemic agents may have either aggravating (sulfonylureas, glinides) or repairing (thiazolidinediones, biguanides, incretins) effects on skeletal muscle atrophy, thereby influencing bone quality. Hence, the therapeutic efficacy of each hypoglycemic agent must also be evaluated in light of its impact, alone or in combination, on musculoskeletal health, when determining an individualized treatment approach. Moreover, the effect of newer medications (potentially seeking expanded clinical indication into the pediatric age range) on the growing skeleton is largely unknown. Herein, we review the available literature regarding effects of diabetes pharmacotherapy, by drug class and/or by clinical indication, on the musculoskeletal health of persons with diabetes.

Impact of Hypoglycemia on Health-Related Quality of Life among Type 2 Diabetes: A Cross-Sectional Study in Thailand

Type 2 diabetes mellitus (T2DM) is one of the most common chronic diseases. Patients are generally advised lifestyle changes with antihyperglycemic agents prescribed. The major drawback of prescribing antihyperglycemic agents is the risk of hypoglycemia which subsequently impacts on health-related quality of life (HRQoL). This study is aimed at examining association between previous history of hypoglycemia and HRQoL. The study was a multicenter cross-sectional study, conducted from February 2013 to March 2015 at 5 tertiary care hospitals in Thailand (Srinagarind, Phramongkutklao, Ramathibodi, King Chulalongkorn Memorial, and Siriraj hospitals). The study population were males or females diagnosed with type 2 DM according to ADA criteria, 30 years of age or older, who had been treated with sulfonylurea (SU) monotherapy or SU and metformin combination for at least 6 months. Prespecified medical factors were extracted from medical records 12 months prior to patients' enrolment. The experience of hypoglycemia questionnaire was used to collect and measure severity of hypoglycemia experienced during the previous 6 months. HRQoL was assessed using the 3-level version of EuroQol-5-dimension (EQ-5D-3L) and visual analogue scale (EQ-VAS) questionnaires. Of 659 eligible patients surveyed, 202 patients (30.65%) had experienced symptoms of hypoglycemia. HRQoL was significantly lower among patients reporting at least one of hypoglycemic symptoms, measured by EQ-VAS scores (mean ± SD; 73.66 ± 13.18, 73.56 ± 15.10, or 68.93 ± 14.76 vs. 77.01 ± 13.02, one-way ANOVA; p = 0.006) and EQ-5D-3L index scores (0.62 ± 0.47, 0.68 ± 0.38, or 0.58 ± 0.51 vs. 0.79 ± 0.31, one-way ANOVA; p < 0.001) for mild, moderate, or severe/very severe hypoglycemic patients compared with patients without hypoglycemic symptoms. After adjusting for confounding factors in a multiple linear regression model, patients with hypoglycemic symptoms either mild, moderate, or severe/very severe demonstrated significantly higher impairment for EQ-VAS and EQ-5D indexes than those who did not experience hypoglycemic symptoms. In conclusion, our study showed decreased HRQoL determined by EQ-5D and EQ-VAS in patients reporting symptoms of hypoglycemia compared with patients not reporting hypoglycemic symptoms, relative to severity of hypoglycemia.

Retrospective Cohort Analysis of the Reduced Burden of Hypoglycemia Associated with Dipeptidyl Peptidase-4 Inhibitor Use in Patients with Type 2 Diabetes Mellitus

INTRODUCTION

The use of antihyperglycemic agents (AHA), especially insulin and sulfonylureas (SU), is a risk factor for hypoglycemia. Despite the significant clinical and economic burdens associated with hypoglycemia and the decreasing use of SU in favor of other oral AHA, relatively little is known about hypoglycemia trends specific to the use of non-insulin AHA. We sought to estimate annual hypoglycemia event rates and costs among patients with type 2 diabetes mellitus (T2DM) who started either SU or dipeptidyl peptidase-4 inhibitors (DPP-4i) and to predict rates and costs in the absence of DPP-4i.

METHODS

Truven's MarketScan Commercial Claims database was used to estimate hypoglycemia event rates and costs from 2007 to 2013. Hypoglycemia, defined using diagnosis codes, was assessed during the 12 months following SU (n = 245,201) or DPP-4i (n = 176,786) initiation by adults with T2DM. Coefficients from a Poisson regression model used to estimate the impact of patient characteristics on hypoglycemia rates for patients who started SU were used to predict rates for patients who started DPP-4i had they started SU instead.

