(8) Cardiovascular disease and risk management

Contemporary Primary Prevention Aspirin Use by Cardiovascular Disease Risk: Impact of US Preventive Services Task Force Recommendations, 2007-2015: A Serial, Cross-sectional Study

BACKGROUND

No previous study has evaluated the impact of past US Preventive Services Task Force statements on primary prevention (PP) aspirin use in a primary care setting. The aim of this study was to evaluate temporal changes in PP aspirin use in a primary care population, stratifying patients by their 10-year global cardiovascular disease risk, in response to the 2009 statement.

METHODS AND RESULTS

This study estimated biannual aspirin use prevalence using electronic health record data from primary care clinics within the Fairview Health System (Minnesota) from 2007 to 2015. A total of 94 270 patient encounters had complete data to estimate a 10-year cardiovascular disease risk score using the 2013 American College of Cardiology/American Heart Association global risk estimator. Patients were stratified into low- (<10%), intermediate- (10-20%), and high- (≥20%) risk groups. Over the 9-year period, PP aspirin use averaged 43%. When stratified by low, intermediate and high risk, average PP aspirin use was 41%, 63%, and 73%, respectively. Average PP aspirin use decreased after the publication of the 2009 US Preventive Services Task Force recommendation statement: from 45% to 40% in the low-risk group; from 66% to 62% in the intermediate-risk group; and from 76% to 73% in the high-risk group, before and after the guideline.

CONCLUSIONS

Publication of the 2009 US Preventive Services Task Force recommendation was not associated with an increase in aspirin use. High risk PP patients utilized aspirin at high rates. Patients at intermediate risk were less intensively treated, and patients at low risk used aspirin at relatively high rates. These data may inform future aspirin guideline dissemination.

Quantifying sociodemographic and income disparities in medical therapy and lifestyle among symptomatic patients with suspected coronary artery disease: a cross-sectional study in North America

OBJECTIVES

To evaluate potential gaps in preventive medical therapy and healthy lifestyle practices among symptomatic patients with suspected coronary artery disease (CAD) seeing primary care physicians and cardiologists and how gaps vary by sociodemographic characteristics and baseline cardiovascular risk.

DESIGN

Cross-sectional study assessing potential preventive gaps.

PARTICIPANTS

10 003 symptomatic outpatients evaluated by primary care physicians, cardiologists or other specialists for suspected CAD.

SETTING

PROspective Multicenter Imaging Study for Evaluation of Chest Painfrom 2010 to 2014.

MEASURES

Primary measures were absence of an antihypertensive, statin or angiotensin-converting enzyme inhibitor/angiotensin receptor blocker for renal protection in patients with hypertension, dyslipidaemia or diabetes, respectively, and being sedentary, smoking or being obese.

RESULTS

Preventive treatment gaps affected 14% of patients with hypertension, 36% of patients with dyslipidaemia and 32% of patients with diabetes. Overall, 49% of patients were sedentary, 18% currently smoked and 48% were obese. Women were significantly more likely to not take a statin for dyslipidaemia and to be sedentary. Patients with lower socioeconomic status were also significantly more likely to not take a statin. Compared with Whites, Blacks were significantly more likely to be obese, while Asians were less likely to smoke or be obese. High-risk patients sometimes experienced larger preventive care gaps than low-risk patients. For patients with dyslipidaemia, the presence of a treatment gap was associated with a higher risk of an adverse event (HR 1.35, 95% CI 1.02 to 1.82).

CONCLUSIONS

Among contemporary, symptomatic patients with suspected CAD, significant gaps exist in preventive care and lifestyle practices, and high-risk patients sometimes had larger gaps. Differences by sex, age, race/ethnicity, socioeconomic status and geography are modest but contribute to disparities and have implications for improving opulation health. For patients with dyslipidaemia, the presence of a treatment gap was associated with a higher risk of an adverse event.

CLINICAL TRIAL REGISTRATION

Clinical Trials.gov identifier NCT01174550.

Changes in Proteinuria on the Risk of All-Cause Mortality in People with Diabetes or Prediabetes: A Prospective Cohort Study

BACKGROUND

Proteinuria has been related to all-cause mortality, showing regression or progression. However, few studies have focused on the relationship between proteinuria changes and all-cause mortality. The main purpose of this paper is to examine the associations between proteinuria changes and all-cause mortality in people with diabetes or prediabetes.

METHODS

Dipstick proteinuria at baseline and a 2-year follow-up were determined in the participants attending the Kailuan prospective cohort study. Participants were then divided into three categories: elevated proteinuria, stable proteinuria, and reduced proteinuria. Four Cox proportional hazard models were built to access the relations of proteinuria changes to all-cause mortality, adjusting for other confounding covariates.

RESULTS

A total of 17,878 participants were finally included in this study. There were 1193 deaths after a median follow-up of 6.69 years. After adjusting for major covariates and proteinuria at baseline, mortality risk was significantly associated with elevated proteinuria (hazard ratio (HR): 1.54, 95% confidence interval (CI): 1.33-1.79) and reduced proteinuria (HR: 0.70, 95% CI: 0.55-0.89), compared to those with stable proteinuria.

CONCLUSION

Proteinuria changes were independently associated with mortality risk in either diabetic or prediabetic population.

Physical inactivity and cardiac events: An analysis of the Detection of Ischemia in Asymptomatic Diabetics (DIAD) study

AIMS

Diabetes affects 29 million adults, and the majority have type 2 diabetes (T2D). Coronary artery disease (CAD) is the leading cause of death, and physical inactivity is an important risk factor. The aims of this study were to examine the contribution of physical inactivity to CAD events, and to identify the independent predictors of CAD events in a sample of older adults with T2D.

METHOD

A secondary data analysis of the prospective randomized screening trial "Detection of Ischemia in Asymptomatic Diabetics (DIAD)" study. Cox proportional hazard modeling was used to examine the outcome of CAD events.

RESULTS

During the five years of follow-up, the CAD event rate for all subjects (n = 1119) was 8.4% (n = 94). In unadjusted analysis, physical inactivity was significantly associated with development of a CAD event. In the final model, nine baseline variables were significant predictors (p < 0.05) of a CAD: physical inactivity, race, diabetes duration, hemoglobin A1c (HbA1c), peripheral numbness, insulin use, increasing waist-to-hip ratio, family history of premature CAD, and a higher pulse pressure. In men only, there were five predictors (p < 0.05) of a CAD event: diabetes duration, peripheral numbness, HbA1c, increasing waist-to-hip ratio, and higher pulse pressure. The final model in women included three independent predictors (p < 0.05) of a CAD event: diabetes duration, a family history of premature CAD, and higher pulse pressure.

CONCLUSION

Several variables predicted CAD events in this sample of older adults with T2D. Understanding baseline characteristics that heighten risk may assist providers in intervening early to prevent its occurrence.

Effect of Multifactorial Treatment Targets and Relative Importance of Hemoglobin A1c, Blood Pressure, and Low-Density Lipoprotein-Cholesterol on Cardiovascular Diseases in Chinese Primary Care Patients With Type 2 Diabetes Mellitus: A Population-Based Retrospective Cohort Study

BACKGROUND

The relative effect of hemoglobin A1c, blood pressure, and low-density lipoprotein-cholesterol (LDL-C) ("ABC" factors) on the prevention of cardiovascular diseases (CVD) among patients with type 2 diabetes mellitus is poorly understood. This study aimed to evaluate the association of key clinical parameters on CVD risk using a multifactorial optimal control approach in Chinese primary care patients with type 2 diabetes mellitus.

