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Gerstein HC, Shah R. Cardiovascular Outcomes Trials of Glucose-Lowering Drugs or Strategies in Type 2 Diabetes. Endocrinol Metab Clin North Am 2018; 47:97-116. [PMID: 29407059 DOI: 10.1016/j.ecl.2017.10.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
As recently as 20 years ago there were no randomized controlled trials of potentially cardiovascular protective therapies in people with type 2 diabetes. The ongoing cardiovascular trials bring needed evidence. Both primary and subsidiary analyses have transformed diabetes from a largely eminence based specialty to one that is firmly evidence based. These studies have provided evidence supporting glucose-lowering drugs for patients with cardiovascular risk factors. Randomized controlled trials such as those described here will continue to challenge assumptions and create new approaches and paradigms that can be pursued to reduce and hopefully eliminate serious cardiovascular and other consequences of diabetes.
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Affiliation(s)
- Hertzel C Gerstein
- Department of Medicine, Population Health Research Institute, McMaster University, Hamilton Health Sciences, HSC 3V38, 1280 Main Street West, Hamilton, Ontario L8S 4K1, Canada.
| | - Reema Shah
- Department of Medicine, Population Health Research Institute, McMaster University, Hamilton Health Sciences, HSC 3V38, 1280 Main Street West, Hamilton, Ontario L8S 4K1, Canada
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Abstract
The American Diabetes Association (ADA) "Standards of Medical Care in Diabetes" includes 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, please refer to the Standards of Care Introduction Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.
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53
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Rutter MK. Devoting attention to glucose variability and hypoglycaemia in type 2 diabetes. Diabetologia 2018; 61:43-47. [PMID: 28913602 DOI: 10.1007/s00125-017-4421-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2017] [Accepted: 08/23/2017] [Indexed: 12/15/2022]
Abstract
In the Trial Comparing Cardiovascular Safety of Insulin Degludec vs Insulin Glargine in Patients with Type 2 Diabetes at High Risk of Cardiovascular Events (DEVOTE), insulin degludec was non-inferior to insulin glargine in terms of cardiovascular events and mortality. However, there were lower rates of severe hypoglycaemia with insulin degludec. DEVOTE investigators now extend these findings by presenting the results of two observational epidemiological analyses based on trial data. In the first of these analyses (DEVOTE 2), Zinman et al (Diabetologia DOI: 10.1007/s00125-017-4423-z ) demonstrate that, compared with individuals with lower day-to-day fasting glycaemic variability, those with higher day-to-day fasting glycaemic variability had a similar risk of major adverse cardiovascular events (MACE) but a higher risk of severe hypoglycaemia and all-cause mortality. In the second analysis (DEVOTE 3), Pieber et al (Diabetologia DOI: 10.1007/s00125-017-4422-0 ) found that individuals who experienced severe hypoglycaemia had a similar risk of MACE compared with those who never experienced severe hypoglycaemia, but had a more than twofold higher risk of subsequent total mortality and cardiovascular disease (CVD) mortality. The strengths of these studies relate to the availability of high-quality prospective data on adjudicated severe hypoglycaemia, MACE and mortality events in a large number of high-risk insulin-treated individuals with type 2 diabetes. Limitations include the observational nature of the data and thus residual confounding remains possible. Furthermore, the short duration of the trial resulted in limited statistical power for some analyses. Therefore, whilst DEVOTE 2 and DEVOTE 3 raise awareness of the mortality risks associated with glucose variability and severe hypoglycaemia in high-risk, insulin-treated patients with type 2 diabetes, they cannot clarify causal relationships. Preventing severe hypoglycaemia in those with type 2 diabetes should already be a priority in clinical practice. However, findings from future clinical trials are needed to guide physicians on whether it is beneficial to target glucose variability, and risk for severe hypoglycaemia, to reduce the risks for CVD events and mortality in these individuals.
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Affiliation(s)
- Martin K Rutter
- Division of Diabetes, Endocrinology and Gastroenterology, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK.
- Manchester Diabetes Centre, 193 Hathersage Road, Central Manchester University hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, M13 0JE, UK.
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Peng CS, Cao YA, Tian YH, Zhang WL, Xia J, Yang L. Features of continuous glycemic profile and glycemic variability in patients with obstructive sleep apnea syndrome. Diabetes Res Clin Pract 2017; 134:106-112. [PMID: 29096240 DOI: 10.1016/j.diabres.2017.08.010] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2017] [Revised: 07/24/2017] [Accepted: 08/15/2017] [Indexed: 12/18/2022]
Abstract
AIMS To investigate glycemic variability (GV) in Obstructive Sleep Apnea Syndrome (OSAS) patients by monitoring continuous blood glucose profile. METHODS OSAS group (n=86) and normal control group (n=40) were included. Continuous blood glucose was monitored. The relationship of GV, insulin resistance index (IRI) and the respiratory disturbance index (AHI) were analyzed. RESULTS The daily average blood glucose level was significantly higher in the OSAS patients than in the control group (6.31±0.61vs. 4.94±0.78; P<0.01). The postprandial glycemic peaks in the OSAS patients were significantly higher and prolonged. The indicators of GV were all significantly higher in the OSAS patients, including blood glucose fluctuation coefficient (BGFC, 1.93±0.71vs. 1.21±0.38, P<0.05), mean amplitude of glycemic excursions (MAGE, 4.18±0.65vs. 2.18±0.48; P<0.05) and night mean amplitude of glycemic excursions (NMAGE, 2.00±0.53vs. 1.11±0.43; P<0.05). Pearson correlation analysis showed that among the OSAS patients, the severity of OSAS (AHI) was positively correlated with the IRI (r=0.310); and the GV indicators (MAGE and NMAGE) were positively correlated with IRI and AHI (r=0.318 and 0.349, respectively) (P<0.01 or 0.001). CONCLUSIONS Continuous glycemic spectrum and GV provide comprehensive glycemic profiles and may reveal important aspects of glucose metabolism abnormality beyond regular examinations, and are therefore of particular significance for glycemic management in OSAS patients.
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Affiliation(s)
- Chao-Sheng Peng
- Naval General Hospital of PLA, Special Care Medical Center, Beijing 100048, China
| | - Yue-An Cao
- Naval General Hospital of PLA, Special Care Medical Center, Beijing 100048, China
| | - Yu-Hong Tian
- Naval General Hospital of PLA, Special Care Medical Center, Beijing 100048, China
| | - Wen-Luo Zhang
- Naval General Hospital of PLA, Special Care Medical Center, Beijing 100048, China
| | - Jing Xia
- Naval General Hospital of PLA, Special Care Medical Center, Beijing 100048, China
| | - Lu Yang
- Naval General Hospital of PLA, Special Care Medical Center, Beijing 100048, China.
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Owens DR, Monnier L, Hanefeld M. A review of glucagon-like peptide-1 receptor agonists and their effects on lowering postprandial plasma glucose and cardiovascular outcomes in the treatment of type 2 diabetes mellitus. Diabetes Obes Metab 2017; 19:1645-1654. [PMID: 28474401 PMCID: PMC5697665 DOI: 10.1111/dom.12998] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2016] [Revised: 04/28/2017] [Accepted: 04/28/2017] [Indexed: 02/06/2023]
Abstract
Type 2 diabetes mellitus (T2DM) is an independent risk factor for cardiovascular (CV) comorbidities, with CV disease being the most common cause of death in adults with T2DM. Although glucocentric therapies may improve glycaemic control (as determined by glycated haemoglobin levels), evidence suggests that this approach alone has limited beneficial effects on CV outcomes relative to improvements in lipid and blood pressure control. This may be explained in part by the fact that current antidiabetic treatment regimens primarily address overall glycaemia and/or fasting plasma glucose, but not the postprandial plasma glucose (PPG) excursions that have a fundamental causative role in increasing CV risk. This literature review evaluates the relationship between PPG and the risk of CV disease, discusses the treatment of T2DM with glucagon-like peptide-1 receptor agonists (GLP-1 RAs) and examines the associated CV outcomes. The literature analysis suggests that exaggerated PPG excursions are a risk factor for CV disease because of their adverse pathophysiologic effects on the vasculature, resulting in increased all-cause and CV-related mortality. Although GLP-1 RAs are well established in the current T2DM treatment paradigm, a subgroup of these compounds has a particularly pronounced, persistent and short-lived effect on gastric emptying and, hence, lower PPG substantially. However, current long-term data on CV outcomes with GLP-1 RAs are contradictory, with both beneficial and adverse effects having been reported. This review explores the opportunity to direct treatment towards controlling PPG excursions, thereby improving not only overall glycaemic control but also CV outcomes.
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Affiliation(s)
- David R. Owens
- Diabetes Research Group, Institute of Life Sciences College of MedicineSwansea UniversitySwanseaUK
| | - Louis Monnier
- Laboratory of Human Nutrition and Atherosclerosis, Institute of Clinical ResearchUniversity of MontpellierMontpellierFrance
| | - Markolf Hanefeld
- Study Centre “Professor Hanefeld”GWT‐Technical University DresdenDresdenGermany
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Yacoub T. Impact of improving postprandial glycemic control with intensifying insulin therapy in type 2 diabetes. Postgrad Med 2017; 129:791-800. [PMID: 29032696 DOI: 10.1080/00325481.2017.1389601] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Worldwide, many people with type 2 diabetes are not at recommended glycemic targets and remain at increased risk of microvascular and macrovascular complications. Reaching recommended glycemic targets requires normalizing both fasting and postprandial glucose (PPG). For some patients, this will require addition of a prandial insulin delivered by injection to control PPG excursions. Evidence from epidemiological studies suggests an association between postprandial hyperglycemia and cardiovascular disease, and thus, expert guidelines recommend that treatment for elevated PPG not be delayed. Indeed, studies have demonstrated that PPG makes the greatest contribution to HbA1c in patients who are approaching, but have not yet reached HbA1c <7.0%. Appropriately timed exposure of the liver to insulin is critical in suppressing hepatic glucose output (and therefore PPG levels) after a meal. Rapid-acting insulin analogs, with their faster onset and shorter duration of action, offer advantages over regular human insulin. Unfortunately, even with improved pharmacokinetic/pharmacodynamic characteristics, rapid-acting insulin analogs are still unable to fully reproduce the rapid release of insulin into the portal circulation and suppression of hepatic glucose output that occurs in the individual without diabetes after starting a meal. The next generation of rapid-acting insulin analogs will have an even more favorable pharmacokinetic profile that should allow patients to further improve glycemic control. Continuous subcutaneous insulin infusion (CSII) represents another option for intensifying therapy and improving postprandial control in some patients, and studies have shown that the benefits are sustainable long-term. However, it is currently unclear which patients stand to benefit the most from the extra expense and complexity of a CSII regimen, and further studies are needed.
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Affiliation(s)
- Tamer Yacoub
- a Endocrinology Division , Prima-Care Medical Center , Fall River , MA , USA
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57
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Marx N, McGuire DK, Perkovic V, Woerle HJ, Broedl UC, von Eynatten M, George JT, Rosenstock J. Composite Primary End Points in Cardiovascular Outcomes Trials Involving Type 2 Diabetes Patients: Should Unstable Angina Be Included in the Primary End Point? Diabetes Care 2017; 40:1144-1151. [PMID: 28830955 DOI: 10.2337/dc17-0068] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2017] [Accepted: 05/26/2017] [Indexed: 02/03/2023]
Abstract
Reductions in cardiovascular (CV) outcomes in recently reported trials, along with the recent approval by the U.S. Food and Drug Administration of an additional indication for empagliflozin to reduce the risk of CV death in type 2 diabetes patients with evidence of CV disease, have renewed interest in CV outcome trials (CVOTs) of glucose-lowering drugs. Composite end points are a pragmatic necessity in CVOTs to ensure that sample size and duration of follow-up remain reasonable. Combining clinical outcomes into a composite end point increases the numbers of events ascertained and thus statistical power and precision. Historically, composite CV end points in diabetes trials have included a larger number of components, while more recent CVOTs almost exclusively use a composite of CV death, nonfatal myocardial infarction (MI), and nonfatal stroke-the so-called three-point major adverse CV event (3P-MACE) composite-or add hospitalization for unstable angina (HUA) to these three outcomes (4P-MACE). The inclusion of HUA increases the number of events for analysis, but noteworthy disadvantages include clinical subjectivity in ascertainment of HUA and its lower prognostic relevance compared with CV death, MI, or stroke. Furthermore, results from recent CVOTs indicate that glucose-lowering agents seem to have minimal impact on HUA. Its inclusion therefore potentially favors a shift of the hazard ratio (HR) toward the null, which is especially problematic in trials designed to demonstrate noninferiority. The primary outcome of 3P-MACE may offer a better balance than 4P-MACE between statistical efficiency, operational complexity, the likelihood of diagnostic precision (and therefore clinical relevance) for each of the component outcomes, clinical importance, and the aim to adequately capture any potential treatment effect of the intervention. Nevertheless, as individual medications may mechanistically differ in their impact on CV outcomes, no particular individual or composite end point can be seen as a "gold standard" for CVOTs of all glucose-lowering drugs.