RESULTS

Hypoglycemia events per 100 patient-years (costs per event) ranged from 5.4 ($565) in 2007 to 10.4 ($1154) in 2013 for patients starting SU; rates (costs) for patients starting DPP-4i ranged from 3.2 ($308) in 2007 to 6.4 ($482) in 2013. Predicted hypoglycemia rates would have been 5.3-9.9 per 100 person-years for patients who started DPP-4i had they started SU instead. Starting DPP-4i, rather than SU, would have resulted in national savings of $750.3 million in healthcare costs due to avoided hypoglycemia events during this period.

CONCLUSIONS

Hypoglycemia rates and costs were consistently higher for patients who started SU rather than DPP-4i. The overall burden of hypoglycemia could be lowered substantially in the USA if, when feasible, patients with T2DM initiate DPP-4i instead of SU.

FUNDING

Merck & Co., Inc., Kenilworth, NJ USA.

Diagnosis and management of bone fragility in diabetes: an emerging challenge

Fragility fractures are increasingly recognized as a complication of both type 1 and type 2 diabetes, with fracture risk that increases with disease duration and poor glycemic control. Yet the identification and management of fracture risk in these patients remains challenging. This review explores the clinical characteristics of bone fragility in adults with diabetes and highlights recent studies that have evaluated bone mineral density (BMD), bone microstructure and material properties, biochemical markers, and fracture prediction algorithms (i.e., FRAX) in these patients. It further reviews the impact of diabetes drugs on bone as well as the efficacy of osteoporosis treatments in this population. We finally propose an algorithm for the identification and management of diabetic patients at increased fracture risk.

FRAX tool in type 2 diabetic subjects: the use of HbA1c in estimating fracture risk

AIMS

Patients with type 2 diabetes mellitus (T2DM) have an increased risk of fractures, despite having greater bone mineral density (BMD) than non-diabetic subjects. This has led to the hypothesis that the presence of impaired bone quality among diabetics reduces bone strength. The Fracture Risk Assessment Score (FRAX) algorithm, introduced to facilitate the evaluation of fracture risk, underestimates the risk of fracture in diabetic patients. The purpose of this study is to confirm the relationship between the degree of metabolic compensation and the 10-year probability of a major fracture or a hip osteoporotic fracture observed in our previous study and to ascertain whether glycosylated hemoglobin (HbA_1c) can improve the predictive value of FRAX in patients with T2DM.

METHODS

Our data derive from a retrospective clinical study conducted at the "Tor Vergata" Polyclinic in Rome on 6355 subjects over 50 years of age evaluated for osteoporosis. All available clinical records were examined. HbA_1c was available for 242 of these subjects and all had had a Dual-energy X-ray Absorption (DXA) scan of the lumbar spine and femoral neck. The risk of fracture was estimated using the Italian version of the FRAX algorithm.

RESULT

Patients with T2DM had BMD and T-scores higher than those of non-diabetic subjects, while FRAX average values were higher in the non-diabetic group. HbA_1c and FRAX are inversely correlated with each other: for each incremental percentage point of HbA_1c growth, the FRAX major osteoporotic fracture probability is reduced by 0.915 points and the FRAX hip osteoporotic fracture probability by 1.438 points. The introduction of a correction factor derived from HbA_1c, resulted in mean FRAX values of diabetic patients equivalent to those of non-diabetic subjects.

CONCLUSIONS

We propose a correction factor derived from HbA_1c that could enhance the predictive ability of fracture risk estimated by the FRAX algorithm in subjects with T2DM.

Real-world antidiabetic drug use and fracture risk in 12,277 patients with type 2 diabetes mellitus: a nested case-control study

We conducted a nested case-control study to study the association between antidiabetic treatments (alone or in combination) use and fracture risk among incident type 2 Diabetes mellitus patients. We found an increased risk of bone fracture with insulin therapy compared to metformin monotherapy.