METHODS AND RESULTS

A population-based retrospective cohort study was conducted on 144 271 Chinese type 2 diabetes mellitus primary care patients, aged 18 to 79 and without prior clinical diagnosis of CVD in 2008-2011. Cox regressions were conducted to examine the association between the combinations of ABC targets (hemoglobin A1c <7%, blood pressure <130/90 mm Hg, and LDL-C <2.6 mmol/L) and risks of CVD (overall), coronary heart disease, stroke, and heart failure. Achieving more ABC targets incrementally reduced the incidence of total CVD and individual disease including coronary heart disease, stroke, and heart failure, irrespective of other patient characteristics. Compared with suboptimal control in all ABC levels, achieving any 1, 2, and all 3 ABC targets reduced the relative risk of CVD by 13% to 42%, 31% to 52%, and 55%, respectively. Among those achieving only 1 ABC target, LDL-C reduction was associated with the greatest CVD risk reduction (42%), followed by blood pressure reduction (18%), and hemoglobin A1c reduction (13%).

CONCLUSIONS

To achieve the greatest risk reduction for the incidence of CVD, the ultimate goal of treatment should be to achieve target control of hemoglobin A1c, blood pressure, and LDL-C. If it is not possible to achieve all 3 targets, efforts should be prioritized on treating the LDL-C to minimize CVD risk.

Hypertension and Type 2 Diabetes Are Associated With Decreased Inhibition of Dipeptidyl Peptidase-4 by Sitagliptin

Context

Patients with diabetes often have comorbidities such as hypertension. It is not known how individual characteristics influence response to dipeptidyl peptidase-4 (DPP4) inhibitors.

Objective

We tested the hypothesis that individual characteristics, sitagliptin dose, and genetic variability in DPP4 influence DPP4 activity during sitagliptin.

Design and Setting

Post hoc analysis of clinical and laboratory data from individuals randomized to sitagliptin versus placebo in crossover studies.

Patients and Interventions

Sixty-five subjects [27 with type 2 diabetes mellitus (T2DM) and hypertension, 38 healthy controls] were randomized to 100 mg/d sitagliptin or 200 mg sitagliptin and matching placebo in double-blind, crossover fashion. Fasting blood was obtained at baseline and 60 to 180 minutes after sitagliptin or placebo.

Main Outcome Measures

DPP4 activity and antigen during placebo and sitagliptin and DPP4 inhibition during sitagliptin.

Results

Sitagliptin 100 mg/d was less effective at inhibiting DPP4 activity in individuals with T2DM and hypertension than in healthy controls (P = 0.001, percent inhibition). In healthy controls, 100 mg/d sitagliptin was not as effective as single-dose 200 mg sitagliptin (P = 0.001, percent inhibition). DPP4 genotypes rs2909451 TT (P = 0.02) and rs759717 CC (P = 0.02) were associated with DPP4 activity during sitagliptin. In multivariable analyses, T2DM with hypertension, sitagliptin dose, age, systolic blood pressure, DPP4 activity during placebo, and rs2909451 genotype were significantly associated with DPP4 activity during sitagliptin.

Conclusions

Sitagliptin is less effective in inhibiting DPP4 in individuals with T2DM and hypertension than in healthy controls. Higher doses of DPP4 inhibitors may be required in patients with the metabolic syndrome.

Using Predicted Cardiovascular Disease Risk in Conjunction With Blood Pressure to Guide Antihypertensive Medication Treatment

Using cardiovascular disease (CVD) risk instead of or in addition to blood pressure (BP) to guide antihypertensive treatment is an active area of research. The purpose of this review is to provide an overview of studies that could inform this treatment paradigm. We review data from randomized trials on relative and absolute CVD risk reduction that can occur when antihypertensive treatment is guided by CVD risk. We also review population-level data on using CVD risk in conjunction with BP to guide antihypertensive treatment, the broad distribution in CVD risk for people with similar BP levels, and the use of CVD risk for guiding antihypertensive treatment among subgroups including older adults, young adults, and those with diabetes mellitus or chronic kidney disease. In addition, we review potential challenges in implementing antihypertensive treatment recommendations that incorporate CVD risk. In closing, we provide recommendations for using CVD risk in combination with BP to guide antihypertensive treatment.

Metabolic syndrome cluster does not provide incremental prognostic information in patients with stable cardiovascular disease: A post hoc analysis of the AIM-HIGH trial

BACKGROUND

Metabolic syndrome (MS) is a well-known risk factor for the development of cardiovascular (CV) disease; yet, controversy persists whether it adds incremental prognostic value in patients with established CV disease.

OBJECTIVES

This study was performed to determine if MS is associated with worse CV outcomes in patients with established CV disease treated intensively with statins.

METHODS

We performed a post hoc analysis of the Atherothrombosis Intervention in Metabolic Syndrome with Low HDL/High Triglycerides and Impact on Global Health Outcomes trial, in which patients with established CV disease and atherogenic dyslipidemia (n = 3414) were randomly assigned to receive extended release niacin or placebo during a mean 36-month follow-up, to assess whether the presence of MS or the number of MS components contributed to CV outcomes.

RESULTS

The composite primary end point of CV events occurred in 15.1% of patients without MS vs 13.8%, 16.9%, and 16.8% of patients with MS in the subsets with 3, 4, and 5 MS components, respectively (corresponding adjusted hazard ratios 0.9, 1.1, and 1.1 relative to patients without MS), P = .55. Comparing subgroups with 3 vs 4 or 5 MS components, there was no significant difference in either the composite primary end point or secondary end points. Patients with diabetes mellitus had higher event rates, with or without the presence of MS.

CONCLUSIONS

The presence of MS was not associated with worse CV outcomes in the AIM-HIGH population. The rate of CV events in statin-treated Atherothrombosis Intervention in Metabolic Syndrome with Low HDL/High Triglycerides and Impact on Global Health Outcomes patients with MS was not significantly influenced by the number of MS components.

Lipid-lowering efficacy and safety of alirocumab in patients with or without diabetes: A sub-analysis of ODYSSEY COMBO II

AIM

This sub-analysis of the ODYSSEY COMBO II study compared the effects of alirocumab, a proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitor, in high cardiovascular risk patients with or without diabetes mellitus (DM) receiving maximally tolerated statin therapy.

METHODS

COMBO II was a 104-week, double-blind study (n = 720) enrolling patients with documented atherosclerotic cardiovascular disease (ASCVD) and baseline LDL-C ≥70 mg/dL (1.8 mmol/L), and patients without documented ASCVD at high cardiovascular risk with LDL-C ≥100 mg/dL (2.6 mmol/L). Patients receiving maximally tolerated statin therapy were randomized (2:1) to alirocumab 75 mg every 2 weeks (Q2W; 1 mL subcutaneous injection) or oral ezetimibe 10 mg daily. Alirocumab dose was increased to 150 mg Q2W (also 1 mL) at Week 12 if Week 8 LDL-C was ≥70 mg/dL.

RESULTS

History of DM was reported in 31% (n = 148) of patients on alirocumab and 32% (n = 77) of patients on ezetimibe. At Week 24, alirocumab consistently reduced LDL-C from baseline in patients with (-49.1%) or without DM (-51.2%) to a significantly greater extent than ezetimibe (-18.4% and -21.8%, respectively). Occurrence of treatment-emergent adverse events was similar between groups. Efficacy results at 104 weeks were similar to those at 24 weeks.