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Affiliation(s)
- Nikolaus Marx
- Department of Internal Medicine I, University Hospital Aachen, RWTH Aachen University, Aachen, Germany
| | - Darren K McGuire
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX
| | - Vlado Perkovic
- The George Institute for Global Health, University of Sydney, Sydney, Australia
| | | | - Uli C Broedl
- Boehringer Ingelheim Pharma GmbH & Co. KG, Ingelheim, Germany
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Burggraaf B, Castro Cabezas M. Interventions in type 2 diabetes mellitus and cardiovascular mortality-An overview of clinical trials. Eur J Intern Med 2017; 42:1-15. [PMID: 28554780 DOI: 10.1016/j.ejim.2017.04.017] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2017] [Revised: 04/22/2017] [Accepted: 04/28/2017] [Indexed: 01/12/2023]
Abstract
Diabetes mellitus type 2 (T2DM) has been associated with an increased cardiovascular risk. Improving glycaemia or other traditional cardiovascular risk factors may reduce cardiovascular risk in patients with T2DM. However, single risk intervention in T2DM has not provided convincing evidence in the reduction of cardiovascular risk. The aim of this paper is to provide an overview of clinical trials involving reduction of cardiovascular outcomes in patients with T2DM. Trials with glucose lowering therapies have shown conflicting results. Intensive therapy to reduce glycaemia has shown some benefit on composite cardiovascular endpoints but these benefits take a longer period to emerge. Recent studies with empagliflozin and glucagon-like peptide-1 (GLP-1) agonists show promising results, but the mechanisms are most likely not mediated by improved glycaemia, given the relatively rapid effects. Both LDL-cholesterol and blood pressure reduction have been proven by large meta-analysis to reduce both cardiovascular events and mortality in all patients with T2DM. Treatment of microalbuminuria and anti-platelet therapy have only been proven in diabetic patients with increased cardiovascular risk. Classical lifestyle interventions have been disappointing with respect to cardiovascular outcome, possibly due to limited weight reduction. So far, the strongest evidence lies on bariatric surgery and a multifactorial intervention to reduce mortality and cardiovascular events in the long term.
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Affiliation(s)
- Benjamin Burggraaf
- Department of Internal Medicine, Center for Diabetes and Vascular Medicine; Franciscus Gasthuis, Rotterdam, The Netherlands.
| | - Manuel Castro Cabezas
- Department of Internal Medicine, Center for Diabetes and Vascular Medicine; Franciscus Gasthuis, Rotterdam, The Netherlands
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59
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Takao T, Suka M, Yanagisawa H, Iwamoto Y. Impact of postprandial hyperglycemia at clinic visits on the incidence of cardiovascular events and all-cause mortality in patients with type 2 diabetes. J Diabetes Investig 2017; 8:600-608. [PMID: 27978599 PMCID: PMC5497051 DOI: 10.1111/jdi.12610] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2016] [Revised: 11/27/2016] [Accepted: 12/06/2016] [Indexed: 12/24/2022] Open
Abstract
AIMS/INTRODUCTION We evaluated the impact of postprandial hyperglycemia at clinic visits on the incidence of cardiovascular diseases (CVD) and all-cause mortality independently of mean glycosylated hemoglobin in type 2 diabetes patients in a real-world setting. MATERIALS AND METHODS The present retrospective observational cohort study included 646 type 2 diabetes patients. All of the participants had their initial consultations at the Institute for Diabetes Care and Research, Asahi Life Foundation affiliated Marunouchi Hospital, Tokyo, Japan, during the period from 1995 to 1996, visited the clinic ≥4 times, had their 2-h post-breakfast blood glucose (2h-PBBG) levels measured and were followed up for ≥1 year. The 646 patients were followed up for survival. Of the 646 patients, 618 had no history of CVD at the first visit and had measured 2h-PBBG until the first CVD onset or censorings. These two cohorts were followed up through June 2012, and subsequently questionnaires were mailed. Multivariate Cox proportional hazard models were used to evaluate the risk of CVD incidence and death. RESULTS CVD occurred in 78 patients, and 56 patients died. The median follow-up periods of the CVD cohort and the mortality cohort were 15.6 and 15.9 years, respectively. The mean 2h-PBBG is a significant predictor of the CVD incidence and all-cause mortality after adjusting for the mean glycosylated hemoglobin, the number of 2h-PBBG measurements, age, sex and classical risk factors. CONCLUSIONS Postprandial hyperglycemia represented by the mean level of 2h-PBBG at clinic visits is associated with CVD incidence and all-cause mortality independently of the mean glycosylated hemoglobin level in type 2 diabetes patients. Prospective interventional trials are warranted to confirm the present findings.
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Affiliation(s)
- Toshiko Takao
- Division of Diabetes and MetabolismThe Institute for Adult DiseasesAsahi Life FoundationTokyoJapan
| | - Machi Suka
- Department of Public Health and Environmental MedicineThe Jikei University School of MedicineTokyoJapan
| | - Hiroyuki Yanagisawa
- Department of Public Health and Environmental MedicineThe Jikei University School of MedicineTokyoJapan
| | - Yasuhiko Iwamoto
- Division of Diabetes and MetabolismThe Institute for Adult DiseasesAsahi Life FoundationTokyoJapan
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Tun NN, Arunagirinathan G, Munshi SK, Pappachan JM. Diabetes mellitus and stroke: A clinical update. World J Diabetes 2017; 8:235-248. [PMID: 28694925 PMCID: PMC5483423 DOI: 10.4239/wjd.v8.i6.235] [Citation(s) in RCA: 80] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2016] [Revised: 02/26/2017] [Accepted: 05/05/2017] [Indexed: 02/05/2023] Open
Abstract
Cardiovascular disease including stroke is a major complication that tremendously increases the morbidity and mortality in patients with diabetes mellitus (DM). DM poses about four times higher risk for stroke. Cardiometabolic risk factors including obesity, hypertension, and dyslipidaemia often co-exist in patients with DM that add on to stroke risk. Because of the strong association between DM and other stroke risk factors, physicians and diabetologists managing patients should have thorough understanding of these risk factors and management. This review is an evidence-based approach to the epidemiological aspects, pathophysiology, diagnostic work up and management algorithms for patients with diabetes and stroke.
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61
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Wright LAC, Hirsch IB. Metrics Beyond Hemoglobin A1C in Diabetes Management: Time in Range, Hypoglycemia, and Other Parameters. Diabetes Technol Ther 2017; 19:S16-S26. [PMID: 28541136 PMCID: PMC5444503 DOI: 10.1089/dia.2017.0029] [Citation(s) in RCA: 119] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
We review clinical instances in which A1C should not be used and reflect on the use of other glucose metrics that can be used, in substitution of or in combination with A1C and SMBG, to tailor an individualized approach that will result in better outcomes and patient empowerment.
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Affiliation(s)
- Lorena Alarcon-Casas Wright
- Department of Medicine, Division of Metabolism, Endocrinology, and Nutrition, University of Washington Medical Center/Roosevelt , Seattle, Washington
| | - Irl B Hirsch
- Department of Medicine, Division of Metabolism, Endocrinology, and Nutrition, University of Washington Medical Center/Roosevelt , Seattle, Washington
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Pasquel FJ, Gianchandani R, Rubin DJ, Dungan KM, Anzola I, Gomez PC, Peng L, Hodish I, Bodnar T, Wesorick D, Balakrishnan V, Osei K, Umpierrez GE. Efficacy of sitagliptin for the hospital management of general medicine and surgery patients with type 2 diabetes (Sita-Hospital): a multicentre, prospective, open-label, non-inferiority randomised trial. Lancet Diabetes Endocrinol 2017; 5:125-133. [PMID: 27964837 DOI: 10.1016/s2213-8587(16)30402-8] [Citation(s) in RCA: 111] [Impact Index Per Article: 15.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2016] [Revised: 10/29/2016] [Accepted: 11/01/2016] [Indexed: 12/11/2022]
Abstract
BACKGROUND The role of incretin-based drugs in the treatment of patients with type 2 diabetes admitted to hospital has not been extensively assessed. In this study, we compared the safety and efficacy of a dipeptidyl peptidase-4 inhibitor (sitagliptin) plus basal insulin with a basal-bolus insulin regimen for the management of patients with type 2 diabetes in general medicine and surgery in hospitals. METHODS We did a multicentre, prospective, open-label, non-inferiority randomised clinical trial (Sita-Hospital) in five hospitals in the USA, enrolling patients aged 18-80 years with type 2 diabetes and a random blood glucose concentration of 7·8-22·2 mmol/L who were being treated with diet or oral antidiabetic drugs or had a total daily insulin dose of 0·6 units per kg or less, admitted to general medicine and surgery services. We randomly assigned patients (1:1) to receive either sitagliptin plus basal glargine once daily (the sitagliptin-basal group) or a basal-bolus regimen with glargine once daily and rapid-acting insulin lispro or aspart before meals (the basal-bolus group) during the hospital stay. All other antidiabetic drugs were discontinued on admission. The randomisation was achieved by computer-generated tables with block stratification according to randomisation blood glucose concentrations (ie, higher or lower than 11·1 mmol/L). The primary endpoint of the trial was non-inferiority in mean differences between groups in their daily blood glucose concentrations during the first 10 days of therapy (point-of-care measurements; non-inferiority was deemed a difference <1 mmol/L). The safety endpoints included hypoglycaemia and uncontrolled hyperglycaemia leading to treatment failure. All participants who received at least one dose of study drug were included in the analysis. This study is registered with ClinicalTrials.gov, number NCT01845831. FINDINGS Between Aug 23, 2013, and July 27, 2015, we recruited 279 patients, and randomly assigned 277 to treatment; 138 to sitagliptin-basal and 139 to basal-bolus. The length of stay in hospital was similar for both groups (median 4 days [IQR 3-8] vs 4 [3-8] days, p=0·54). The mean daily blood glucose concentration in the sitagliptin-basal group (9·5 mmol/L [SD 2·7]) was not inferior to that in the basal-bolus group 9·4 mmol/L [2·7]) with a mean blood glucose difference of 0·1 mmol/L (95% CI -0·6 to 0·7). No deaths occurred in this trial. Treatment failure occurred in 22 patients (16%) in the sitagliptin-basal group versus 26 (19%) in the basal-bolus group (p=0·54). Hypoglycaemia occurred in 13 patients (9%) in the sitagliptin-basal group and in 17 (12%) in the basal-bolus group (p=0·45). No differences in hospital complications were noted between groups. Seven patients (5%) developed acute kidney injury in the sitagliptin-basal group and six (4%) in the basal-bolus group. One patient (0·7%) developed acute pancreatitis (in the basal-bolus group). INTERPRETATION The trial met the non-inferiority threshold for the primary endpoint, because there was no significant difference between groups in mean daily blood glucose concentrations. Treatment with sitagliptin plus basal insulin is as effective and safe as, and a convenient alternative to, the labour-intensive basal-bolus insulin regimen for the management of hyperglycaemia in patients with type 2 diabetes admitted to general medicine and surgery services in hospital in the non-intensive-care setting. FUNDING Merck.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Tim Bodnar
- University of Michigan, Ann Arbor, MI, USA
| | | | | | - Kwame Osei
- Ohio State University, Columbus, OH, USA
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The Landscape of Glucose-Lowering Therapy and Cardiovascular Outcomes: From Barren Land to Metropolis. BIOMED RESEARCH INTERNATIONAL 2017; 2017:9257930. [PMID: 29270438 PMCID: PMC5705897 DOI: 10.1155/2017/9257930] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/14/2017] [Revised: 08/24/2017] [Accepted: 09/14/2017] [Indexed: 12/11/2022]
Abstract
The choice of glucose-lowering therapy (GLT) has expanded to include 11 different classes in addition to insulin. Since the 2008 Food and Drug Administration guidance for industry and mandate of demonstrating cardiovascular (CV) safety prior to any new drug approval, there were several trials primarily conducted to establish that goal. Some had neutral effects, while there were positively beneficial outcomes with more recent studies. Hospitalization for congestive heart failure has also been a heterogeneous finding among the different classes of GLT, with drug outcomes ranging from risky to beneficial. The current review selectively focuses on the evidence for CV outcomes for each class of GLT and summarizes the existing guidelines with regard to these drugs in heart disease. Moreover, it illustrates the dynamic status in the development of evidence. Finally, the review enables healthcare providers to formulate a plan for hypoglycemic therapy which will optimize CV health, in a patient-centered manner.