INTRODUCTION

Patients with type 2 diabetes mellitus (T2DM) have an increased risk of fragility fractures, to which antidiabetic therapies may contribute. We aimed to characterize the risk of fracture associated with different antidiabetic treatments as usually prescribed to T2DM patients in actual practice conditions.

METHODS

A case-control study was nested within a cohort of incident T2DM patients registered in 2006-2012 in the Information System for Research Development in Primary Care (Catalan acronym, SIDIAP), a database which includes records for > 5.5 million patients in Catalonia (Spain). Each case (incident major osteoporotic fracture) was risk-set matched with up to five same-sex controls by calendar year of T2DM diagnosis and year of birth (± 10 years). Study exposure included previous use of all antidiabetic medications (alone or in combination), as dispensed in the 6 months before the index date, with metformin (MTF) monotherapy, the most commonly used drug, as a reference group (active comparator).

RESULTS

Data on 12,277 T2DM patients (2049 cases and 10,228 controls) were analyzed. Insulin use was associated with increased fracture risk (adjusted OR 1.63 (95% CI 1.30-2.04)), as was the combination of MTF and sulfonylurea (SU) (adjusted OR 1.29 (1.07-1.56)), compared with MTF monotherapy. Sensitivity analyses suggest possible causality for insulin therapy but not for the MTF + SU combination association. No significant association was found with any other antidiabetic medications.

CONCLUSIONS

Insulin monotherapy was associated with an increased fracture risk compared to MTF monotherapy in T2DM patients. Fracture risk should be taken into account when starting a glucose-lowering drug as part of T2DM treatment.

Prevention and Management of Severe Hypoglycemia and Hypoglycemia Unawareness: Incorporating Sensor Technology

PURPOSE OF REVIEW

In addition to assisting in achieving improved glucose control, continuous glucose monitoring (CGM) sensor technology may also aid in detection and prevention of hypoglycemia. In this paper, we report on the current scientific evidence on the effectiveness of this technology in the prevention of severe hypoglycemia and hypoglycemia unawareness.

RECENT FINDINGS

Recent studies have found that the integration of CGM with continuous subcutaneous insulin infusion (CSII) therapy, a system known as sensor-augmented pump (SAP) therapy, very significantly reduces the occurrence of these conditions by providing real-time glucose readings/trends and automatically suspending insulin infusion when glucose is low (LGS) or, even, before glucose is low but is predicted to soon be low (PLGS). Initial data indicate that even for patients with type 1 diabetes treated with multiple daily injections, real-time CGM alone has been found to reduce both severe hypoglycemia and hypoglycemia unawareness. Closed loop systems (artificial pancreas) comprised of CGM and CSII without patient intervention to adjust basal insulin, which automatically reduce, increase, and suspend insulin delivery, represent a potential new option that is moving toward becoming a reality in the near future. Sensor technology promises to continue to improve patients' lives not only by attaining glycemic control but also by reducing hypoglycemia, a goal best achieved in conjunction with structured individualized patient education.

Assessment of bone quality in patients with diabetes mellitus

Substantial evidence exists that diabetes mellitus is associated with an increased risk of osteoporotic fractures. Low bone strength as well as bone extrinsic factors are probably contributing to the increased bone fragility in diabetes. Bone density and quality are important determinants of bone strength. Although bone mineral density (BMD) and the fracture risk assessment tool (FRAX) are very useful clinical tools in assessing bone strength, they may underestimate the fracture risk in diabetes mellitus. Through advances in new technologies such as trabecular bone score (TBS) and peripheral quantitative computed tomography (pQCT), we can better assess the bone quality and fracture risk of patients with diabetes mellitus. Invasive assessments such as microindentation and histomorphometry have been great complement to the existing bone analysis techniques. Bone turnover markers have been found to be altered in diabetes mellitus patients and may be associated with fractures. This review will give a brief summary of the current development and clinical uses of these assessments.