CONCLUSIONS

Over a 104-week double-blind study period, alirocumab provided consistently greater LDL-C reductions than ezetimibe, with similar LDL-C results in patients with or without DM. Safety of alirocumab was similar regardless of baseline DM status.

Glycemic Control Status After Percutaneous Coronary Intervention and Long-Term Clinical Outcomes in Patients With Type 2 Diabetes Mellitus

BACKGROUND

Data on the association between glycemic control after percutaneous coronary intervention and clinical outcomes are limited and controversial in diabetic patients.

METHODS AND RESULTS

We studied 980 patients with type 2 diabetes mellitus undergoing percutaneous coronary intervention using drug-eluting stents. Based on 2-year glycosylated hemoglobin A (HbA1c) levels, we divided patients into 2 groups of HbA1c<7.0 (n=489) and HbA1c≥7.0 (n=491). Propensity score-matched analysis was performed in 322 pairs. The primary outcome was major adverse cardiac and cerebrovascular events (MACCE), defined as a composite of cardiac death, myocardial infarction, repeat revascularization, or stroke. Median follow-up duration was 5.4 years. The 7-year incidence of MACCE was lower in the HbA1c<7.0 group than in the HbA1c≥7.0 group (26.9% versus 40.3%; adjusted hazard ratio, 0.75; 95% confidence interval, 0.57-0.98; P=0.03). After propensity score matching, the 7-year incidence of MACCE was still lower in the HbA1c<7.0 group than in the HbA1c≥7.0 group (27.5% versus 37.4%; hazard ratio, 0.71; 95% confidence interval, 0.52-0.97; P=0.03), mainly because of a reduction in repeat revascularization (19.9% versus 29.5%; hazard ratio, 0.66; 95% confidence interval, 0.47-0.93; P=0.02). In subgroup analyses, the benefit of glycemic control for MACCE was more prominent in patients with residual SYNTAX score (Synergy Between PCI With Taxus and Cardiac Surgery) >4 than in those with the residual SYNTAX score ≤4 (P_interaction=0.004).

CONCLUSIONS

HbA1c<7.0 measured 2 years after percutaneous coronary intervention was associated with a reduced rate of MACCE. Our data suggest that high HbA1c levels 2 years after percutaneous coronary intervention may identify a population at increased risk of adverse events, especially repeat revascularization.

Dietary interventions to contrast the onset and progression of diabetic nephropathy: A critical survey of new data

This article is a critical overview of recent contributions on the dietary corrections and the foods that have been claimed to delay or hinder the onset of diabetic nephropathy (DN) and its progression to end-stage renal disease. Innovative dietary and behavioral approaches to the prevention and therapy of DN appear to be the most captivating in consideration of the rather well-established protocols for glucose and blood pressure control in use. In addition to restricted caloric intake to contrast obesity and the metabolic syndrome, adjustments in the patient's macronutrients intake, and in particular some degree of reduction in protein, have been long considered in the prevention of DN progression. More recently, the focus has shifted to the source of proteins and the content of glycotoxins in the diet as well as to the role of specific micronutrients. Few clinical trials have specifically addressed the role of those micronutrients associated with diet proteins that show the most protective effect against DN. Research on clinical outcome and mechanisms of action of such micronutrients appears the most promising in order to develop both effective intervention on nutritional education of the patient and selection of functional foods capable of contrasting the onset and progression of DN.

Silent coronary heart disease in patients with type 2 diabetes: application of a screening approach in a follow-up study

AIMS

The cost-effectiveness of screening for silent coronary heart disease (CHD) in type 2 diabetes (DM2) is still debated.

METHODS

We applied a diagnostic algorithm for silent CHD detection, in a cohort of 102 asymptomatic DM2 subjects (57±7years), attending 5 Italian outpatient clinics, to verify its predictive value. The risk of silent CHD was calculated considering classical risk factors, and presence of microangiopathy/macroangiopathy. Patients were divided in 3 groups, i.e. group 1: normal ECG and low silent CHD risk; group 2: abnormal ECG, irrespective of silent CHD risk; group 3: high silent CHD risk, irrespective of ECG. To group 2 and 3, a functional test was recommended and performed in 78% of patients.

RESULTS

Silent CHD prevalence was similar in group 2 and 3 (25 vs. 17% respectively; p=0.495). However, evaluating the entire cohort, a significant higher prevalence of silent CHD was observed in subjects with abnormal vs. normal ECG (23 vs. 4%; P=0.004), but not in subjects with high vs. low pre-test silent CHD risk (14 vs. 9%; p=0.472).

CONCLUSIONS

An abnormal ECG was a strong, independent predictor of silent CHD (OR 8.9; CI 1.27-62.5; p=0.028) in DM2. Therefore, a functional stress testing should be considered in DM2 patients with ECG abnormalities.

Presence, Characteristics, and Volumes of Coronary Plaque Determined by Computed Tomography Angiography in Young Type 2 Diabetes Mellitus

Prevention and management of coronary artery disease (CAD) is of great concern in patients with diabetes mellitus. Although the impact of coronary atherosclerosis is described well for subjects older than 40 years, the prevalence and types of coronary atherosclerosis in young patients are not well known. The aim of this study was to evaluate the prevalence, extent, severity, and volumes of coronary plaque in type 2 diabetes mellitus (T2DM) population younger than of 40 years. This prospective study enrolled 181 subjects (25-40 year old) undergoing coronary computed tomography angiography, with 86 T2DM and 95 nondiabetic age/gender-matched subjects. Coronary artery calcium (CAC), plaque assessment including total segment stenosis (sum of individual segmental stenosis), total plaque scores (sum of semiquantitative segmental plaque burden), segment involvement scores (number of segments with plaque) were evaluated. In addition, we quantitatively measured plaque volumes in total, fibrous, fibrous fatty, dense calcified, and low-attenuation plaque using novel plaque software. Compared with nondiabetic patients, the prevalence of CAD, calcified, and noncalcified plaques was higher in patients with T2DM (19% vs 58%; p <0.001). In patients with a zero CAC, T2DM had a higher prevalence (46%) of noncalcified plaque (p <0.0001). In multivariate linear regression models after adjusting for traditional cardiovascular risk factors, increased total segmental stenosis, total plaque scores, and segment involvement scores were associated with T2DM. Regarding quantitative plaque assessment, all volumes in noncalcified plaque type were approximately threefold higher in patients with T2DM. In conclusion, young patients with T2DM are susceptible to premature CAD with more calcified and noncalcified plaques. Early prevention program using computed tomography angiography might be helpful in identifying young diabetic patients with subclinical atherosclerosis.