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Gamble JM, Chibrikov E, Twells LK, Midodzi WK, Young SW, MacDonald D, Majumdar SR. Association of insulin dosage with mortality or major adverse cardiovascular events: a retrospective cohort study. Lancet Diabetes Endocrinol 2017; 5:43-52. [PMID: 27865756 DOI: 10.1016/s2213-8587(16)30316-3] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2016] [Revised: 10/03/2016] [Accepted: 10/13/2016] [Indexed: 12/25/2022]
Abstract
BACKGROUND Existing studies have shown conflicting evidence regarding the safety of exogenous insulin therapy in patients with type 2 diabetes. In particular, observational studies have reported an increased risk of death and cardiovascular disease among users of higher versus lower doses of insulin. We aimed to quantify the association between increasing dosage of insulin exposure and death and cardiovascular events, while taking into account time-dependent confounding and mediation that might have biased previous studies. METHODS We did a cohort study using primary care records from the UK-based Clinical Practice Research Datalink (CPRD). New users of metformin monotherapy were identified in the period between Jan 1, 2001, and Dec 31, 2012. We then identified those in this group with a new prescription for insulin. Insulin exposure was categorised into groups according to the mean dose (units) per day within 180-day time segments throughout each patient's follow-up. Relative differences in mortality and major adverse cardiovascular events (non-fatal myocardial infarction, non-fatal stroke, cardiovascular-related mortality) were assessed using conventional multivariable Cox proportional hazards models. Marginal structural models were then applied to reduce bias introduced by the time-dependent confounders affected by previous treatment. FINDINGS We identified 165 308 adults with type 2 diabetes in the CPRD database. After applying our exclusion criteria, 6072 (mean age 60 years [SD 12·5], 3281 [54%] men, mean HbA1c 8·5% [SD 1·75], and median follow-up 3·1 years [IQR 1·7-5·3) were new add-on insulin users and were included in the study cohort; 3599 were new add-on insulin users and were included in the subcohort linked to hospital records and death certificate information. Crude mortality rates were comparable between insulin dose groups; <25 units per day (46 per 1000 person-years), 25 to <50 units per day (39 per 1000 person-years), 50 to <75 units per day (27 per 1000 person-years), 75 to <100 units per day (34 per 1000 person-years), and at least 100 units per day (32 per 1000 person-years; p>0·05 for all; mean rate of 31 deaths per 1000 person-years [95% CI 29-33]). With adjustment for baseline covariates, mortality rates were higher for increasing insulin doses: less than 25 units per day [reference group]; 25 to <50 units per day, hazard ratio (HR) 1·41 [95% CI 1·12-1·78]; 50 to <75 units per day, 1·37 [1·04-1·80]; 75 to <100 units per day, 1·85 [1·35-2·53]; and at least 100 units per day, 2·16 [1·58-2·93]. After applying marginal structural models, insulin dose was not associated with mortality in any group (p>0·1 for all). INTERPRETATION In conventional multivariable regression analysis, higher insulin doses are associated with increased mortality after adjustment for baseline covariates. However, this effect seems to be confounded by time-dependent factors such as insulin exposure, glycaemic control, bodyweight gain, and the occurrence of cardiovascular and hypoglycaemic events. This study provides reassurance of the overall safety of insulin use in the treatment of type 2 diabetes and contributes to our understanding of the contrasting conclusions from non-randomised and randomised studies regarding dose-dependent effects of insulin on cardiovascular events and mortality. FUNDING Canadian Institutes of Health Research, Heart and Stroke Foundation of Canada, and the Newfoundland and Labrador Research and Development Corporation.
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Affiliation(s)
- John-Michael Gamble
- School of Pharmacy, Memorial University of Newfoundland, St John's, NL, Canada.
| | - Eugene Chibrikov
- School of Pharmacy, Memorial University of Newfoundland, St John's, NL, Canada
| | - Laurie K Twells
- School of Pharmacy, Memorial University of Newfoundland, St John's, NL, Canada; Faculty of Medicine, Memorial University of Newfoundland, St John's, NL, Canada
| | - William K Midodzi
- Faculty of Medicine, Memorial University of Newfoundland, St John's, NL, Canada
| | - Stephanie W Young
- School of Pharmacy, Memorial University of Newfoundland, St John's, NL, Canada
| | - Don MacDonald
- School of Pharmacy, Memorial University of Newfoundland, St John's, NL, Canada; Faculty of Medicine, Memorial University of Newfoundland, St John's, NL, Canada; Newfoundland and Labrador Centre for Health Information, St John's, NL, Canada
| | - Sumit R Majumdar
- Division of General Internal Medicine, Department of Medicine, University of Alberta, Edmonton, AB, Canada
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Khunti K, Bellary S, Karamat MA, Patel K, Patel V, Jones A, Gray J, Shepherd P, Hanif W. Representation of people of South Asian origin in cardiovascular outcome trials of glucose-lowering therapies in Type 2 diabetes. Diabet Med 2017; 34:64-68. [PMID: 26926478 DOI: 10.1111/dme.13103] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2015] [Revised: 01/18/2016] [Accepted: 02/25/2016] [Indexed: 11/29/2022]
Abstract
AIMS Our aim was to investigate the proportional representation of people of South Asian origin in cardiovascular outcome trials of glucose-lowering drugs or strategies in Type 2 diabetes, noting that these are among the most significant pieces of evidence used to formulate the guidelines on which clinical practice is largely based. METHODS We searched for cardiovascular outcome trials in Type 2 diabetes published before January 2015, and extracted data on the ethnicity of participants. These were compared against expected values for proportional representation of South Asian individuals, based on population data from the USA, from the UK, and globally. RESULTS Twelve studies met our inclusion criteria and, of these, eight presented a sufficiently detailed breakdown of participant ethnicity to permit numerical analysis. In general, people of South Asian origin were found to be under-represented in trials compared with UK and global expectations and over-represented compared with US expectations. Among the eight trials for which South Asian representation could be reliably estimated, seven under-represented this group relative to the 11.2% of the UK diabetes population estimated to be South Asian, with the representation in these trials ranging from 0.0% to 10.0%. CONCLUSIONS Clinicians should exercise caution when generalizing the results of trials to their own practice, with regard to the ethnicity of individuals. Efforts should be made to improve reporting of ethnicity and improve diversity in trial recruitment, although we acknowledge that there are challenges that must be overcome to make this a reality.
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Affiliation(s)
- K Khunti
- Leicester Diabetes Centre, University of Leicester, Leicester, UK
| | - S Bellary
- Aston Research Centre for Healthy Ageing, Aston University, Birmingham, UK
| | - M A Karamat
- Heart of England NHS Foundation Trust, Birmingham, UK
| | - K Patel
- Heart of England NHS Foundation Trust, Birmingham, UK
| | - V Patel
- Warwick Medical School, University of Warwick, Coventry, UK
| | - A Jones
- SB Communications Group, London, UK
| | - J Gray
- SB Communications Group, London, UK
| | | | - W Hanif
- University Hospital Birmingham, Birmingham, UK
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Miñambres I, Pérez A. Is there a justification for classifying GLP-1 receptor agonists as basal and prandial? Diabetol Metab Syndr 2017; 9:6. [PMID: 28115994 PMCID: PMC5241936 DOI: 10.1186/s13098-017-0204-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2016] [Accepted: 01/06/2017] [Indexed: 12/18/2022] Open
Abstract
Several GLP-1 receptor agonists are currently available for treatment of type 2 diabetic patients. Based on their pharmacokinetic/pharmacodynamic profile, these drugs are classified as short-acting GLP-1 receptor agonists (exenatide and lixisenatide) or long-acting GLP-1 receptor agonists (exenatide-LAR, liraglutide, albiglutide, and dulaglutide). In clinical practice, they are also classified as basal or prandial GLP-1 receptor agonists to differentiate between patients who would benefit more from one or another based on characteristics such as previous treatment and the predominance of fasting or postprandial hyperglycemia. In the present article we examine available data on the pharmacokinetic characteristics of the various GLP-1 agonists and compare their effects with respect to the main parameters used to evaluate glycemic control. The article also analyzes whether the differences between the different GLP-1 agonists justify their classification as basal or prandial.
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Affiliation(s)
- Inka Miñambres
- Endocrinology and Nutrition Department, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, San Antoni Mª Claret, 167, 08025 Barcelona, Spain
| | - Antonio Pérez
- Endocrinology and Nutrition Department, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, San Antoni Mª Claret, 167, 08025 Barcelona, Spain
- Centro de Investigación Biomédica en Red, Diabetes y Enfermedades Metabólicas Asociadas (CIBERDEM), Madrid, Spain
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Liebl A. Management of postprandial glucose: Recommended targets and treatment with biphasic insulin. Prim Care Diabetes 2016; 10:391-397. [PMID: 27427307 DOI: 10.1016/j.pcd.2016.06.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2015] [Revised: 05/11/2016] [Accepted: 06/14/2016] [Indexed: 01/03/2023]
Abstract
Increases in glycaemia, particularly following meals, have been independently associated with diabetes complications, most notably cardiovascular disease. Control of postprandial plasma glucose (PPG) therefore plays an important role in diabetes management. International diabetes guidelines acknowledge the value of PPG monitoring yet place relatively little emphasis on PPG control. This article considers the impact of suboptimal PPG control and current recommendations with regard to management of PPG. Specific consideration is given to the role of biphasic insulins, one of the treatment options recognised by the International Diabetes Federation as preferentially lowering PPG levels.
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Affiliation(s)
- Andreas Liebl
- Department of Internal Medicine, Centre for Diabetes and Metabolism, Fachklinik Bad Heilbrunn, Bad Heilbrunn, Germany.
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Postprandial and basal hyperglycaemia in type 2 diabetes: Contributions to overall glucose exposure and diabetic complications. DIABETES & METABOLISM 2016; 41:6S9-6S15. [PMID: 26774019 DOI: 10.1016/s1262-3636(16)30003-9] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Both postprandial and fasting (basal) hyperglycaemia contribute to overall hyperglycaemia (ambient hyperglycaemia) in type 2 diabetes (T2D). Postprandial glucose is the main contributor in fairly well controlled individuals, whereas basal hyperglycaemia becomes the preponderant contributor in poorly controlled patients. A more generally acceptable description of the contribution of postprandial glucose is to simply say that the absolute impact of postprandial glucose to HbA1c remains constant at approximately 1% across the entire HbA1c spectrum of non-insulin-treated patients with T2D. While epidemiological and pathophysiological studies seem to indicate that excessive postprandial glucose excursions play a role in or are predictors of cardiovascular diseases, there is still currently a lack of clinical evidence that correcting post-meal hyperglycaemia can improve clinical outcomes. However, even in the absence of consensus, there are many reasons for thinking that excessive postprandial glucose might be an independent risk factor for diabetic complications as it contributes to both overall glucose exposure and glycaemic variability, especially in those who have HbA1c levels < 7.5-8%. Given that excessive glucose fluctuations from peaks to nadirs activate oxidative stress, it seems reasonable to consider that a key player in the pathogenesis of diabetic complications, according to the latest IDF guidelines, is post-meal glucose, thereby warranting its assessment and treatment when found at abnormally elevated levels. Nevertheless, healthcare professionals should bear in mind that targeting both post-meal and basal plasma glucose, giving equal consideration to both of them, is probably the best strategy for achieving optimal glycaemic control and thus preventing or reducing the risk of diabetic complications.
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Schnell O, Rydén L, Standl E, Ceriello A. Current perspectives on cardiovascular outcome trials in diabetes. Cardiovasc Diabetol 2016; 15:139. [PMID: 27716274 PMCID: PMC5045635 DOI: 10.1186/s12933-016-0456-8] [Citation(s) in RCA: 56] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2016] [Accepted: 09/23/2016] [Indexed: 12/23/2022] Open
Abstract
Cardiovascular disease (CVD) is one of the most common diabetes-associated complications, as well as a leading cause for death in type 2 diabetes patients (T2D). Despite the well-known correlation between the two, up until the 2008 FDA industry guidance for licensing of new anti-hyperglycemic drugs, which required an investigation of cardiovascular outcomes (CVO) of glucose-lowering agents, only a few studies had looked into the relationship between glucose lowering drugs and cardiovascular (CV) risk. Thereafter, CVOT design has focused on non-inferiority short-term studies on high-risk patient populations aiming at capturing CV safety issues. Despite the wealth of information and useful data provided by CVOTs, this approach still suffers from certain limitations. The present review will condense the main results of the most recently completed CVOTs, reflect on the lessons learned, discuss on the issues presented by current CVOT design and offer some suggestions for improvement.