The effects of diabetes therapy on bone: A clinical perspective

The effects of diabetes and diabetes therapy on bone are less known among clinicians. Traditionally, the emphasis of diabetes therapy has been on reducing cardiovascular risk by facilitating reductions in weight, blood pressure, blood sugar, systemic inflammation, and lipid levels. Now, with ample research demonstrating that patients with diabetes are more susceptible to bone fractures relative to controls, there has been a greater or renewed interest in studying the effects of diabetes therapy on bone. Interestingly, the majority of antidiabetic agents positively affect bone, but a few have detrimental effects. Specifically, although insulin has been demonstrated to be anabolic to bone, the rate of hypoglycemic episodes are increased with exogenous infusion; consequently, there is an increased fall and fracture frequency. Other agents such as thiazolidinediones have more direct negative effects on bone through transcriptional regulation. Even metabolic surgery, to a varying operation-dependent extent, exacerbates bone strength and may heighten fracture rate. The remaining diabetes agents seem to have neutral or positive effects on bone. With the increasing incidence of diabetes, it is more pertinent than ever to fully comprehend the effects of diabetes-related therapeutic modalities.

Severe hypoglycemia is associated with high risk for falls in adults with type 1 diabetes

We evaluated fall frequency and factors affecting falls among middle-aged and older adults with type 1 diabetes (T1D) from T1D Exchange Registry. Twenty-nine percent of T1D participants reported falls within the past 12 months. Severe hypoglycemia, diabetic peripheral neuropathy, and depression were associated with falls in adults with T1D.

PURPOSE

Fall is an important risk factor for osteoporotic fracture; we evaluated fall frequency and factors affecting falls among middle-aged and older adults with type 1 diabetes (T1D).

METHODS

Participants aged ≥ 55 years with T1D completed an email-based questionnaire on falls in the prior 12 months. Demographic, clinical, and fall-related information were gathered from the questionnaire; HbA1c was recorded from medical record data extraction.

RESULTS

Four hundred and thirty five adults with T1D completed the fall questionnaire (mean age 64 ± 7 years, 57% females, and 97% were non-Hispanic whites). The mean diabetes duration was 36 years with mean HbA1c of 7.3%. Among the 435 participants, 126 reported at least one fall in the prior 12 months (29%). The fall frequency values in adults (55-64 years) with T1D and older adults (> 65 years) were 26 and 32%, respectively (p = 0.16). There was no significant difference in frequency of fall between female and male participants (31 vs. 26%, p = 0.33). Of 126 participants who had a fall, 44% had injuries due to fall, 24% required medical attention, and 13 participants reported fracture (10%). Severe hypoglycemia (odds ratio (OR) 3.6), diabetic peripheral neuropathy (OR 2.2), and depression (OR 1.7) were associated with falls in adults with T1D. Forty-one percent of participants were fearful of falls.

CONCLUSIONS

This is the first study on prevalence and risk factors for falls suggesting that falls are common in T1D and severe hypoglycemia is a unique diabetes-related factor associated with threefold higher risk for falls.

Higher dietary glycemic index and glycemic load values increase the risk of osteoporotic fracture in the PREvención con DIeta MEDiterránea (PREDIMED)-Reus trial

Background

High glucose and insulin concentrations seem to have a negative impact on bone health. However, the relation between the dietary glycemic index (DGI) and the dietary glycemic load (DGL), which has proved to be effective at modulating blood glucose concentrations after carbohydrate consumption, has yet to be explored in relation to bone health.

Objective

The aim of the study was to examine the associations between the DGI or DGL and the risk of osteoporotic-related fractures in an elderly Mediterranean population.

Design

The study was conducted in 870 subjects aged 55-80 y at high cardiovascular disease risk participating in the PREvención con DIeta MEDiterránea (PREDIMED)-Reus study. The DGI and DGL were estimated from validated food-frequency questionnaires with the use of the international glycemic index and glycemic load values, with glucose as reference. Data on osteoporotic fractures were acquired from a systematic review of medical records. We used Cox proportional hazard models to assess the risk of osteoporotic fracture according to tertiles of average DGI and DGL.

Results

A total of 114 new cases of osteoporotic-related fractures were documented after a mean follow-up of 8.9 y. Participants in the highest tertile of DGI and DGL had a significantly higher risk of osteoporotic fractures than those in the lowest tertile after adjusting for potential confounders (HR: 1.80; 95% CI: 1.03, 3.15 and HR: 3.20; 95% CI: 1.25, 8.18, respectively).