Effect of lifestyle interventions on cardiovascular risk factors among adults without impaired glucose tolerance or diabetes: A systematic review and meta-analysis

Structured lifestyle interventions can reduce diabetes incidence and cardiovascular disease (CVD) risk among persons with impaired glucose tolerance (IGT), but it is unclear whether they should be implemented among persons without IGT. We conducted a systematic review and meta-analyses to assess the effectiveness of lifestyle interventions on CVD risk among adults without IGT or diabetes. We systematically searched MEDLINE, EMBASE, CINAHL, Web of Science, the Cochrane Library, and PsychInfo databases, from inception to May 4, 2016. We selected randomized controlled trials of lifestyle interventions, involving physical activity (PA), dietary (D), or combined strategies (PA+D) with follow-up duration ≥12 months. We excluded all studies that included individuals with IGT, confirmed by 2-hours oral glucose tolerance test (75g), but included all other studies recruiting populations with different glycemic levels. We stratified studies by baseline glycemic levels: (1) low-range group with mean fasting plasma glucose (FPG) <5.5mmol/L or glycated hemoglobin (A1C) <5.5%, and (2) high-range group with FPG ≥5.5mmol/L or A1C ≥5.5%, and synthesized data using random-effects models. Primary outcomes in this review included systolic blood pressure (SBP), diastolic blood pressure (DBP), total cholesterol (TC), low density lipoprotein cholesterol (LDL-C), high density lipoprotein cholesterol (HDL-C), and triglycerides (TG). Totally 79 studies met inclusion criteria. Compared to usual care (UC), lifestyle interventions achieved significant improvements in SBP (-2.16mmHg[95%CI, -2.93, -1.39]), DBP (-1.83mmHg[-2.34, -1.31]), TC (-0.10mmol/L[-0.15, -0.05]), LDL-C (-0.09mmol/L[-0.13, -0.04]), HDL-C (0.03mmol/L[0.01, 0.04]), and TG (-0.08mmol/L[-0.14, -0.03]). Similar effects were observed among both low-and high-range study groups except for TC and TG. Similar effects also appeared in SBP and DBP categories regardless of follow-up duration. PA+D interventions had larger improvement effects on CVD risk factors than PA alone interventions. In adults without IGT or diabetes, lifestyle interventions resulted in significant improvements in SBP, DBP, TC, LDL-C, HDL-C, and TG, and might further reduce CVD risk.

Bile acid sequestrants for glycemic control in patients with type 2 diabetes: A systematic review with meta-analysis of randomized controlled trials

AIM

To evaluate the effects of bile acid sequestrants (BASs) versus placebo, no intervention or active comparators on glycemic control in type 2 diabetes.

METHODS

Data were retrieved and a systematic review with meta-analyses was performed. We evaluated bias control and subgroup and sensitivity analyses were performed to evaluate heterogeneity and bias.

RESULTS

We included 17 trials with a total of 2950 patients randomized to BASs (colesevelam or colestimide) versus placebo, no intervention, statins or sitagliptin. Random-effects meta-analysis showed that patients randomized to BASs had a lower hemoglobin A_1c at the end of treatment compared with the control group (mean difference-0.55%; 95% confidence interval-0.64 to -0.46). Analysis of trials with low risk of bias in all domains confirmed the findings. Data on adverse events were limited. There were no differences between trials stratified by the control group and no evidence of publication bias or small study effects.

CONCLUSIONS

Our analyses found that BAS treatment improves glycemic control. The size of the effect was clinically relevant and despite limited safety data, our findings support the inclusion of BASs in current diabetes management algorithms for type 2 diabetes.

Targeting Select Cellular Stress Pathways to Prevent Hyperglycemia-Related Complications: Shifting the Paradigm

Despite the advances made in preventing complications of diabetes, there is still substantial residual risk. Hence the need for developing new therapeutic agents that target the various facets of the pathogenesis of complications in people with diabetes. Traditionally four general biochemical pathways had been recognized as major contributors to glucotoxicity. These include the polyol pathway, the protein kinase C (PKC) pathway, glycosylation pathway, and oxidative stress. The latter has been proposed as a common impetus of the other pathways of glucotoxicity. More recently, the cross talk between oxidative stress and other recognized cellular stresses such as endoplasmic reticulum (ER), inflammatory, and mitochondrial stresses has emerged as an important additional mechanism of glucotoxicity. The observation that targeting oxidative stress with antioxidants has been associated with unfavorable clinical outcomes and the recognition that in cell cultures antioxidants may aggravate ER stress, suggests that selective targeting of individual cellular stresses may not be sufficient for preventing glucotoxicity. Future efforts should focus on developing therapeutic agents that can ameliorate cellular stress globally by simultaneously targeting the oxidative, ER, mitochondrial, and inflammatory stresses.

Association Between Weight Change, Clinical Outcomes, and Health Care Costs in Patients with Type 2 Diabetes

BACKGROUND

Previous research suggests that weight loss is associated with decreases in health care costs among individuals with type 2 diabetes mellitus (T2DM) and that weight change can affect clinical measures, including hemoglobin A1c (A1c), low-density lipoprotein cholesterol (LDLC), and blood pressure. Previous research has also demonstrated more pronounced impact of weight change among patients with T2DM who are obese and have no evidence of cardiovascular disease (CVD).

OBJECTIVES

To (a) examine the association between weight change and all-cause and diabetes-related health care costs among patients with T2DM; (b) examine the association between weight change and select clinical measures among patients with T2DM; and (c) analyze a subgroup of obese patients with no previous CVD.

METHODS

This retrospective, observational cohort study used U.S. insurance claims linked to laboratory and electronic medical records. This study included patients with T2DM aged 18 years or older who added or switched to a nonmetformin antidiabetes medication after metformin monotherapy between January 1, 2007, and June 30, 2012 (date of add/switch was the index date). The primary predictor was percentage weight change (PWC) between a weight measurement at index and a follow-up measurement 6 months later; PWC ranged from negative (weight loss) to positive (weight gain). Outcomes, measured in the 12-month period beginning at the time of follow-up weight measurement, included all-cause and diabetes-related health care costs and achievement of thresholds for A1c, blood pressure, and LDL-C. Multivariable models quantified the association between PWC (linear effect) and study outcomes.

RESULTS

A total of 1,520 patients (mean age 55 years; 47% female) were included, with 780 patients (mean age 53 years; 51% female) in the subgroup sample. Mean (SD) index weight and PWC were 224.6 (52.8) lbs and +0.2% (4.7%) in the primary analysis, and 241.3 (47.3) lbs and -0.2% (4.6%) in the subgroup sample. In adjusted analyses, decreasing PWC was associated with decreasing diabetes-specific pharmacy costs (P < 0.001) in the primary analysis sample and with decreasing all-cause pharmacy costs (P = 0.018), diabetes-specific total costs (P = 0.039), diabetes-specific medical costs (P = 0.002), and diabetes-specific pharmacy costs (P < 0.001) in the subgroup sample. PWC was not associated with all-cause total health care costs or all-cause medical costs in either sample. In adjusted analyses, decreasing PWC was also associated with increasing odds of attaining the A1c goals of < 6.5% (P < 0.001) and < 7.0% (P < 0.001) in the primary analysis sample and increasing odds of attaining the A1c goals of < 6.5% (P < 0.001), < 7.0% (P < 0.001), and < 8.0% (P = 0.010) in the subgroup sample. PWC was not associated with any of the other clinical measures in either of the study samples.

CONCLUSIONS

This real-world study suggests that among patients with T2DM, weight loss over a short-term (6-month) period is associated with positive impact on attainment of A1c goals and decreased diabetes-specific pharmacy costs over the subsequent 12 months. In the subset of patients who were obese and had no previus CVD, weight loss over the 6-month period was also associated with decreased all-cause pharmacy costs, diabetes-specific medical costs, and diabetes-specific total health care costs. Future research is warranted to examine whether these associations change over longer-term periods of follow-up.