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Affiliation(s)
- Oliver Schnell
- Forschergruppe Diabetes e.V., Munich, Ingolstaedter Landstrasse 1, 85764, Neuherberg (Munich), Germany.
| | - Lars Rydén
- Cardiology Unit, Department of Medicine K2, Karolinska Institutet, 171 76, Stockholm, Sweden
| | - Eberhard Standl
- Forschergruppe Diabetes e.V., Munich, Ingolstaedter Landstrasse 1, 85764, Neuherberg (Munich), Germany
| | - Antonio Ceriello
- Institut d'Investigacions Biomèdiques August Pi i Sunyer-IDIBAPS, Mallorca, 183, 08036, Barcelona, Spain.,IRCCS MultiMedica, Via Milanese, 300, 20099, Milan, Italy
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Giorgino F, Bonadonna RC, Gentile S, Vettor R, Pozzilli P. Treatment intensification in patients with inadequate glycemic control on basal insulin: rationale and clinical evidence for the use of short-acting and other glucagon-like peptide-1 receptor agonists. Diabetes Metab Res Rev 2016; 32:497-511. [PMID: 26787264 PMCID: PMC5071744 DOI: 10.1002/dmrr.2775] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2015] [Revised: 12/07/2015] [Accepted: 12/18/2015] [Indexed: 12/17/2022]
Abstract
A substantial proportion of patients with type 2 diabetes mellitus do not reach glycemic targets, despite treatment with oral anti-diabetic drugs and basal insulin therapy. Several options exist for treatment intensification beyond basal insulin, and the treatment paradigm is complex. In this review, the options for treatment intensification will be explored, focusing on drug classes that act via the incretin system and paying particular attention to the short-acting glucagon-like peptide-1 receptor agonists exenatide and lixisenatide. Current treatment guidelines will be summarized and discussed. © 2016 The Authors. Diabetes/Metabolism Research and Reviews Published by John Wiley & Sons Ltd.
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Affiliation(s)
- Francesco Giorgino
- Dipartimento dell'Emergenza e dei Trapianti di Organi, Sezione di Medicina Interna, Endocrinologia, Andrologia e Malattie MetabolicheUniversità degli Studi di Bari Aldo MoroBariItaly
| | - Riccardo C. Bonadonna
- Dipartimento di Medicina Clinica e Sperimentale, Divisione di EndocrinologiaUniversità degli Studi di Parma, and AOU di ParmaParmaItaly
| | - Sandro Gentile
- Dipartimento di Medicina Clinica e SperimentaleSeconda Università degli Studi di NapoliNaplesItaly
| | - Roberto Vettor
- Dipartimento di Medicina – DIMED, Clinica Medica 3Università di PadovaPadovaItaly
| | - Paolo Pozzilli
- Department of Endocrinology & DiabetesUniversità Campus Bio‐MedicoRomeItaly
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Low Wang CC, Hess CN, Hiatt WR, Goldfine AB. Clinical Update: Cardiovascular Disease in Diabetes Mellitus: Atherosclerotic Cardiovascular Disease and Heart Failure in Type 2 Diabetes Mellitus - Mechanisms, Management, and Clinical Considerations. Circulation 2016; 133:2459-502. [PMID: 27297342 PMCID: PMC4910510 DOI: 10.1161/circulationaha.116.022194] [Citation(s) in RCA: 650] [Impact Index Per Article: 81.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Cardiovascular disease remains the principal cause of death and disability among patients with diabetes mellitus. Diabetes mellitus exacerbates mechanisms underlying atherosclerosis and heart failure. Unfortunately, these mechanisms are not adequately modulated by therapeutic strategies focusing solely on optimal glycemic control with currently available drugs or approaches. In the setting of multifactorial risk reduction with statins and other lipid-lowering agents, antihypertensive therapies, and antihyperglycemic treatment strategies, cardiovascular complication rates are falling, yet remain higher for patients with diabetes mellitus than for those without. This review considers the mechanisms, history, controversies, new pharmacological agents, and recent evidence for current guidelines for cardiovascular management in the patient with diabetes mellitus to support evidence-based care in the patient with diabetes mellitus and heart disease outside of the acute care setting.
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Affiliation(s)
- Cecilia C Low Wang
- From Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, University of Colorado School of Medicine, Aurora (C.C.L.); CPC Clinical Research, Aurora, CO (C.C.L., C.N.H., W.R.H.); Division of Cardiology, Department of Medicine, University of Colorado School of Medicine, Aurora (C.N.H., W.R.H.); Joslin Diabetes Center, and Harvard Medical School, Boston, MA (A.B.G.)
| | - Connie N Hess
- From Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, University of Colorado School of Medicine, Aurora (C.C.L.); CPC Clinical Research, Aurora, CO (C.C.L., C.N.H., W.R.H.); Division of Cardiology, Department of Medicine, University of Colorado School of Medicine, Aurora (C.N.H., W.R.H.); Joslin Diabetes Center, and Harvard Medical School, Boston, MA (A.B.G.)
| | - William R Hiatt
- From Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, University of Colorado School of Medicine, Aurora (C.C.L.); CPC Clinical Research, Aurora, CO (C.C.L., C.N.H., W.R.H.); Division of Cardiology, Department of Medicine, University of Colorado School of Medicine, Aurora (C.N.H., W.R.H.); Joslin Diabetes Center, and Harvard Medical School, Boston, MA (A.B.G.)
| | - Allison B Goldfine
- From Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, University of Colorado School of Medicine, Aurora (C.C.L.); CPC Clinical Research, Aurora, CO (C.C.L., C.N.H., W.R.H.); Division of Cardiology, Department of Medicine, University of Colorado School of Medicine, Aurora (C.N.H., W.R.H.); Joslin Diabetes Center, and Harvard Medical School, Boston, MA (A.B.G.).
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Hoogwerf BJ, Lincoff AM, Rodriguez A, Chen L, Qu Y. Major adverse cardiovascular events with basal insulin peglispro versus comparator insulins in patients with type 1 or type 2 diabetes: a meta-analysis. Cardiovasc Diabetol 2016; 15:78. [PMID: 27188479 PMCID: PMC4869328 DOI: 10.1186/s12933-016-0393-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2016] [Accepted: 04/29/2016] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND To identify possible differences in cardiovascular (CV) risk among different insulin therapies, we performed pre-specified meta-analyses across the clinical program for basal insulin peglispro (BIL), in patients randomized to treatment with BIL or comparator insulin [glargine (IG) or NPH]. METHODS One phase 2 (12-week) and 6 phase 3 (26 to 78-week) randomized studies of BIL compared to IG or NPH, in patients with type 1 or type 2 diabetes, were included. The participants were diverse with respect to demographics, baseline glycemic control, and concomitant disease or medications, but treatment groups were comparable in each study. For any potential CV or neurovascular event, relevant medical information was provided to a blinded external clinical events committee (C5Research, Cleveland Clinic, Cleveland, OH, USA) for adjudication. Cox regression analysis was used to compare treatment groups. The primary endpoint was a composite of adjudicated MACE+ [CV death, myocardial infarction (MI), stroke, or hospitalization for unstable angina]. RESULTS The pooled population included 5862 patients in the safety evaluation, with randomization to BIL:IG:NPH of 3578:2072:212. Mean age was 54.1 years, 27 % had type 1 diabetes, 56 % were male, and 88 % were white. Baseline demographic and clinical characteristics, including use of statins or other lipid-lowering drugs, were comparable between BIL and comparators. A total of 83 patients experienced at least 1 MACE+ and 70 patients experienced at least 1 MACE (CV death, MI, or stroke). Overall, there were no treatment-associated differences in time to MACE+ [hazard ratio (HR) for BIL versus comparator insulin (95 % CI): 0.82 (0.53-1.27)] or MACE [0.83 (0.51-1.33)]. In 4297 patients with type 2 diabetes, there were 71 MACE+ events [HR: 1.02 (95 % CI: 0.63-1.65), p = 0.94]. In 1565 patients with type 1 diabetes, there were only 12 MACE+ [0.24 (0.07-0.85), p = 0.027]. There were no differences in all-cause death between BIL and comparators. Sub-group analyses did not identify any sub-population with increased risk with BIL versus comparator insulins. CONCLUSIONS Treatment with BIL versus comparator insulin in patients with type 1 diabetes or type 2 diabetes was not associated with increased risk for major CV events in the studies analyzed.
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Affiliation(s)
- Byron J. Hoogwerf
- />Lilly Corporate Center, Eli Lilly and Company, Drop Code 2240, Indianapolis, IN 46285 USA
| | - A. Michael Lincoff
- />Cleveland Clinic Coordinating Center for Clinical Research (C5 Research), Cleveland Clinic, Cleveland, OH USA
| | | | - Lei Chen
- />Lilly Corporate Center, Eli Lilly and Company, Drop Code 2240, Indianapolis, IN 46285 USA
| | - Yongming Qu
- />Lilly Corporate Center, Eli Lilly and Company, Drop Code 2240, Indianapolis, IN 46285 USA
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Bansal B, Carvalho P, Mehta Y, Yadav J, Sharma P, Mithal A, Trehan N. Prognostic significance of glycemic variability after cardiac surgery. J Diabetes Complications 2016; 30:613-7. [PMID: 26965795 DOI: 10.1016/j.jdiacomp.2016.02.010] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2015] [Revised: 02/08/2016] [Accepted: 02/09/2016] [Indexed: 01/08/2023]
Abstract
INTRODUCTION The prognostic significance of acute glycemic variability (GV) after cardiac surgery is not known. This study was therefore planned to analyze the independent prognostic value of GV after cardiac surgery. MATERIALS AND METHODS This is a single center prospective observational study in 870 consecutive cardiac surgery patients over a 3-month period at a tertiary care institute in India. RESULTS In linear regression analysis, GV was a significant predictor of length of stay in intensive care unit (LOS-ICU) (beta 0.102, p=0.007) and rise in creatinine after surgery (beta 0.229, p<0.001). Mean POC-BG was a significant positive predictor of length of stay in hospital (LOS-hospital) (beta 0.1, p=0.004). In multivariable logistic regression analysis, GV predicted prolonged LOS-ICU (p=0.006, OR 1.016) and acute kidney injury (p<0.001, OR 1.034). CONCLUSION This study showed that GV, as measured by standard deviation, was a predictor of LOS-ICU, rise in creatinine and AKI after cardiac surgery. GV is therefore a new dimension in postoperative glycemic management in cardiac surgery patients, which needs to be explored.
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Affiliation(s)
- Beena Bansal
- Division of Endocrinology and Diabetes, Medanta, The Medicity.
| | | | - Yatin Mehta
- Institute of Critical Care & Anaesthesiology, Medanta, the Medicity.
| | - Jitender Yadav
- Division of Endocrinology and Diabetes, Medanta, The Medicity.
| | | | - Ambrish Mithal
- Division of Endocrinology and Diabetes, Medanta, The Medicity.
| | - Naresh Trehan
- Heart Institute- Division of Cardio Thoracic & Vascular Surgery, Medanta, the Medicity.
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Madsbad S. Impact of postprandial glucose control on diabetes-related complications: How is the evidence evolving? J Diabetes Complications 2016; 30:374-85. [PMID: 26541075 DOI: 10.1016/j.jdiacomp.2015.09.019] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2015] [Revised: 09/30/2015] [Accepted: 09/30/2015] [Indexed: 12/14/2022]
Abstract
Conflicting findings in the literature and lack of long-term definitive outcome studies have led to difficulty in drawing conclusions about the role of postprandial hyperglycemia in diabetes and its complications. Recent scientific publications support the role of postprandial glucose (PPG) as a key contributor to overall glucose control and a predictor of microvascular and macrovascular events. However, the need remains for definitive evidence to support the precise relationship between PPG excursions and the development and progression of cardiovascular complications of diabetes. Drawing firm conclusions on the relationship between PPG and microvascular and macrovascular complications is challenged by the absence of antidiabetic agents that can specifically exert their action on PPG alone, without a basal glucose-lowering effect. Areas under investigation include interventions that more closely approximate 'normal' physiological postprandial responses, as well as technologies that advance the mode of insulin delivery or optimize methods to sense glycemic levels and variation. In conclusion, the precise role of postprandial hyperglycemia in relation to development of diabetic complications is unclarified and is one of the remaining unanswered questions in diabetes. Nevertheless, current evidence supports PPG control as an important strategy to consider in the comprehensive management plan of individuals with diabetes.