Conclusions

A high DGI and DGL are associated with a higher risk of osteoporosis-related fractures in an elderly Mediterranean population at high cardiovascular disease risk. This trial was registered at isrctn.com as ISRCTN35739639.

DEVOTE 5: Evaluating the Short-Term Cost-Utility of Insulin Degludec Versus Insulin Glargine U100 in Basal-Bolus Regimens for Type 2 Diabetes in the UK

INTRODUCTION

The aim of this study was to evaluate the short-term cost-utility of insulin degludec (degludec) versus insulin glargine 100 units/mL (glargine U100) for the treatment of type 2 diabetes in the basal-bolus subgroup of the head-to-head cardiovascular (CV) outcome trial, DEVOTE.

METHODS

A cost-utility analysis was conducted over a 2-year time horizon using a decision analytic model to compare costs in patients receiving once daily degludec or glargine U100, both as part of a basal-bolus regimen, in addition to standard care. Clinical outcomes and patient characteristics were taken exclusively from DEVOTE, whilst health-related quality of life utilities and UK-specific costs (expressed in 2016 GBP) were obtained from the literature. The analysis was conducted from the perspective of the National Health Service.

RESULTS

Degludec was associated with mean cost savings of GBP 28.78 per patient relative to glargine U100 in patients with type 2 diabetes at high CV risk. Cost savings were driven by the reduction in risk of diabetes-related complications with degludec, which offset the higher treatment costs relative to glargine U100. Degludec was associated with a mean improvement of 0.0064 quality-adjusted life-years (QALYs) compared with glargine U100, with improvements driven predominantly by lower rates of severe hypoglycemia with degludec versus glargine U100. Improvements in quality-adjusted life expectancy combined with cost neutrality resulted in degludec being dominant over glargine U100. Sensitivity analyses demonstrated that the incremental cost-utility ratio was stable to variations in the majority of model inputs.

CONCLUSION

The present short-term modeling analysis found that for the basal-bolus subgroup of patients in DEVOTE, with a high risk of CV events, degludec was cost neutral (no additional costs) compared with glargine U100 over a 2-year time horizon in the UK setting. Furthermore, there were QALY gains with degludec, particularly due to the reduction in the risk of severe hypoglycemia.

FUNDING

Novo Nordisk A/S.

TRIAL REGISTRATION

ClinicalTrials.gov identifier, NCT01959529.

[The status of glycemic control and hypoglycemia in elderly patients visiting the outpatient department specializing in diabetes]

AIM

The Japan Diabetes Society (JDS)/Japan Geriatrics Society (JGS) Joint Committee reported 'Glycemic Targets for Elderly Patients with Diabetes' in 2016. Based on this recommendation, we aimed to clarify 1) the achievement status of glycemic targets in the elderly and 2) the presence of hypoglycemia in real life among elderly individuals with an HbA1c below the lower limit.

SUBJECTS AND METHODS

[Analysis I] In 326 elderly with diabetes ≥65 years of age visiting the outpatient department specializing in diabetes, the proportions of patients with HbA1c values below the lower limit and the use of drugs potentially associated with severe hypoglycemia (e.g. insulin formulations, sulfonylureas, glinides) were investigated. [Analysis II] Of the patients with HbA1c values below the lower limit, seven were tested for hypoglycemia in real life using a continuous glucose monitoring system (CGM).

RESULTS

[Analysis I] Among the 326 subjects, 235 (72.1%) were using drugs potentially associated with severe hypoglycemia, and 63 (19.3%) had an HbA1c value below the lower limit. [Analysis II] In the seven patients examined using CGM, hypoglycemia was detected in five, all of whom were unaware.

CONCLUSIONS

A considerable number of elderly patients were taking drugs associated with hypoglycemic risks and had an HbA1c value below the lower limit, some of whom actually had hypoglycemia as detected by CGM. Using tools such as CGM, preventive measures against hypoglycemia should be taken.

Risk of hip fractures in patients with depressive disorders: A nationwide, population-based, retrospective, cohort study

Background

Some studies have suggested that depressive disorders may play a vital role in the incidence of hip fractures. However, nationwide data are lacking regarding the association between depressive disorders and hip fractures.

Objective

We aimed to explore the association between depressive disorders and new-onset hip fractures.