DISCLOSURES

This study was sponsored by AstraZeneca and Bristol-Myers Squibb. Truven Health Analytics received funding from Bristol-Myers Squibb and AstraZeneca to conduct this study. Mukherjee is an employee of Bristol-Myers Squibb. Bell and Sternhufvud are employees of AstraZeneca. Johnston, Stott-Miller, and McMorrow are employees of Truven Health Analytics. Nancy Smith is a consultant to Bristol-Myers Squibb and is employed by GreenKey Resources. Study concept was created by Mukherjee, Sternhufvud, Bell, and Johnston. Stott-Miller and McMorrow took the lead in data collection, along with Johnston, with data interpretation performed by Mukherjee, Sternhufvud, Smith, Stott-Miller, and Johnston. The manuscript was written by Mukherjee, Johnston, and Stott-Miller, along with Sternhufvud and Smith, and revised by Mukherjee, Smith, and Johnston, along with Sternhufvud and Stott-Miller.

A comparison of effects of DPP-4 inhibitor and SGLT2 inhibitor on lipid profile in patients with type 2 diabetes

BACKGROUND

Previous studies suggest that dipeptidyl peptidase-4 (DPP-4) inhibitors and sodium glucose cotransporter 2 (SGLT2) inhibitors have different effects on the lipid profile in patients with type 2 diabetes. We investigated the effects of DPP-4 inhibitors and SGLT2 inhibitors on the lipid profile in patients with type 2 diabetes.

METHODS

From January 2013 to December 2015, a total of 228 patients with type 2 diabetes who were receiving a DPP-4 inhibitor or SGLT2 inhibitor as add-on therapy to metformin and/or a sulfonylurea were consecutively enrolled. We compared the effects of DPP-4 inhibitors and SGLT2 inhibitors on the lipid profile at baseline and after 24 weeks of treatment. To compare lipid parameters between the two groups, we used the analysis of covariance (ANCOVA).

RESULTS

A total of 184 patients completed follow-up (mean age: 53.1 ± 6.9 years, mean duration of diabetes: 7.1 ± 5.7 years). From baseline to 24 weeks, HDL-cholesterol (HDL-C) levels were increased by 0.5 (95% CI, -0.9 to 2.0) mg/dl with a DPP-4 inhibitor and by 5.1 (95% CI, 3.0 to 7.1) mg/dl with an SGLT2 inhibitor (p = 0.001). LDL-cholesterol (LDL-C) levels were reduced by 8.4 (95% CI, -14.0 to -2.8) mg/dl with a DPP-4 inhibitor, but increased by 1.3 (95% CI, -5.1 to 7.6) mg/dl with an SGLT2 inhibitor (p = 0.046). There was no significant difference in the mean hemoglobin A1c (8.3 ± 1.1 vs. 8.0 ± 0.9%, p = 0.110) and in the change of total cholesterol (TC) (p = 0.836), triglyceride (TG) (p = 0.867), apolipoprotein A (p = 0.726), apolipoprotein B (p = 0.660), and lipoprotein (a) (p = 0.991) between the DPP-4 inhibitor and the SGLT2 inhibitor.

CONCLUSIONS

The SGLT2 inhibitor was associated with a significant increase in HDL-C and LDL-C after 24 weeks of SGLT2 inhibitor treatment in patients with type 2 diabetes compared with those with DPP-4 inhibitor treatment in this study.

TRIAL REGISTRATION

This study was conducted by retrospective medical record review.

Serum bilirubin concentrations and incident coronary heart disease risk among patients with type 2 diabetes: the Dongfeng-Tongji cohort

AIMS

Elevated serum bilirubin levels are associated with decreased coronary heart disease (CHD) risk in cross-sectional studies among diabetic patients, but prospective evidence is limited. We investigated the relationship of serum bilirubin levels with incident CHD risk among type 2 diabetes patients.

METHODS

In a prospective study of 2918 type 2 diabetes embedded in the Dongfeng-Tongji cohort, serum total bilirubin (TBil), direct bilirubin (DBil), and indirect bilirubin (IBil) were measured at baseline. Cox proportional hazards models were used to examine the association between serum bilirubin levels and CHD risk.

RESULTS

A total of 440 CHD cases were identified during 12,017 person-years of follow-up. Compared with extreme quartiles, the adjusted hazard ratio and 95% confidence interval of incident CHD were 0.74 (0.56-0.99) with P trend = 0.08 in IBil, while in TBil and DBil, the bilirubin-CHD associations were not significant. Moreover, serum TBil and IBil levels were interacted with drinking status on the risk of incident CHD (P interaction = 0.021 and 0.037, respectively), and the associations were evident in ever drinkers. In drinkers, when serum TBil or IBil concentrations increased 1 μmol/L, the CHD risk both decreased 6% (95% CIs 0.89-0.99 and 0.87-1.00, respectively).

CONCLUSIONS

Serum IBil levels were marginally related to decreased incident CHD risk among type 2 diabetes. Drinking could potentially enhance the associations of serum TBil and DBil levels with incident CHD risk.

The Role of the Pharmacist in Managing Type 2 Diabetes with Glucagon-Like Peptide-1 Receptor Agonists as Add-On Therapy

The prevalence and associated clinical burden of type 2 diabetes (T2D) is increasing in the USA and other countries. As a consequence, the role of the pharmacist in managing T2D is expanding, and it is becoming increasingly important for pharmacists to have a complete understanding of the disease course and treatment options. Pharmacists have a key role in the use of injectable therapies, including incretin-based treatment with glucagon-like peptide-1 receptor agonists (GLP-1RAs). This article discusses the role of the pharmacist in the management of patients with T2D, particularly with respect to the use of GLP-1RAs to achieve glycemic control. GLP-1RAs are a class of injectable agents used as an adjunct to diet and exercise to improve glycemic control in adults with T2D. GLP-1RAs have been shown to lower glucose levels, slow gastric emptying, enhance satiety, and reduce body weight without increasing the risk of hypoglycemia. GLP-1RAs currently approved in the USA include exenatide twice daily, liraglutide once daily, and albiglutide, dulaglutide, and exenatide once weekly. Pharmacists can work with physicians to help identify patients for whom GLP-1RA therapy is appropriate. In addition, pharmacists can educate patients regarding medication storage, preparation, and injection techniques, glycated hemoglobin (HbA_1c) targets, pre- and post-meal blood glucose goals, adverse events and management strategies, and the long-term benefits of reducing HbA_1c. As members of the diabetes care team, pharmacists play an important role in improving patient outcomes.

FUNDING

AstraZeneca.

Statin therapy reduces the likelihood of suboptimal blood pressure control among Ugandan adult diabetic patients

BACKGROUND

Hypertension is one of the recognized risk factors of cardiovascular diseases in adult diabetic patients. High prevalence of suboptimal blood pressure (BP) control has been well documented in the majority of studies assessing BP control in diabetic patients in sub-Saharan Africa. In Uganda, there is a dearth of similar studies. This study evaluated the prevalence and correlates of suboptimal BP control in an adult diabetic population in Uganda.

PATIENTS AND METHODS

This was a cross-sectional study that enrolled 425 eligible ambulatory adult diabetic patients attending three urban diabetic outpatient clinics over 11 months. Data about their sociodemographic characteristics and clinical history were collected using pre-tested questionnaires. Suboptimal BP control was defined according to the 2015 American Diabetes Association standards of diabetes care guideline as BP levels ≥140/90 mmHg.