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Affiliation(s)
- Sten Madsbad
- Department of Endocrinology, Hvidovre University Hospital, University of Copenhagen, Denmark.
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Monnier L, Colette C, Dejager S, Owens DR. Near normal HbA1c with stable glucose homeostasis: the ultimate target/aim of diabetes therapy. Rev Endocr Metab Disord 2016; 17:91-101. [PMID: 26803295 DOI: 10.1007/s11154-016-9325-8] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Achieving near normal glucose homeostasis implies that all components of dysglycemia that are present in diabetes states be eliminated. Reducing ambient/overall hyperglycemia is a pre-requisite to eliminate the risk of development and progression of diabetes complications. More controversially however, are the relative and related contributions of postprandial glucose excursions, glucose variability, hypoglycemia and the dawn phenomenon across the spectrum of dysglycemia. For instance, it is likely that the dawn phenomenon contributes to ambient hyperglycemia and that postprandial glucose excursions are at the cross road of ambient hyperglycemia and glucose variability with glucose fluctuations as causative risk factors for hypoglycemia. Proof-of-concept trials such as the ongoing FLAT-SUGAR study are necessary for gaining further insight into the possible harmful effects of some of these features such as excessive glycemic variability and glucose excursions, still considered to be of minor relevance by several diabetologists. Whether their role will be more thoroughly proven through further intervention trials with "hard" endpoints, remains to be seen. In the meantime more consideration should be given to medications aimed at concomitantly reducing ambient/overall hyperglycemia and those additional abnormal glycemic features of dysglycemia.
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Affiliation(s)
- L Monnier
- Institute of Clinical Research, University of Montpellier, 641 Avenue Doyen Giraud, 34093 Cedex 5, Montpellier, France.
| | - C Colette
- Institute of Clinical Research, University of Montpellier, 641 Avenue Doyen Giraud, 34093 Cedex 5, Montpellier, France
| | - S Dejager
- Department of Endocrinology, Hospital Pitié Salpétrière, Paris, France
| | - D R Owens
- Diabetes Research Group, Swansea University, Swansea, UK
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Cahn A, Cernea S, Raz I. Outcome studies and safety as guide for decision making in treating patients with type 2 diabetes. Rev Endocr Metab Disord 2016; 17:117-27. [PMID: 27106831 DOI: 10.1007/s11154-016-9351-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Cardiovascular disease is the leading cause of mortality in patients with diabetes. Over the past 20 years multiple CV outcome studies have been conducted assessing the cardiovascular benefits of tight glycemic control or of particular glucose lowering agents. Improved glycemic control per-se failed to significantly reduce the risk of adverse cardiovascular outcomes in the short term, and it is only after >15 years that a reduction in adverse CV outcomes with tight glycemic control was perceived. Moreover tight glycemic control and increased attendant hypoglycemia led to increased mortality observed in the ACCORD trial. These data highlighted the importance of setting individualized glycemic targets and assessing the CV safety of the individual glucose lowering agents. Three DPP-4 inhibitors have presented CV outcome data to date demonstrating overall CV safety yet the question of increased hospitalization for heart failure with saxagliptin remains unexplained. Lixisenatide was the first GLP-1 receptor agonist to publish CV outcome data which demonstrated overall safety. The SGLT-2 inhibitor empagliflozin demonstrated CV superiority and a reduction in all-cause mortality and hospitalization for heart failure vs. placebo via mechanisms which remain to be fully elucidated. The outcome studies, though large and costly, have had a considerable effect on diabetes guidelines, these now emphasizing the importance of individualization of care. The outcome studies will presumably influence the new guidelines and dictate better tailoring of the drug regimen to the individual patient, matching patient comorbidities to the accumulating data regarding the safety and efficacy of each drug and class.
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Affiliation(s)
- Avivit Cahn
- Diabetes Unit, Department of Internal Medicine, Hadassah Hebrew University Hospital, PO Box 12000, 91120, Jerusalem, Israel
- Endocrinology and Metabolism Unit, Department of Internal Medicine, Hadassah Hebrew University Hospital, Jerusalem, Israel
| | - Simona Cernea
- Department M3/Internal Medicine IV, University of Medicine and Pharmacy, Târgu Mureş, Romania
- Diabetes, Nutrition and Metabolic Diseases Outpatient Unit, Emergency County Clinical Hospital, Târgu Mureş, Romania
| | - Itamar Raz
- Diabetes Unit, Department of Internal Medicine, Hadassah Hebrew University Hospital, PO Box 12000, 91120, Jerusalem, Israel.
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Lundby-Christensen L, Vaag A, Tarnow L, Almdal TP, Lund SS, Wetterslev J, Gluud C, Boesgaard TW, Wiinberg N, Perrild H, Krarup T, Snorgaard O, Gade-Rasmussen B, Thorsteinsson B, Røder M, Mathiesen ER, Jensen T, Vestergaard H, Hedetoft C, Breum L, Duun E, Sneppen SB, Pedersen O, Hemmingsen B, Carstensen B, Madsbad S. Effects of biphasic, basal-bolus or basal insulin analogue treatments on carotid intima-media thickness in patients with type 2 diabetes mellitus: the randomised Copenhagen Insulin and Metformin Therapy (CIMT) trial. BMJ Open 2016; 6:e008377. [PMID: 26916685 PMCID: PMC4771974 DOI: 10.1136/bmjopen-2015-008377] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
OBJECTIVE To assess the effect of 3 insulin analogue regimens on change in carotid intima-media thickness (IMT) in patients with type 2 diabetes. DESIGN AND SETTING Investigator-initiated, randomised, placebo-controlled trial with a 2 × 3 factorial design, conducted at 8 hospitals in Denmark. PARTICIPANTS AND INTERVENTIONS Participants with type 2 diabetes (glycated haemoglobin (HbA1c) ≥ 7.5% (≥ 58 mmol/mol), body mass index >25 kg/m(2)) were, in addition to metformin versus placebo, randomised to 18 months open-label biphasic insulin aspart 1-3 times daily (n=137) versus insulin aspart 3 times daily in combination with insulin detemir once daily (n=138) versus insulin detemir alone once daily (n=137), aiming at HbA1c ≤ 7.0% (≤ 53 mmol/mol). OUTCOMES Primary outcome was change in mean carotid IMT (a marker of subclinical cardiovascular disease). HbA1c, insulin dose, weight, and hypoglycaemic and serious adverse events were other prespecified outcomes. RESULTS Carotid IMT change did not differ between groups (biphasic -0.009 mm (95% CI -0.022 to 0.004), aspart+detemir 0.000 mm (95% CI -0.013 to 0.013), detemir -0.012 mm (95% CI -0.025 to 0.000)). HbA1c was more reduced with biphasic (-1.0% (95% CI -1.2 to -0.8)) compared with the aspart+detemir (-0.4% (95% CI -0.6 to -0.3)) and detemir (-0.3% (95% CI -0.4 to -0.1)) groups (p<0.001). Weight gain was higher in the biphasic (3.3 kg (95% CI 2.7 to 4.0) and aspart+detemir (3.2 kg (95% CI 2.6 to 3.9)) compared with the detemir group (1.9 kg (95% CI 1.3 to 2.6)). Insulin dose was higher with detemir (1.6 IU/kg/day (95% CI 1.4 to 1.8)) compared with biphasic (1.0 IU/kg/day (95% CI 0.9 to 1.1)) and aspart+detemir (1.1 IU/kg/day (95% CI 1.0 to 1.3)) (p<0.001). Number of participants with severe hypoglycaemia and serious adverse events did not differ. CONCLUSIONS Carotid IMT change did not differ between 3 insulin regimens despite differences in HbA1c, weight gain and insulin doses. The trial only reached 46% of planned sample size and lack of power may therefore have affected our results. TRIAL REGISTRATION NUMBER NCT00657943.
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Affiliation(s)
- Louise Lundby-Christensen
- Steno Diabetes Center, Gentofte, Denmark
- Department of Endocrinology, Hvidovre, Copenhagen University Hospital, Hvidovre, Denmark
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- Department of Paediatrics, Hvidovre, Copenhagen University Hospital, Hvidovre, Denmark
| | - Allan Vaag
- Steno Diabetes Center, Gentofte, Denmark
- Department of Endocrinology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
- University of Copenhagen, Copenhagen, Denmark
| | - Lise Tarnow
- Steno Diabetes Center, Gentofte, Denmark
- Department of Cardiology, Nephrology and Endocrinology, Nordsjællands University Hospital—Hillerød, Hillerød, Denmark
- Department of Health, University of Aarhus, Aarhus, Denmark
| | - Thomas P Almdal
- Department of Endocrinology, Hvidovre, Copenhagen University Hospital, Hvidovre, Denmark
- Department of Endocrinology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Søren S Lund
- Steno Diabetes Center, Gentofte, Denmark
- Boehringer Ingelheim Pharma GmbH & Co KG, Ingelheim, Germany
| | - Jørn Wetterslev
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Christian Gluud
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | | | - Niels Wiinberg
- Department of Physiology and Nuclear Medicine, Frederiksberg, Copenhagen University Hospital, Frederiksberg, Denmark
| | - Hans Perrild
- Department of Endocrinology, Bispebjerg, Copenhagen University Hospital, Copenhagen, Denmark
| | - Thure Krarup
- Department of Endocrinology, Bispebjerg, Copenhagen University Hospital, Copenhagen, Denmark
| | - Ole Snorgaard
- Department of Endocrinology, Hvidovre, Copenhagen University Hospital, Hvidovre, Denmark
| | - Birthe Gade-Rasmussen
- Department of Endocrinology, Hvidovre, Copenhagen University Hospital, Hvidovre, Denmark
| | - Birger Thorsteinsson
- University of Copenhagen, Copenhagen, Denmark
- Department of Cardiology, Nephrology and Endocrinology, Nordsjællands University Hospital—Hillerød, Hillerød, Denmark
| | - Michael Røder
- Department of Cardiology, Nephrology and Endocrinology, Nordsjællands University Hospital—Hillerød, Hillerød, Denmark
- Department of Medicine, Gentofte, Copenhagen University Hospital, Gentofte, Denmark
| | - Elisabeth R Mathiesen
- Department of Endocrinology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
- University of Copenhagen, Copenhagen, Denmark
| | - Tonny Jensen
- Department of Endocrinology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Henrik Vestergaard
- University of Copenhagen, Copenhagen, Denmark
- Department of Endocrinology, Herlev, Copenhagen University Hospital, Herlev, Denmark
- Section of Metabolic Genetics, The Novo Nordisk Foundation Center for Basic Metabolic Research, University of Copenhagen,Copenhagen, Denmark
| | | | - Leif Breum
- Department of Medicine, University Hospital Køge, Køge, Denmark
| | - Elsebeth Duun
- Department of Medicine, Gentofte, Copenhagen University Hospital, Gentofte, Denmark
| | - Simone B Sneppen
- Department of Medicine, Gentofte, Copenhagen University Hospital, Gentofte, Denmark
| | - Oluf Pedersen
- Steno Diabetes Center, Gentofte, Denmark
- University of Copenhagen, Copenhagen, Denmark
- Section of Metabolic Genetics, The Novo Nordisk Foundation Center for Basic Metabolic Research, University of Copenhagen,Copenhagen, Denmark
| | - Bianca Hemmingsen
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- Department of Cardiology, Nephrology and Endocrinology, Nordsjællands University Hospital—Hillerød, Hillerød, Denmark
| | | | - Sten Madsbad
- Department of Endocrinology, Hvidovre, Copenhagen University Hospital, Hvidovre, Denmark
- University of Copenhagen, Copenhagen, Denmark
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Selvin E, Rawlings A, Lutsey P, Maruthur N, Pankow JS, Steffes M, Coresh J. Association of 1,5-Anhydroglucitol With Cardiovascular Disease and Mortality. Diabetes 2016; 65:201-8. [PMID: 26395741 PMCID: PMC4686946 DOI: 10.2337/db15-0607] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2015] [Accepted: 09/16/2015] [Indexed: 12/16/2022]
Abstract
In diabetes, low concentrations of the biomarker 1,5-anhydroglucitol (1,5-AG) reflect hyperglycemic excursions over the prior 1-2 weeks. To the extent that hyperglycemic excursions are important in atherogenesis, 1,5-AG may provide independent information regarding cardiovascular risk. Nonetheless, few studies have evaluated associations of 1,5-AG with long-term cardiovascular outcomes in a population-based setting. We measured 1,5-AG in 11,106 participants in the Atherosclerosis Risk in Communities (ARIC) study without cardiovascular disease at baseline (1990-1992) and examined prospective associations with coronary heart disease (n = 1,159 events), ischemic stroke (n = 637), heart failure (n = 1,553), and death (n = 3,120) over 20 years of follow-up. Cox proportional hazards models were adjusted for demographic and cardiovascular risk factors. Compared with persons with 1,5-AG ≥6 μg/mL and no history of diabetes, persons with diabetes and 1,5-AG <6.0 μg/mL had an increased risk of coronary heart disease (HR 3.85, 95% CI 3.11-4.78), stroke (HR 3.48, 95% CI 2.66-4.55), heart failure (HR 3.50, 95% CI 2.93-4.17), and death (HR 2.44, 95% CI 2.11-2.83). There was a threshold effect, with little evidence for associations at "nondiabetic" concentrations of 1,5-AG (e.g., >10 μg/mL). Associations remained but were attenuated with additional adjustment for fasting glucose or HbA1c. These data add to the growing evidence for the prognostic value of 1,5-AG for long-term complications in the setting of diabetes.