Methods

We conducted a retrospective study of 11,207 patients with depressive disorders and 11,207 control patients using Taiwan’s National Health Insurance Research Database. A Cox regression model was used to evaluate the risk of hip fractures in patients with depressive disorders.

Results

The incidence rate ratio of hip fractures between patients with depressive disorders and controls was 1.6 (95% confidence interval [CI] = 1.29–1.99, P < .001). After adjustment for potential confounders in multivariate analysis using the Cox regression model, patients with depressive disorders were found to have 1.34 times higher risk of hip fractures than controls (95% CI = 1.08–1.66, P = .008). Furthermore, age (hazard ratio [HR] = 7.43, 95% CI = 4.94–11.19, P < .001), hypertension (HR = 1.63, 95% CI = 1.17–2.28, P = .004), diabetes mellitus (HR = 1.47, 95% CI = 1.08–1.99, P = .014), cerebrovascular disease (HR = 1.76, 95% CI = 1.31–2.35, P < .001), living in rural areas (HR = 1.88, 95% CI = 1.30–2.70, P = .001), and low monthly income (NT$0–NT$19,000: HR = 4.08, 95% CI = 1.79–9.29, P = .001 and NT$19,100–NT$42,000: HR = 4.09, 95% CI = 1.76–9.49, P = .001) were independent risk factors for new-onset hip fractures in patients with depressive disorders.

Conclusion

Depressive disorders might increase the risk of new-onset hip fractures, particularly in older patients and patients with hypertension, diabetes mellitus, cerebrovascular disease, or low socioeconomic status.

Clinical and Cost Implications of Insulin Degludec in Patients with Type 1 Diabetes and Problematic Hypoglycemia: A Quality Improvement Project

INTRODUCTION

To assess the real-life clinical benefits and cost implications of switching from another basal insulin to insulin degludec (degludec) in patients with type 1 diabetes (T1D) on basal-bolus regimens with recurrent hypoglycemia and/or hypoglycemia unawareness.

METHODS

Patients with T1D who were aged ≥ 18 years, were on a basal-bolus regimen, and had switched to degludec plus bolus insulin for at least 6 months were included. Patients had to have switched to degludec as a result of recurrent hypoglycemia and/or hypoglycemia unawareness.

RESULTS

Six months of follow-up data were available for 42 patients. At 6 months, there was a significant reduction in median (interquartile range) HbA_1c, from 8.6 (8.0-9.3)% [70 (64-78) mmol/mol] to 8.4 (7.9-8.9)% [68 (63-74) mmol/mol]; p < 0.05. Median daily basal insulin dose reduced significantly from 30.0 (14.7-45.0) to 25.5 (14.0-30.2) units; p < 0.0001. Data from hospital records showed reductions in the frequency of episodes of severe hypoglycemia from eight in the 6 months preceding degludec initiation to two in the 6 months following initiation. In the same period, diabetic ketoacidosis (DKA) episodes reduced from two before degludec initiation to no episodes after initiation. No patients reported worsening treatment satisfaction after switching to degludec. Considering the reductions in the basal dose required and the frequency of hypoglycemia episodes, we estimate that switching such patients to degludec from other basal insulins could provide significant savings in direct healthcare costs.

CONCLUSION

In patients with T1D, switching to degludec was associated with an improvement in HbA_1c and reductions in basal insulin dose, severe hypoglycemia, and DKA. When used in appropriate patients, degludec could lead to significant cost savings.

FUNDING

Novo Nordisk.

Are we missing hypoglycaemia? Elderly patients with insulin-treated diabetes present to primary care frequently with non-specific symptoms associated with hypoglycaemia

INTRODUCTION

We assessed if patients with known hypoglycaemia present on other occasions with non-specific symptoms associated with (but not diagnosed as) hypoglycaemia, potentially representing missed hypoglycaemia.

METHODS

335 primary care records (5/2/12-4/2/13) from patients aged >65 (79 on insulin, 85 on sulphonylureas, 121 on metformin only, 50 without diabetes) were assessed for hypoglycaemia episodes and consultations with non-specific symptoms, "hypo clues".