RESULTS

The mean age of the study participants was 52.2±14.4 years, with the majority being females (283, 66.9%). Suboptimal BP control was documented in 192 (45.3%) study participants and was independently associated with the study site (private hospitals; odds ratio 2.01, 95% confidence interval 1.18-3.43, P=0.01) and use of statin therapy (odds ratio 0.5, 95% confidence interval 0.26-0.96, P=0.037).

CONCLUSION

Suboptimal BP control was highly prevalent in this study population. Strategies to improve optimal BP control, especially in the private hospitals, and the use of statin therapy should be encouraged in adult diabetic patients.

Protocol for the analysis of a natural experiment on the impact of the Affordable Care Act on diabetes care in community health centers

Background

It is hypothesized that Affordable Care Act (ACA) Medicaid expansions could substantially improve access to health insurance and healthcare services for patients at risk for diabetes mellitus (DM), with pre-DM, or already diagnosed with DM. The ACA called for every state to expand Medicaid coverage by 2014. In a 2012 legal challenge, the US Supreme Court ruled that states were not required to implement Medicaid expansions. This 'natural experiment' presents a unique opportunity to learn whether and to what extent Medicaid expansion can affect healthcare access and services for patients with DM risk, pre-DM, or DM.

Methods/design

Data from electronic health records (EHRs) from the Accelerating Data Value Across a National Community Health Center Network (ADVANCE) clinical data research network, which has data from >700 community health centers (CHCs), was included in the study. EHR data will be linked to Oregon Medicaid claims data. Data collection will include information on changes in health insurance, service receipt, and health outcomes, spanning 9 years (pre- and post-expansion), comparing states that expanded Medicaid, and those that did not. Patients included in this study will be diagnosed with DM, be at risk for DM, or have pre-DM, between the ages of 19 and 64, with ≥1 ambulatory visit. Sample size is estimated to be roughly 275,000 patients. Biostatistical analyses will include the difference-in-differences (DID) methodology and a generalized linear mixed model. Econometric analyses will include a DID two-part method to calculate the difference in Medicaid expenditures in Oregon among newly insured CHC patients.

Discussion

Findings will have national relevance on DM health services and outcomes and will be shared through national conferences and publications. The findings will provide information needed to impact the policy as it is related to access to health insurance and receipt of healthcare among a vulnerable population.

Trial registration

This project is registered with ClinicalTrials.gov (NCT02685384). Registered 18 May 2016.

Addition of or switch to insulin therapy in people treated with glucagon-like peptide-1 receptor agonists: A real-world study in 66 583 patients

BACKGROUND

Real world outcomes of addition or switch to insulin therapy in type 2 diabetes (T2DM) patients on glucagon-like paptide-1 receptor agonist (GLP-1RA) with inadequately controlled hyperglycaemia, are not known.

MATERIALS AND METHODS

Patients with T2DM (n = 66 583) with a minimum of 6 months of GLP-1RA treatment and without previous insulin treatment were selected. Those who added insulin (n = 39 599) or switched to insulin after GLP-1RA cessation (n = 4706) were identified. Adjusted changes in glycated haemoglobin (HbA1c), weight, systolic blood pressure (SBP), and LDL cholesterol were estimated over 24 months follow-up.

RESULTS

Among those who continued with GLP-1RA treatment without adding or switching to insulin, the highest adjusted mean HbA1c change was achieved within 6 months, with no further glycaemic benefits observed during 24 months of follow-up. Addition of insulin within 6 months of GLP-1RA initiation was associated with 18% higher odds of achieving HbA1c <7% at 24 months, compared with adding insulin later. At 24 months, those who added insulin reduced HbA1c significantly by 0.55%, while no glycaemic benefit was observed in those who switched to insulin. Irrespective of intensification with insulin, weight, SBP and LDL cholesterol were significantly reduced by 3 kg, 3 mm Hg, and 0.2 mmol/L, respectively, over 24 months.

CONCLUSIONS

Significant delay in intensification of treatment by addition of insulin is observed in patients with T2DM inadequately controlled with GLP-1RA. Earlier addition of insulin is associated with better glycaemic control, while switching to insulin is not clinically beneficial during 2 years of treatment. Non-responding patients on GLP-1RA would benefit from adding insulin therapy, rather than switching to insulin.

The effect of fluvastatin on cardiac fibrosis and angiotensin-converting enzyme-2 expression in glucose-controlled diabetic rat hearts

Independently of the lipid-lowering effects, statin has been reported to attenuate the development of diabetic cardiomyopathy. However, the effect of statin in glucose-controlled diabetic condition has not been demonstrated. We evaluated the effect of fluvastatin on cardiac function, fibrosis, and angiotensin-converting enzyme-2 (ACE2) expression in glucose-controlled diabetic rats. Male Wistar rats were randomly divided into four groups: control (Group C), diabetes (Group D), diabetes with insulin (Group I), and diabetes with insulin and fluvastatin (Group I+F). Diabetes was induced by a single injection of streptozotocin (65 mg/kg). After 8 weeks, the hearts were extracted following echocardiographic evaluation. Cardiac fibrosis was analyzed using Masson's trichrome stain. Collagens I and III and ACE2 expressions were evaluated by immunohistochemistry and western blot. Group D showed reduced cardiac systolic function compared to the other groups (all P < 0.05). However, diastolic function estimated by E/A ratio was significantly decreased in groups D and I (median: 0.88 and 1.45, respectively) compared to groups C and I+F (2.97 and 2.15) (all P < 0.05). Cardiac fibrosis was more severe in groups D and I than in groups C and I+F (all P < 0.05) on Masson's trichrome stain. On immunohistochemistry, ACE2 expression was significantly decreased only in group D (all P < 0.05). However, collagen I and III showed higher expressions in group D compared to groups C and I+F while no significant difference was observed compared with group I (all P < 0.05). On western blot, collagen I and ACE2 expressions in group D (median: 1.78 and 0.35, respectively) were significantly different from groups C (references: 1) and I+F (0.76 and 1.21) (all P < 0.05), but not from group I (1.19 and 0.92). Our study suggested a combination of fluvastatin and insulin would be more effective than insulin alone in diabetic hearts. However, the exact mechanism remains to be elucidated.

Risk Factors for Hearing Impairment among Adults with Diabetes: The Hispanic Community Health Study/Study of Latinos (HCHS/SOL)

AIM

The aim was to examine risk factors for hearing impairment among Hispanic/Latino adults with diabetes.

METHODS

Findings are based on 3384 participants aged 18-76 years with diagnosed or previously undetected diabetes who completed audiometric testing as part of the Hispanic Community Health Study/Study of Latinos. We defined hearing impairment as the pure-tone average (PTA) >25 decibels hearing level [dB HL] of pure-tone thresholds at high frequencies (3000, 4000, 6000, and 8000 Hz) in the worse ear and defined a second hearing impairment outcome with the additional requirement of PTA >25 dB HL of low/mid-frequency (500, 1000, and 2000 Hz) thresholds in the worse ear. We identified independent associations using logistic regression.