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Affiliation(s)
- Elizabeth Selvin
- Department of Epidemiology and the Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD Division of General Internal Medicine, Department of Medicine, Johns Hopkins University, Baltimore, MD
| | - Andreea Rawlings
- Department of Epidemiology and the Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Pamela Lutsey
- Division of Epidemiology and Community Health, University of Minnesota, Minneapolis, MN
| | - Nisa Maruthur
- Department of Epidemiology and the Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD Division of General Internal Medicine, Department of Medicine, Johns Hopkins University, Baltimore, MD
| | - James S Pankow
- Division of Epidemiology and Community Health, University of Minnesota, Minneapolis, MN
| | - Michael Steffes
- Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, MN
| | - Josef Coresh
- Department of Epidemiology and the Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD Division of General Internal Medicine, Department of Medicine, Johns Hopkins University, Baltimore, MD
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82
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Conget I, Castaneda J, Petrovski G, Guerci B, Racault AS, Reznik Y, Cohen O, Runzis S, de Portu S, Aronson R. The Impact of Insulin Pump Therapy on Glycemic Profiles in Patients with Type 2 Diabetes: Data from the OpT2mise Study. Diabetes Technol Ther 2016; 18:22-8. [PMID: 26241790 PMCID: PMC4717502 DOI: 10.1089/dia.2015.0159] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND The OpT2mise randomized trial was designed to compare the effects of continuous subcutaneous insulin infusion (CSII) and multiple daily injections (MDI) on glucose profiles in patients with type 2 diabetes. RESEARCH DESIGN AND METHODS Patients with glycated hemoglobin (HbA1c) levels of ≥8% (64 mmol/mol) and ≤12% (108 mmol/mol) despite insulin doses of 0.7-1.8 U/kg/day via MDI were randomized to CSII (n=168) or continued MDI (n=163). Changes in glucose profiles were evaluated using continuous glucose monitoring data collected over 6-day periods before and 6 months after randomization. RESULTS After 6 months, reductions in HbA1c levels were significantly greater with CSII (-1.1±1.2% [-12.0±13.1 mmol/mol]) than with MDI (-0.4±1.1% [-4.4±12.0 mmol/mol]) (P<0.001). Similarly, compared with patients receiving MDI, those receiving CSII showed significantly greater reductions in 24-h mean sensor glucose (SG) (treatment difference, -17.1 mg/dL; P=0.0023), less exposure to SG >180 mg/dL (-12.4%; P=0.0004) and SG >250 mg/dL (-5.5%; P=0.0153), and more time in the SG range of 70-180 mg/dL (12.3%; P=0.0002), with no differences in exposure to SG<70 mg/dL or in glucose variability. Changes in postprandial (4-h) glucose area under the curve >180 mg/dL were significantly greater with CSII than with MDI after breakfast (-775.9±1,441.2 mg/dL/min vs. -160.7±1,074.1 mg/dL/min; P=0.0015) and after dinner (-731.4±1,580.7 mg/dL/min vs. -71.1±1,083.5 mg/dL/min; P=0.0014). CONCLUSIONS In patients with suboptimally controlled type 2 diabetes, CSII significantly improves selected glucometrics, compared with MDI, without increasing the risk of hypoglycemia.
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Affiliation(s)
- Ignacio Conget
- Diabetes Unit, Endocrinology and Nutrition Department, University Hospital Clinic, Barcelona, Spain
| | | | | | | | | | - Yves Reznik
- Department of Endocrinology, University of Caen Côte de Nacre Regional Hospital Center, Caen, France
| | - Ohad Cohen
- Medtronic International Trading Sàrl, Tolochenaz, Switzerland
| | - Sarah Runzis
- Medtronic International Trading Sàrl, Tolochenaz, Switzerland
| | - Simona de Portu
- Medtronic International Trading Sàrl, Tolochenaz, Switzerland
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83
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Abstract
Type 2 diabetes mellitus (T2DM) is a progressive disease, and most patients ultimately require two or more antidiabetes drugs in addition to lifestyle changes to achieve and maintain glycemic control. Current consensus statements and guidelines recommend metformin as first-line pharmacotherapy for the treatment of T2DM in most patients. When glycemic control cannot be maintained with metformin alone, the sequential, stepwise addition of other agents is recommended. Agents such as thiazolidinediones or sulfonylureas have typically been added to metformin therapy. Although effective in reducing glycated hemoglobin, these drugs are often associated with adverse effects, most notably weight gain, and in the case of sulfonylureas, hypoglycemia. Sodium-glucose cotransporter 2 inhibitors, such as dapagliflozin, are the newest class of antidiabetes drugs approved for the treatment of T2DM. Dapagliflozin effectively improves glycemic control by increasing the renal excretion of excess glucose. In clinical trials, dapagliflozin has been well tolerated and has additional benefits of weight loss, low risk of hypoglycemia and reduction in blood pressure. This review discusses the clinical evidence and rationale for the use of dapagliflozin as add-on therapy in T2DM. The results suggest that dapagliflozin add-on therapy is a promising new treatment option for a wide range of patients with T2DM. Results from an ongoing cardiovascular outcomes trial are needed to establish the long-term safety of dapagliflozin.
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Affiliation(s)
- Tamer Yacoub
- a Endocrinology , Prima Care, P.C ., Fall River , MA , USA
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84
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Glucose lowering effect of montbretin A in Zucker Diabetic Fatty rats. Mol Cell Biochem 2015; 411:373-81. [DOI: 10.1007/s11010-015-2599-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2015] [Accepted: 10/29/2015] [Indexed: 11/27/2022]
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85
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Fisher M. Recent cardiovascular safety trials with antidiabetic drugs: time to change the guidelines! PRACTICAL DIABETES 2015. [DOI: 10.1002/pdi.1980] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
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86
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Wang P, Huang R, Lu S, Xia W, Sun H, Sun J, Cai R, Wang S. HbA1c below 7% as the goal of glucose control fails to maximize the cardiovascular benefits: a meta-analysis. Cardiovasc Diabetol 2015; 14:124. [PMID: 26392171 PMCID: PMC4578327 DOI: 10.1186/s12933-015-0285-1] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2015] [Accepted: 09/09/2015] [Indexed: 12/16/2022] Open
Abstract
Objective Whether lowering glycosylated haemoglobin (HbA1c) level below 7.0 % improves macro-vascular outcomes in diabetes remains unclear. Here, we aimed to assess the effect of relatively tight glucose control resulting in a follow-up HbA1c level of less or more than 7.0 % on cardiovascular outcomes in diabetic patients. Research design and methods We systematically searched Medline, Web of science and Cochrane Library for prospective randomized controlled trials published between Jan 1, 1996 and July 1, 2015 that recorded cardiovascular outcome trials of glucose-lowering drugs or strategies in patients with type 2 diabetes mellitus. Results Data from 15 studies involving 88,266 diabetic patients with 4142 events of non-fatal myocardial infarction, 6997 of major cardiovascular events, 3517 of heart failure, 6849 of all-cause mortality, 2084 of non-fatal stroke, 3816 of cardiovascular death were included. A 7 % reduction of major cardiovascular events was observed only when relatively tight glucose control resulted in a follow-up HbA1c level above 7.0 % (OR 0.93, 95 % CI 0.88–0.98; I2 = 33 %), however, the patients can benefit from reduction incidence of non-fatal myocardial infarction only when the follow-up HbA1c value below 7.0 % (OR 0.85, 95 % CI 0.74–0.96). Apart from the HbA1c value above 7.0 % (OR 1.22, 95 % CI 1.06–1.40), the application of thiazolidinediones (OR 1.39, 95 % CI 1.14–1.69) also increased the risk of heart failure, while the gliptins shows neutral effects to heart failure (OR 1.14, 95 % CI 0.97–1.34). Conclusions Relatively tight glucose control has some cardiovascular benefits. HbA1c below 7.0 % as the goal to maximize the cardiovascular benefits remains suspended.
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Affiliation(s)
- Pin Wang
- Department of Endocrinology, Affiliated ZhongDa Hospital of Southeast University, No. 87 DingJiaQiao Road, Nanjing, 210009, People's Republic of China. .,Department of Endocrinology, Sichuan Academy of Medical Science and Sichuan Provincial People's Hospital, East District, No. 32, Section 2, 1st Ring Road (West), Chengdu, 610072, Sichuan, People's Republic of China.
| | - Rong Huang
- Department of Endocrinology, Affiliated ZhongDa Hospital of Southeast University, No. 87 DingJiaQiao Road, Nanjing, 210009, People's Republic of China.
| | - Sen Lu
- Department of Intensive Care Unit, Sichuan Academy of Medical Science and Sichuan Provincial People's Hospital, No. 32, Section 2, 1st Ring Road (West), Chengdu, 610072, Sichuan, People's Republic of China.
| | - Wenqing Xia
- Department of Endocrinology, Affiliated ZhongDa Hospital of Southeast University, No. 87 DingJiaQiao Road, Nanjing, 210009, People's Republic of China.
| | - Haixia Sun
- Department of Endocrinology, Affiliated ZhongDa Hospital of Southeast University, No. 87 DingJiaQiao Road, Nanjing, 210009, People's Republic of China.
| | - Jie Sun
- Department of Endocrinology, Affiliated ZhongDa Hospital of Southeast University, No. 87 DingJiaQiao Road, Nanjing, 210009, People's Republic of China.
| | - Rongrong Cai
- Department of Endocrinology, Affiliated ZhongDa Hospital of Southeast University, No. 87 DingJiaQiao Road, Nanjing, 210009, People's Republic of China.
| | - Shaohua Wang
- Department of Endocrinology, Affiliated ZhongDa Hospital of Southeast University, No. 87 DingJiaQiao Road, Nanjing, 210009, People's Republic of China.
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87
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Yoo S, Chin SO, Lee SA, Koh G. Factors Associated with Glycemic Variability in Patients with Type 2 Diabetes: Focus on Oral Hypoglycemic Agents and Cardiovascular Risk Factors. Endocrinol Metab (Seoul) 2015; 30:352-60. [PMID: 26248860 PMCID: PMC4595361 DOI: 10.3803/enm.2015.30.3.352] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2015] [Revised: 04/27/2015] [Accepted: 06/11/2015] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND The role of glycemic variability (GV) in development of cardiovascular diseases remains controversial, and factors that determine glucose fluctuation in patients with diabetes are unknown. We investigated relationships between GV indices, kinds of oral hypoglycemic agents (OHAs), and cardiovascular risk factors in patients with type 2 diabetes mellitus (T2DM). METHODS We analyzed 209 patients with T2DM. The GV index (standard deviation [SD] and mean absolute glucose change [MAG]) were calculated from 7-point self-monitoring of blood glucose profiles. The patients were classified into four groups according to whether they take OHAs known as GV-lowering (A) and GV-increasing (B): 1 (A only), 2 (neither), 3 (both A and B), and 4 (B only). The 10-year risk for atherosclerotic cardiovascular disease (ASCVD) was calculated using the Pooled Cohort Equations. RESULTS GV indices were significantly higher in patients taking sulfonylureas (SUs), but lower in those taking dipeptidyl peptidase-4 inhibitors. In hierarchical regression analysis, the use of SUs remained independent correlates of the SD (γ=0.209, P=0.009) and MAG (γ=0.214, P=0.011). In four OHA groups, GV indices increased progressively from group 1 to group 4. However, these did not differ according to quartiles of 10-year ASCVD risk. CONCLUSION GV indices correlated significantly with the use of OHAs, particularly SU, and differed significantly according to combination of OHAs. However, cardiovascular risk factors and 10-year ASCVD risk were not related to GV indices. These findings suggest that GV is largely determined by properties of OHAs and not to cardiovascular complications in patients with T2DM.