RESULTS

27/79(34%) insulin-treated patients had >1 documented hypoglycaemia episode, compared to 4/85(5%) sulphonylurea-treated patients, 2/121(2%) metformin-only treated patients, and none without diabetes, p<0.001. "Hypo clue" consultations were common: 1.37 consultations/patient/year in insulin-treated patients, 0.98/patient/year in sulphonylurea-treated, 0.97/patient/year in metformin only-treated, and 0.78/patient/year in non-diabetic patients, p=0.34. In insulin-treated patients with documented hypoglycaemia, 20/27(74%) attended on another occasion with a "hypo clue" symptom, compared to 21/52(40%) of those without hypoglycaemia, p=0.008. No significant difference in the other treatment groups. Nausea, falls and unsteadiness were the most discriminatory symptoms: 7/33(21%) with hypoglycaemia attended on another occasion with nausea compared to 14/302(5%) without hypoglycaemia, p=0.002; 10/33(30%) vs 36/302(12%) with falls, p=0.007; and 5/33(15%) vs 13/302(4%) with unsteadiness, p=0.023.

CONCLUSIONS

Non-specific symptoms are common in those >65 years. In insulin-treated patients at high hypoglycaemia risk, nausea, falls and unsteadiness should prompt consideration of hypoglycaemia.

Management of diabetes in older adults

Type 2 diabetes prevalence is high in older adults and is expected to rise in the next decades. Diabetes in the population of frail older adults is accompanied by functional disability, several comorbidities, and premature mortality. A comprehensive geriatric assessment, including functional, cognitive, mental and social status, is advisable for identifying the glycemic targets and glucose-lowering therapies, focused on patient preferences, needs, and risks. The therapeutic options for older adults with diabetes are like those for the adult population. However, the pharmacological treatments must be carefully prescribed and monitored, taking into consideration the patient cognitive capacities, the potentially life-threatening drug-drug interactions, the cardiovascular risk, and with the main goal of avoiding hypoglycemia. Also, a careful nutritional evaluation with appropriate tools, as well as a balanced and periodically monitored physical activity, contribute to an effective tailored care plan, as needed by older adults with diabetes. This review evaluates the currently available hypoglycemic drugs and the current indications to the Italian diabetology community, specifically with regard to the treatment of adults aged 75 years or older with diabetes, including the unmet needs by the guidelines.

Sulfonylureas as Initial Treatment for Type 2 Diabetes and the Risk of Severe Hypoglycemia

PURPOSE

The magnitude of the risk of severe hypoglycemia associated with sulfonylureas as the initial treatment for type 2 diabetes in the real-world setting is unknown. We assessed the risk of severe hypoglycemia associated with initiating monotherapy with sulfonylurea compared with metformin for the treatment of type 2 diabetes.

METHODS

By using the UK Clinical Practice Research Datalink and Hospital Episode Statistics linked to the Office for National Statistics, we identified a cohort of patients with type 2 diabetes who initiated sulfonylureas or metformin monotherapy between April 1, 1998, and December 31, 2012, with follow-up until December 31, 2013. Sulfonylurea users were matched one-to-one to metformin users by high-dimensional propensity scores. Hazard ratios (HRs) and 95% confidence intervals (CIs) of severe hypoglycemia, defined as requiring hospitalization, were estimated using Cox proportional hazards models comparing sulfonylureas with metformin monotherapy.

RESULTS

The study cohort consisted of 14,012 initiators of sulfonylureas matched to 14,012 initiators of metformin. The mean treated follow-up time was 1.41 (standard deviation, 1.84) years. Use of sulfonylurea was associated with an elevated incidence of severe hypoglycemia compared with metformin as the initiating monotherapy for type 2 diabetes (incidence rate, 2.4/1000 person-years; 95% CI, 1.90-2.90; HR, 4.53; 95% CI, 2.76-7.45).

CONCLUSIONS

Sulfonylureas, when prescribed as the initiating monotherapy for the treatment of type 2 diabetes, is associated with a 4.5-fold increase in the risk of severe hypoglycemia. Given the negative consequences of this outcome, clinicians should consider alternative hypoglycemic agents when metformin is not tolerated or contraindicated.