RESULTS

Controlling for age and Hispanic/Latino background, prevalence ratios for hearing impairment in the high plus low/mid frequencies were 1.35 (95% CI 1.07, 1.71) for current smoking, 1.64 (1.14, 2.38) for alcohol consumption (≥ 14 drinks/week for men or ≥ 7 drinks/week for women), and 1.29 (1.06, 1.56) for triglycerides ≥ 150 mg/dL. For high-frequency only hearing impairment, the prevalence ratio for estimated glomerular filtration rate 30-59 mL/min/1.73m2 was 1.23 (1.03, 1.47) adjusted for age and sex. People with family income less than $20,000 had almost twice the prevalence of hearing impairment (PR=1.93 (1.34, 2.78)) as people with income over $40,000.

CONCLUSIONS

Current smoking, alcohol consumption, high triglycerides, and chronic kidney disease are potentially preventable correlates of hearing impairment for persons with diabetes. Low income is a marker of increased likelihood of hearing impairment.

Diabetes, diabetes severity, and coronary heart disease risk equivalence: REasons for Geographic and Racial Differences in Stroke (REGARDS)

BACKGROUND

Evidence is mixed regarding whether diabetes confers equivalent risk of coronary heart disease (CHD) as prevalent CHD. We investigated whether diabetes and severe diabetes are CHD risk equivalents.

METHODS

At baseline, participants in the REasons for Geographic and Racial Differences in Stroke (REGARDS) study (black and white US adults ≥45 years old recruited in 2003-2007) were categorized as having prevalent CHD only (self-reported or electrocardiogram evidence; n = 3,043), diabetes only (self-reported or elevated glucose; n = 4,012), diabetes and prevalent CHD (n = 1,529), and neither diabetes nor prevalent CHD (n = 17,155). Participants with diabetes using insulin and/or with albuminuria (urinary albumin-to-creatinine ratio ≥30 mg/g) were categorized as having severe diabetes. Participants were followed up through 2011 for CHD events (myocardial infarction or fatal CHD).

RESULTS

During a mean follow-up of 5 years, 1,385 CHD events occurred. The hazard ratios of CHD events comparing participants with diabetes only, diabetes, and prevalent CHD and neither diabetes nor prevalent CHD with those with prevalent CHD were 0.65 (95% CI 0.54-0.77), 1.54 (95% CI 1.30-1.83), and 0.41 (95% CI 0.35-0.47), respectively, after adjustment for demographics and risk factors. Compared with participants with prevalent CHD, the hazard ratio of CHD events for participants with severe diabetes was 0.88 (95% CI 0.72-1.09).

CONCLUSIONS

Participants with diabetes had lower risk of CHD events than did those with prevalent CHD. However, participants with severe diabetes had similar risk to those with prevalent CHD. Diabetes severity may need consideration when deciding whether diabetes is a CHD risk equivalent.

Years of life gained by multifactorial intervention in patients with type 2 diabetes mellitus and microalbuminuria: 21 years follow-up on the Steno-2 randomised trial

AIMS/HYPOTHESIS

The aim of this work was to study the potential long-term impact of a 7.8 years intensified, multifactorial intervention in patients with type 2 diabetes mellitus and microalbuminuria in terms of gained years of life and years free from incident cardiovascular disease.

METHODS

The original intervention (mean treatment duration 7.8 years) involved 160 patients with type 2 diabetes and microalbuminuria who were randomly assigned (using sealed envelopes) to receive either conventional therapy or intensified, multifactorial treatment including both behavioural and pharmacological approaches. After 7.8 years the study continued as an observational follow-up with all patients receiving treatment as for the original intensive-therapy group. The primary endpoint of this follow-up 21.2 years after intervention start was difference in median survival time between the original treatment groups with and without incident cardiovascular disease. Non-fatal endpoints and causes of death were adjudicated by an external endpoint committee blinded for treatment allocation.

RESULTS

Thirty-eight intensive-therapy patients vs 55 conventional-therapy patients died during follow-up (HR 0.55 [95% CI 0.36, 0.83], p = 0.005). The patients in the intensive-therapy group survived for a median of 7.9 years longer than the conventional-therapy group patients. Median time before first cardiovascular event after randomisation was 8.1 years longer in the intensive-therapy group (p = 0.001). The hazard for all microvascular complications was decreased in the intensive-therapy group in the range 0.52 to 0.67, except for peripheral neuropathy (HR 1.12).

CONCLUSIONS/INTERPRETATION

At 21.2 years of follow-up of 7.8 years of intensified, multifactorial, target-driven treatment of type 2 diabetes with microalbuminuria, we demonstrate a median of 7.9 years of gain of life. The increase in lifespan is matched by time free from incident cardiovascular disease.

TRIAL REGISTRATION

ClinicalTrials.gov registration no. NCT00320008.

FUNDING

The study was funded by an unrestricted grant from Novo Nordisk A/S.

Comparative effectiveness of outpatient cardiovascular disease and diabetes care delivery between advanced practice providers and physician providers in primary care: Implications for care under the Affordable Care Act

BACKGROUND

The objective was to compare quality of diabetes and cardiovascular disease (CVD) care between advanced practice providers (APPs) and physicians in a primary care setting.

METHODS

We identified diabetes (n=1,022,588) and CVD (n=1,187,035) patients receiving primary care between October 2013 and September 2014 in 130 Veterans Affairs facilities. We compared glycemic control (hemoglobin A1c <7%) in diabetic patients, blood pressure (BP) <140/90 mmHg in diabetic or CVD patients, cholesterol control (low-density lipoprotein cholesterol<100 mg/dL, receiving a statin) in diabetic or CVD patients, and those receiving a β-blocker (with history of myocardial infarction in the last 2 years) among patients receiving care from physicians and APPs. We also compared the proportion meeting composite measure (glycemic, BP, and cholesterol control in diabetic patients; BP, cholesterol control, and receipt of β-blocker among eligible CVD patients).

RESULTS

Diabetic patients receiving care from APPs were statistically more likely to have glycemic (50% vs 51.4%, odds ratio [OR] 1.06 [1.05-1.08]) and BP control (77.5% vs 78.4%, OR 1.04 [1.03-1.06]), whereas patients receiving care from physicians were more likely to have cholesterol control (receipt of statin 68% vs 66.5%, OR 0.94 [0.93-0.95]) in adjusted models, although these differences are not clinically significant. Similar results were seen in CVD patients. Few patients met the composite measure (27.1% and 27.6% of diabetic and 54.0% and 54.8% of CVD patients receiving care from physicians and APPs, respectively).

CONCLUSIONS

Diabetes and CVD care quality was comparable between physicians and APPs with clinically insignificant differences. Regardless of provider type, there is a need to improve performance on eligible measures in diabetes or CVD patients.

Treatment Intensification for Hypertension in US Ambulatory Medical Care

Background

Hypertension is widely prevalent yet remains uncontrolled in nearly half of US hypertensive adults. Treatment intensification for hypertension reduces rates of major cardiovascular events and all‐cause mortality, but clinical inertia remains a notable impediment to further improving hypertension control. This study examines the likelihood and determinants of treatment intensification with new medication in US ambulatory medical care.