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Affiliation(s)
- Soyeon Yoo
- Department of Internal Medicine, Jeju National University Hospital, Jeju, Korea
| | - Sang Ouk Chin
- Department of Internal Medicine, Jeju National University Hospital, Jeju, Korea
| | - Sang Ah Lee
- Department of Internal Medicine, Jeju National University Hospital, Jeju, Korea
- Department of Internal Medicine, Jeju National University School of Medicine, Jeju, Korea
| | - Gwanpyo Koh
- Department of Internal Medicine, Jeju National University School of Medicine, Jeju, Korea
- Department of Internal Medicine, Jeju National University Hospital, Jeju, Korea.
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88
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Abstract
There is no argument that improving mean levels of glycemic control as judged by assays for glycated hemoglobin (HbA(1c)) reduces the risks of microvascular complications and cardiovascular disease events in patients with type 1 and type 2 diabetes. However, observations in some trials have suggested that targeting HbA(1c) to suggested targets may not always result in improved outcomes for people with long-standing type 2 diabetes. The reasons why the glycemic control strategies that primarily use HbA(1c) in these studies did not have predicted outcomes are not clear. Thus, controversy remains as to whether there are glycemic metrics beyond HbA(1c) that can be defined as effective measures that can be used in addition to HbA(1c) to help in assessing the risk of an individual developing diabetes complications. In this regard, the concept of "glycemic variability" (GV) is one metric that has attracted a lot of attention. GV can be simply defined as the degree to which a patient's blood glucose level fluctuates between high (peaks) and low (nadir) levels. The best and most precise way to assess GV is also one that is still debated. Thus, while there is universal agreement that HbA(1c) is the current gold standard for the primary clinical target, there is no consensus as to whether other proposed glycemic metrics hold promise to provide additional clinical data or whether there should be additional targets beyond HbA(1c). Therefore, given the current controversy, we provide a Point-Counterpoint debate on this issue. In the point narrative below, Dr. Hirsch provides his argument that fluctuations in blood glucose as assessed by GV metrics are deleterious and control of GV should be a primary treatment target. In the following counterpoint narrative, Dr. Bergenstal argues that there are better markers to assess the risk of diabetes than GV and provides his consideration of other concepts.
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Affiliation(s)
- Irl B Hirsch
- University of Washington School of Medicine, Seattle, WA
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89
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Bergenstal RM. Glycemic Variability and Diabetes Complications: Does It Matter? Simply Put, There Are Better Glycemic Markers! Diabetes Care 2015. [PMID: 26207055 DOI: 10.2337/dc15-0099] [Citation(s) in RCA: 99] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
There is no argument that improving mean levels of glycemic control as judged by assays for glycated hemoglobin (HbA(1c)) reduces the risks of microvascular complications and cardiovascular disease events in patients with type 1 and type 2 diabetes. However, observations in some trials have suggested that targeting HbA(1c) to suggested targets may not always result in improved outcomes for people with long-standing type 2 diabetes. The reasons why the glycemic control strategies that primarily use HbA(1c) in these studies did not have predicted outcomes are not clear. Thus, controversy remains as to whether there are glycemic metrics beyond HbA(1c) that can be defined as effective measures that can be used in addition to HbA(1c) to help in assessing the risk of an individual developing diabetes complications. In this regard, the concept of "glycemic variability" (GV) is one metric that has attracted a lot of attention. GV can be simply defined as the degree to which a patient's blood glucose level fluctuates between high (peaks) and low (nadir) levels. The best and most precise way to assess GV is also one that is still debated. Thus, while there is universal agreement that HbA(1c) is the current gold standard for the primary clinical target, there is no consensus as to whether other proposed glycemic metrics hold promise to provide additional clinical data or whether there should be additional targets beyond HbA(1c). Therefore, given the current controversy, we provide a Point-Counterpoint debate on this issue. In the preceding point narrative, Dr. Hirsch provides his argument that fluctuations in blood glucose as assessed by GV metrics are deleterious and control of GV should be a primary treatment target. In the counterpoint narrative below, Dr. Bergenstal argues that there are better markers to assess the risk of diabetes than GV and provides his consideration of other concepts.
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90
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Hemmingsen B, Lund SS, Gluud C, Vaag A, Almdal TP, Wetterslev J. WITHDRAWN: Targeting intensive glycaemic control versus targeting conventional glycaemic control for type 2 diabetes mellitus. Cochrane Database Syst Rev 2015; 2015:CD008143. [PMID: 26222248 PMCID: PMC10637254 DOI: 10.1002/14651858.cd008143.pub4] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The Cochrane Metabolic and Endocrine Disorders Group withdrew this review as of Issue 7, 2015 because the involvement of two authors (C Hemmingsen and SS Lund) being employed in pharmaceutical companies. The authors of the review and the Cochrane Metabolic and Endocrine Disorders Group did not find that this was a breach of the rules of the Cochrane Collaboration at the time when it was published. However, after the publication of the review, the Cochrane Collaboration requested withdrawal of the review due to the employment of the two authors. A new protocol for a review to cover this topic will be published. This will have a new title and a markedly improved protocol fulfilling new and important developments and standards within the Cochrane Collaboration as well as an improved inclusion and search strategy making it necessary to embark on a completely new review project. The editorial group responsible for this previously published document have withdrawn it from publication.
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Affiliation(s)
- Bianca Hemmingsen
- Department 7812, Rigshospitalet, Copenhagen University HospitalCopenhagen Trial Unit, Centre for Clinical Intervention ResearchBlegdamsvej 9CopenhagenDenmarkDK‐2100
| | - Søren S Lund
- Boehringer Ingelheim Pharma GmbH & Co. KGIngelheimGermany
| | - Christian Gluud
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department 7812, Rigshospitalet, Copenhagen University HospitalThe Cochrane Hepato‐Biliary GroupBlegdamsvej 9CopenhagenDenmarkDK‐2100
| | - Allan Vaag
- Rigshospitalet and Copenhagen UniversityDepartment of Endocrinology, Diabetes and MetabolismAfsnit 7652København NDenmark2200
| | - Thomas P Almdal
- Copenhagen University Hospital GentofteDepartment of Medicine FHellerupDenmark2900
| | - Jørn Wetterslev
- Department 7812, Rigshospitalet, Copenhagen University HospitalCopenhagen Trial Unit, Centre for Clinical Intervention ResearchBlegdamsvej 9CopenhagenDenmarkDK‐2100
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91
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Almeida-Pititto B, Ribeiro-Filho FF, Lotufo PA, Bensenor IM, Ferreira SRG. Novel biomarkers of cardiometabolic risk are associated with plasma glucose within non-diabetic range. The Brazilian Longitudinal Study of Adult Health - ELSA-Brasil. Diabetes Res Clin Pract 2015; 109:110-6. [PMID: 25958099 DOI: 10.1016/j.diabres.2015.04.021] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2014] [Revised: 03/23/2015] [Accepted: 04/15/2015] [Indexed: 12/20/2022]
Abstract
Abnormal glucose metabolism preceding overt diabetes is associated with increased cardiovascular risk. Whether novel biomarkers are useful to identify this condition is unclear. The objective was to investigate associations of biomarkers of atherogenesis with plasma glucose within non-diabetic range. 998 participants (35-54 years) of the Brazilian Longitudinal Study of Adult Health without diabetes or cardiovascular disease were classified as normal glucose tolerance (NGT), impaired fasting glycemia (IFG) and impaired glucose tolerance (IGT). Traditional risk factors and markers of atherogenesis were evaluated among groups and across plasma glucose concentrations. IFG and IGT had worse profile considering traditional cardiovascular risk factors than the NGT group, although these values were within the reference range. NGT, IFG and IGT groups differed (medians and interquartile intervals) regarding transforming growth factor-β1 [12.2 (6.4-22.3), 16.8 (8.4-26.5), and 15.5 (8.0-26.1)pg/mL, p<0.05], C-reactive protein [1.1 (0.6-2.9), 1.2 (0.6-2.7), and 1.4 (0.8-3.7)ng/mL, p<0.001] and monocyte chemoattractant protein-1 [35.9 (21.2-57.8), 32.2 (18.7-55.8), and 34.1 (18.6-52.4)pg/mL, p<0.05]. TGF-β1 and E-selectin concentrations increased while MCP-1 decreased across quartiles of fasting plasma glucose. C-reactive protein increased with increments in 2-h plasma glucose. In linear regression, TGF-β1 was independently associated with fasting plasma glucose, and C-reactive protein with 2-h plasma glucose after adjustments. In conclusion, association of TGF-β1, E-selectin, C-reactive protein and MCP-1 with slight elevations in glycemia may be anticipating alterations in traditional cardiovascular risk factors. Independent association of TGF-β1 with plasma glucose suggests that this may be useful to identifying atherogenic process, deserving further investigation on the prediction of cardiovascular outcomes.
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Affiliation(s)
| | | | - Paulo A Lotufo
- Center of Clinical and Epidemiologic Research, University Hospital, University of São Paulo, SP, Brazil
| | - Isabela M Bensenor
- Center of Clinical and Epidemiologic Research, University Hospital, University of São Paulo, SP, Brazil
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92
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Affiliation(s)
- J Hans DeVries
- Department of Endocrinology, Academic Medical Centre , Amsterdam, The Netherlands
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93
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Boyle SM, Simon B, Kobrin SM. Antidiabetic Therapy in End-Stage Renal Disease. Semin Dial 2015; 28:337-44. [DOI: 10.1111/sdi.12368] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Affiliation(s)
- Suzanne M. Boyle
- Division of Nephrology and Hypertension; Drexel University College of Medicine; Philadelphia Pennsylvania
| | - Barbara Simon
- Division of Endocrinology; Drexel University College of Medicine; Philadelphia Pennsylvania
| | - Sidney M. Kobrin
- Renal, Electrolyte, and Hypertension Division; Hospital of the University of Pennsylvania; Perelman School of Medicine; University of Pennsylvania; Philadelphia Pennsylvania
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94
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Sun XQ, Bao BN, Gao XY, Yan DE, Zhou YS. Effect of glycated hemoglobin on heart function of the patients with revascularization of coronary artery. INTERNATIONAL JOURNAL OF CLINICAL AND EXPERIMENTAL PATHOLOGY 2015; 8:7181-7188. [PMID: 26261612 PMCID: PMC4525946] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 04/15/2015] [Accepted: 05/28/2015] [Indexed: 06/04/2023]
Abstract
BACKGROUND Patients with diabetes after coronary artery bypass graft (CABG) or percutaneous coronary intervention (PCI) treatment for coronary artery disease (CAD) had higher mortality rates than those without diabetes. There were limited data comparing the cardiac and metabolic differences between diabetes and non-diabetes for CABG and PCI and about impact of pre-procedure GHb level on systolic heart function in patients with diabetes. AIMS To explore the cardio-metabolic differences and to evaluate their potential as significant risk factors. SUBJECTS AND METHOD 124 patients with diabetes and 170 patients without diabetes were enrolled. Coronary lesions (≥ 70% stenosis in at least one major coronary artery) were documented by angiography. Patients with diabetes were divided into different groups by GHb, Coronary lesions (≥ 70% stenosis in at least one major coronary artery) were documented by angiography. CABG and PCI were performed for all the patients. Cardio-metabolic risk factors before revascularization were compared between them. RESULTS Diabetics with GHb ≥ 8% had lower cardiac ejection fraction (EF) values than those with GHb<8% (P<0.05) or patients without diabetes (P<0.05). And count of vascular lesions between the groups was not statistically significant. Observed EF as a dependent variable negatively correlated to GHb levels (P<0.05). The levels of glycated hemoglobin A1c (GHbA1c) rose with increased fasted blood glucose (FBG) values (P<0.001). Even with treatment for hyperglycemia and dyslipidemia, overall levels of fasting blood sugar (FBG, P<0.001), GHbA1c (P<0.001), and triglycerides (TG, P<0.05) in patients with diabetes were still higher than those without diabetes respectively. CONCLUSION Poorer glucose control with GHb ≥ 8% and decreased systolic heart function are significant risk factors that potentially contribute to worse prognosis for CABG or PCI treatment. Elevated levels of FBG, GHbA1c, and TG are evident for patients with diabetes compared to patients without diabetes prior to revascularization.