INSULIN GLARGINE 300 U/ML IS ASSOCIATED WITH LESS WEIGHT GAIN WHILE MAINTAINING GLYCEMIC CONTROL AND LOW RISK OF HYPOGLYCEMIA COMPARED WITH INSULIN GLARGINE 100 U/ML IN AN AGING POPULATION WITH TYPE 2 DIABETES

OBJECTIVE

Assess efficacy, hypoglycemia, and weight gain in patients with type 2 diabetes (T2D) treated with insulin glargine 300 U/mL (Gla-300) or 100 U/mL (Gla-100) across different age groups.

METHODS

Pooled data were generated for patients randomized to Gla-300 or Gla-100 in the EDITION 2 (NCT01499095) and 3 (NCT01676220) studies. In 4 age groups (<55, ≥55 to <60, ≥60 to <65, ≥65 years), glycated hemoglobin A1C (A1C), percentage of patients reaching A1C <7.5% (58 mmol/mol), weight change, confirmed hypoglycemia (blood glucose ≤70 mg/dL), and/or severe hypoglycemia (events requiring third-party assistance) were analyzed with descriptive statistics and logistic, binomial, and analysis of covariance regression modeling.

RESULTS

A1C reductions from baseline and proportions of patients at target were similar for Gla-300 and Gla-100 across all age groups at 6 and 12 months, but hypoglycemia incidence and event rate were lower with Gla-300 at 6 (both P<.001) and 12 months ( P<.001 and P = .005, respectively). Patients on Gla-300 gained less weight than those on Gla-100 at 6 ( P = .027) and 12 months ( P = .021). Changes in weight and daily weight-adjusted insulin dose decreased with increasing age at 6 ( P<.001 and P = .017, respectively) and 12 months ( P<.001 and P = .011, respectively).

CONCLUSION

Older patients with T2D may benefit from treatment with Gla-300, which is associated with a lower hypoglycemia rate and less weight gain with similar efficacy compared with Gla-100.

ABBREVIATIONS

A1C = glycated hemoglobin A1C BMI = body mass index Gla-100 = insulin glargine 100 U/mL Gla-300 = insulin glargine 300 U/mL OAD = oral antidiabetes drug T2D = type 2 diabetes.

Increased risk of hip fractures in Korean patients with type 2 diabetes: a 6-year nationwide population-based study

We compared the incidence and risk of hip fractures in Korean patients with type 2 diabetes and non-diabetic subjects in a nationwide population-based study. The study included 17,110 patients diagnosed with type 2 diabetes in 2004 and 34,220 randomly selected age- and sex-matched control subjects drawn from the Korean National Health Insurance Research database. Fracture events occurring between 2004 and 2010 were identified from medical claims data. The adjusted hazard ratios (HRs) and 95% confidence intervals (CIs) for fractures associated with diabetes were calculated. A total of 3855 fractures of any type (3029 in females and 826 in males) and 493 hip fractures (353 in females and 140 in males) were observed in 51,330 subjects over a 6-year follow-up period. The risk of hip fractures was significantly higher in female (HR 1.73; 95% CI 1.38-2.16) and male (HR 1.84; 95% CI 1.29-2.63) diabetics than in non-diabetic controls after adjusting for multiple confounders. Stratification by age revealed that the adjusted HR for hip fractures was highest in diabetic patients aged 50-64 years (HR 2.54 in females and 2.70 in males) and decreased with increasing age. The risk of other fractures did not differ between the groups. Korean males and females with type 2 diabetes are at an increased risk of hip fractures compared with non-diabetic individuals. Osteoporosis assessments and fracture prevention strategies are necessary for Koreans with type 2 diabetes.

Bone Metabolism and Fracture Risk in Diabetes Mellitus

Individuals with Type 1 diabetes mellitus (T1DM) and type 2 diabetes mellitus (T2DM) are at increased risk for fragility fractures. Bone mineral density (BMD) is decreased in T1DM but often normal or even elevated in T2DM when compared with age-matched non-DM populations. However, bone turnover is decreased in both T1DM and T2DM. The pathophysiologic mechanisms leading to bone fragility is multifactorial, and potentially leads to reduced bone formation, altered bone microstructure and decreased bone strength. Interestingly, different antidiabetic treatments may influence fracture risk due to effects on glycemic control, triggering of hypoglycemic events or osteoblastogenesis.