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Affiliation(s)
- X Q Sun
- Department of Endocrinology & Metabolism, Beijing Anzhen Hospital Affiliated to Capital Medical University Beijing, China
| | - B N Bao
- Department of Endocrinology & Metabolism, Beijing Anzhen Hospital Affiliated to Capital Medical University Beijing, China
| | - X Y Gao
- Department of Endocrinology & Metabolism, Beijing Anzhen Hospital Affiliated to Capital Medical University Beijing, China
| | - D E Yan
- Department of Endocrinology & Metabolism, Beijing Anzhen Hospital Affiliated to Capital Medical University Beijing, China ; Beijing Institute of Heart, Lung, and Blood Vessel Diseases Beijing, China
| | - Y S Zhou
- Department of Endocrinology & Metabolism, Beijing Anzhen Hospital Affiliated to Capital Medical University Beijing, China ; Beijing Institute of Heart, Lung, and Blood Vessel Diseases Beijing, China
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95
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Jung HS. Clinical Implications of Glucose Variability: Chronic Complications of Diabetes. Endocrinol Metab (Seoul) 2015; 30:167-74. [PMID: 26194076 PMCID: PMC4508260 DOI: 10.3803/enm.2015.30.2.167] [Citation(s) in RCA: 69] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2015] [Revised: 05/22/2015] [Accepted: 05/22/2015] [Indexed: 01/28/2023] Open
Abstract
Glucose variability has been identified as a potential risk factor for diabetic complications; oxidative stress is widely regarded as the mechanism by which glycemic variability induces diabetic complications. However, there remains no generally accepted gold standard for assessing glucose variability. Representative indices for measuring intraday variability include calculation of the standard deviation along with the mean amplitude of glycemic excursions (MAGE). MAGE is used to measure major intraday excursions and is easily measured using continuous glucose monitoring systems. Despite a lack of randomized controlled trials, recent clinical data suggest that long-term glycemic variability, as determined by variability in hemoglobin A1c, may contribute to the development of microvascular complications. Intraday glycemic variability is also suggested to accelerate coronary artery disease in high-risk patients.
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Affiliation(s)
- Hye Seung Jung
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea.
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96
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Tay J, Thompson CH, Brinkworth GD. Glycemic Variability: Assessing Glycemia Differently and the Implications for Dietary Management of Diabetes. Annu Rev Nutr 2015; 35:389-424. [PMID: 25974701 DOI: 10.1146/annurev-nutr-121214-104422] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
The primary therapeutic target for diabetes management is the achievement of good glycemic control, of which glycated hemoglobin (HbA1c) remains the standard clinical marker. However, glycemic variability (GV; the amplitude, frequency, and duration of glycemic fluctuations around mean blood glucose) is an emerging target for blood glucose control. A growing body of evidence supports GV as an independent risk factor for diabetes complications. Several techniques have been developed to assess and quantify intraday and interday GV. Additionally, GV can be influenced by several nutritional factors, including carbohydrate quality, quantity; and distribution; protein intake; and fiber intake. These factors have important implications for clinical nutrition practice and for optimizing blood glucose control for diabetes management. This review discusses the available evidence for GV as a marker of glycemic control and risk factor for diabetes complications. GV quantification techniques and the influence of nutritional considerations for diabetes management are also discussed.
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Affiliation(s)
- Jeannie Tay
- Commonwealth Scientific and Industrial Research Organisation (CSIRO)-Food and Nutrition Flagship, Adelaide, South Australia 5000, Australia;
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97
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Sottero B, Gargiulo S, Russo I, Barale C, Poli G, Cavalot F. Postprandial Dysmetabolism and Oxidative Stress in Type 2 Diabetes: Pathogenetic Mechanisms and Therapeutic Strategies. Med Res Rev 2015; 35:968-1031. [PMID: 25943420 DOI: 10.1002/med.21349] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Postprandial dysmetabolism in type 2 diabetes (T2D) is known to impact the progression and evolution of this complex disease process. However, the underlying pathogenetic mechanisms still require full elucidation to provide guidance for disease prevention and treatment. This review focuses on the marked redox changes and inflammatory stimuli provoked by the spike in blood glucose and lipids in T2D individuals after meals. All the causes of exacerbated postprandial oxidative stress in T2D were analyzed, also considering the consequence of enhanced inflammation on vascular damage. Based on this in-depth analysis, current strategies of prevention and pharmacologic management of T2D were critically reexamined with particular emphasis on their potential redox-related rationale.
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Affiliation(s)
- Barbara Sottero
- Department of Clinical and Biological Sciences, University of Turin, San Luigi Gonzaga Hospital, Orbassano, Turin, 10043, Italy
| | - Simona Gargiulo
- Department of Clinical and Biological Sciences, University of Turin, San Luigi Gonzaga Hospital, Orbassano, Turin, 10043, Italy
| | - Isabella Russo
- Internal Medicine and Metabolic Disease Unit, Department of Clinical and Biological Sciences, University of Turin, San Luigi Gonzaga Hospital, Orbassano, Turin, 10043, Italy
| | - Cristina Barale
- Internal Medicine and Metabolic Disease Unit, Department of Clinical and Biological Sciences, University of Turin, San Luigi Gonzaga Hospital, Orbassano, Turin, 10043, Italy
| | - Giuseppe Poli
- Department of Clinical and Biological Sciences, University of Turin, San Luigi Gonzaga Hospital, Orbassano, Turin, 10043, Italy
| | - Franco Cavalot
- Internal Medicine and Metabolic Disease Unit, Department of Clinical and Biological Sciences, University of Turin, San Luigi Gonzaga Hospital, Orbassano, Turin, 10043, Italy
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98
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Udell JA, Cavender MA, Bhatt DL, Chatterjee S, Farkouh ME, Scirica BM. Glucose-lowering drugs or strategies and cardiovascular outcomes in patients with or at risk for type 2 diabetes: a meta-analysis of randomised controlled trials. Lancet Diabetes Endocrinol 2015; 3:356-66. [PMID: 25791290 DOI: 10.1016/s2213-8587(15)00044-3] [Citation(s) in RCA: 197] [Impact Index Per Article: 21.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2015] [Accepted: 03/02/2015] [Indexed: 12/11/2022]
Abstract
BACKGROUND Some glucose-lowering drugs or strategies adversely affect cardiovascular outcomes. We aimed to assess the extent to which glucose lowering by various drugs or strategies increases the risk of heart failure in patients with or at risk for type 2 diabetes, and to establish whether risk is associated with achieved differences in glycaemia or weight control. METHODS We searched Ovid Medline, the Cochrane Library, and meeting abstracts up to Feb 20, 2015, for large randomised controlled trials of glucose-lowering drugs or strategies that assessed cardiovascular outcomes. The primary endpoint was incidence of heart failure. We derived pooled risk ratios (RRs) with random-effects models. FINDINGS We included data from 14 trials, with mean duration 4·3 (2·3) years, comprising 95 502 patients, of whom 3907 (4%) patients developed a heart failure event. Glucose-lowering drugs or strategies were associated with a 0·50% (SD 0·33) reduction in HbA1c and a 1·7 kg (2·8) weight gain. Overall, glucose-lowering drugs or strategies increased the risk of heart failure compared with standard care (RR 1·14, 95% CI 1·01-1·30; p=0·041). The magnitude of this effect varied dependent on the method of glucose lowering (p for interaction=0·00021). Across drug classes, risk was highest with peroxisome proliferator-activated receptor agonists (RR 1·42, 95% CI 1·15-1·76; six trials), intermediate with dipeptidyl peptidase-4 inhibitors (1·25, 1·08-1·45; two trials), and neutral with insulin glargine (0·90, 0·77-1·05; one trial). Target-based intensive glycaemic control strategies (RR 1·00, 95% CI 0·88-1·13; four trials) and intensive weight loss (0·80, 95% CI 0·62-1·04; one trial) were also not associated with development of heart failure. Meta-regression analysis showed that for every 1·0 kg of weight gain associated with glucose-lowering drugs or strategies, there was a 7·1% (95% CI 1·0-13·6) relative increase in the risk of heart failure compared with standard care (p=0·022). INTERPRETATION Compared with standard care, glycaemic lowering by various drugs or strategies might increase the risk of heart failure, with the magnitude of risk dependent on the method of glucose lowering and, potentially, weight gain. FUNDING None.
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Affiliation(s)
- Jacob A Udell
- Women's College Research Institute and Cardiovascular Division, Department of Medicine, Women's College Hospital, Heart and Stroke/Richard Lewar Centre of Excellence, University of Toronto, Toronto, ON, Canada; Peter Munk Cardiac Centre, University Health Network, Heart and Stroke/Richard Lewar Centre of Excellence, University of Toronto, Toronto, ON, Canada.
| | - Matthew A Cavender
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Deepak L Bhatt
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Saurav Chatterjee
- Division of Cardiology, St Luke's-Roosevelt Hospital, Mount Sinai Health System, New York, NY, USA
| | - Michael E Farkouh
- Peter Munk Cardiac Centre, University Health Network, Heart and Stroke/Richard Lewar Centre of Excellence, University of Toronto, Toronto, ON, Canada
| | - Benjamin M Scirica
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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99
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Katalenich B, Shi L, Liu S, Shao H, McDuffie R, Carpio G, Thethi T, Fonseca V. Evaluation of a Remote Monitoring System for Diabetes Control. Clin Ther 2015; 37:1216-25. [PMID: 25869625 DOI: 10.1016/j.clinthera.2015.03.022] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2015] [Revised: 03/23/2015] [Accepted: 03/23/2015] [Indexed: 11/26/2022]
Abstract
PURPOSE The use of technology to implement cost-effective health care management on a large scale may be an alternative for diabetes management but needs to be evaluated in controlled trials. This study assessed the utility and cost-effectiveness of an automated Diabetes Remote Monitoring and Management System (DRMS) in glycemic control versus usual care. METHODS In this randomized, controlled study, patients with uncontrolled diabetes on insulin were randomized to use of the DRMS or usual care. Participants in both groups were followed up for 6 months and had 3 clinic visits at 0, 3, and 6 months. The DRMS used text messages or phone calls to remind patients to test their blood glucose and to report results via an automated system, with no human interaction unless a patient had severely high or low blood glucose. The DRMS made adjustments to insulin dose(s) based on validated algorithms. Participants reported medication adherence through the Morisky Medication Adherence Scale-8, and diabetes-specific quality of life through the diabetes Daily Quality of Life questionnaire. A cost-effectiveness analysis was conducted based on the estimated overall costs of DRMS and usual care. FINDINGS A total of 98 patients were enrolled (59 [60%] female; mean age, 59 years); 87 participants (89%) completed follow-up. HbA1c was similar between the DRMS and control groups at 3 months (7.60% vs 8.10%) and at 6 months (8.10% vs 7.90%). Changes from baseline to 6 months were not statistically significant for self-reported medication adherence and diabetes-specific quality of life, with the exception of the Daily Quality of Life-Social/Vocational Concerns subscale score (P = 0.04). IMPLICATIONS An automated system like the DRMS may improve glycemic control to the same degree as usual clinic care and may significantly improve the social/vocational aspects of quality of life. Cost-effectiveness analysis found DRMS to be cost-effective when compared to usual care and suggests DRMS has a good scale of economy for program scale up. Further research is needed to determine how to sustain the benefits seen with the automated system over longer periods.
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Affiliation(s)
- Bonnie Katalenich
- Tulane University Health Sciences Center, New Orleans, Louisiana; Southeast Louisiana Veterans Health Care Systems, New Orleans, Louisiana.
| | - Lizheng Shi
- Tulane University Health Sciences Center, New Orleans, Louisiana
| | - Shuqian Liu
- Tulane University Health Sciences Center, New Orleans, Louisiana
| | - Hui Shao
- Tulane University Health Sciences Center, New Orleans, Louisiana
| | - Roberta McDuffie
- Tulane University Health Sciences Center, New Orleans, Louisiana; Southeast Louisiana Veterans Health Care Systems, New Orleans, Louisiana
| | - Gandahari Carpio
- Tulane University Health Sciences Center, New Orleans, Louisiana; Southeast Louisiana Veterans Health Care Systems, New Orleans, Louisiana
| | - Tina Thethi
- Tulane University Health Sciences Center, New Orleans, Louisiana; Southeast Louisiana Veterans Health Care Systems, New Orleans, Louisiana
| | - Vivian Fonseca
- Tulane University Health Sciences Center, New Orleans, Louisiana; Southeast Louisiana Veterans Health Care Systems, New Orleans, Louisiana
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100
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Affiliation(s)
- John A. Bittl
- From the Munroe Heart and Vascular Institute, Munroe Regional Medical Center, Ocala, FL
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