Methods and Results

Using the nationally representative National Ambulatory Medical Care Survey (2005–2012) and National Hospital Ambulatory Medical Care Survey (2005–2011), we identified adult primary care visits with diagnosed hypertension and documented blood pressure exceeding goal targets and assessed the weighted prevalence and odds ratios of treatment intensification by initiation or addition of new medication. Approximately 41.7 million yearly primary care visits (crude N: 14 064, 2005–2012) occurred among US hypertensive adults with documented blood pressure ≥140/90 mm Hg, where treatment intensification may be beneficial. However, only 7.0 million of these visits (95% confidence interval 6.2–7.8 million) received treatment intensification with new medication, a weighted prevalence of 16.8% (15.8% to 17.9%). This proportion was consistently low and decreased over time. This decline was largely driven by decreasing medication initiation levels among patients on no previous hypertension medications from 31.8% (26.0% to 38.4%) in 2007 to 17.4% (14.0% to 21.4%) in 2012, while medication addition levels remained more stable over time.

Conclusions

US hypertensive adults received treatment intensification with new medication in only 1 out of 6 primary care visits, a fraction that is declining over time. A profound increase in intensification remains a vast opportunity to maximally reduce hypertension‐related morbidity and mortality nationwide.

Comparison of Optimal Cardiovascular Risk Factor Management in Patients with Type 2 Diabetes Who Attended Urban Medical Health Center with those Attended a Tertiary Care Center: Experiences from Tehran, Iran

Background:

Diabetes is a leading cause of cardiovascular disease (CVD). Moreover, CVD accounts for primary cause of death among diabetic patients. Physicians, especially in the primary care setting, have effective role in the management of cardiovascular risk factors. Therefore, we aimed to compare the prevalence of modifiable cardiovascular risk factors in Type 2 diabetic patients attending to an urban health center as a primary care center with Institute of Endocrinology and Metabolism Diabetes Clinic (IEMDC) as a tertiary center.

Methods:

This cross-sectional study was performed on 200 adult diabetic patients attending urban health center (Abouzar Health Center) and 201 diabetic patients in a tertiary center. The patients’ cardiovascular risk factors including lipid profile, systolic and diastolic blood pressure (BP), and smoking history were recorded. The number of patients who did not achieve the target according to the American Diabetes Association guidelines was determined and compared.

Results:

The patients in urban health center were older than those who attending IEMDC (P = 0.004). The duration of diabetes was longer among urban center patients (P < 0.001). Comparison of cardiovascular risk factors between two groups of patients showed a significant number of patients with poor-controlled low-density lipoprotein (75% vs. 44.7%) and triglyceride (74% vs. 51.7%) in patients attending primary center (P < 0.001). However, the prevalence of high diastolic BP (60.6% vs. 44.5%) was significantly higher in patients attending IEMDC (P = 0.001). There was no significant difference between the two centers’ findings in glycosylated hemoglobin level, high-density lipoprotein level, and systolic BP.

Conclusions:

Both centers have failure in target achievement in some risk factors; however, the inability of the primary care center in controlling hyperlipidemia in comparison with the tertiary center is a serious warning to provide training about managing dyslipidemia in these centers.

Vejle Diabetes Biobank - a resource for studies of the etiologies of diabetes and its comorbidities

Aims

Carefully designed and established biobanks are considered one of the most essential resources to foster biomedical research as they provide cost-effective and rapid access to a vast variety of biological materials and related anthropometrics allowing for testing of various biomarkers as well as numerous original and pertinent bioclinical hypotheses related to human disease etiology and prognosis. The objective of the present study was to present the baseline data, design, and methods used for the establishment of the Vejle Diabetes Biobank. Further aims included assessment of the prevalence of diabetes and quality of diabetes treatment in a specified Danish region.

Methods

The Vejle Diabetes Biobank was established from 2007 to 2010 as a regional Biobank containing blood, DNA, and urine samples from patients with diabetes and a gender- and age-matched control population aged 25–75 years. Anthropometrics were obtained by physical examination, questionnaires, and interviews at the time of inclusion into the Biobank. The cohort was linked to the Danish Civil Registration System, the Danish National Patient Registry, and the Danish National Prescription Registry.

Results

In total, 4,255 nondiabetic individuals and 3,320 patients with diabetes were included. Type 2 diabetes (T2D) patients had a higher body mass index (30 kg/m²) than type 1 diabetes (T1D) patients (25 and 26 kg/m² in women and men, respectively) and control subjects (25 and 27 kg/m² in women and men, respectively). Fasting levels of plasma triglycerides and blood pressure were higher in T2D patients (1.5 mmol/L and 148/85 mmHg, respectively) compared with T1D patients (0.9 mmol/L and 139/81 mmHg, respectively), whereas glycated hemoglobin (HbA1c), plasma high density lipoprotein, low density lipoprotein, and total cholesterol were lower in T2D patients (51 mmol/mol, 1.2 mmol/L, 2.2 mmol/L, and 4.2 mmol/L, respectively) compared with findings in T1D patients (61 mmol/mol, 1.6 mmol/L, 2.3 mmol/L, and 4.4 mmol/L, respectively). At the time of inclusion into the Biobank, 56% of the T2D patients and 25% of T1D patients had an HbA1c <7% (53 mmol/mol). Only 28% and 34% of the T2D patients, respectively, reached treatment target for blood pressure and lipids.

Conclusion

The Vejle Diabetes Biobank represents one of the largest open diabetes case-control cohorts in Denmark. The Biobank invites collaborative investigations of diabetes and diabetes complication etiologies as well as studies of prognostic or predictive biomarkers.

Sex and age differences in the achievement of control targets in patients with type 2 diabetes: results from a population-based study in a South European region

Background

We aimed to determine the degree to which control targets of glycaemia and cardiovascular risk factors were achieved among patients with type 2 diabetes and to investigate sex- and age-related differences in this population.

Methods

This cross-sectional, population-based study was conducted in Spain. Glycated hemoglobin (HbA1c), blood pressure, LDL-c, HDL-c, triglycerides, BMI, and smoking history were obtained from electronic clinical primary care records (n = 32,638 cases). The proportions of patients who met control targets were determined according to sex and age groups. Comparisons between groups were conducted with t-tests for continuous variables, tests for trends in proportions for categorical and ordinal variables, and Pearson’s chi-square tests and binary logistic regression models for categorical variables.

Results

The overall proportions of patients with type 2 diabetes who met the target objectives for HbA1c (<7 %, 53 mmol/mol), blood pressure (130/80 mmHg), and LDL-cholesterol (100 mg/dl) were 60, 40 and 41 %, respectively. Women were less likely than men to meet the control targets of HbA1c (59 vs 61 %), LDL (35 vs 45 %), and HDL (58 vs 78 %). Patients under 65 years of age presented poorer control than older age groups. Only a minority of patients with type 2 diabetes met the composite target objectives for glycemic control, blood pressure, and LDL.

Conclusions

There are differential gaps in the control results of female patients and younger patients, which should prompt improvements in case management and care. There is room for further improvement in the cardiometabolic control of patients with type 2 diabetes.

Electronic supplementary material

The online version of this article (doi:10.1186/s12875-016-0533-9) contains supplementary material, which is available to authorized users.

Cardiovascular health in adults with type 1 diabetes

Adults with type 1 diabetes (T1D) are at risk for cardiovascular (CV) disease. Managing CV risk is an important prevention strategy. The American Heart Association has defined 7 factors for ideal CV health. The purpose of this 2016 secondary analysis was to assess the prevalence of 6 CV health factors in a sample of adults ≥18 (n=7153) in the T1D Exchange Clinic registry. CV health factors include: hemoglobin A1c (HbA1c) <7%, BMI<25kg/m2, blood pressure<120/80mmHg, total cholesterol <200mg/dL, non-smoking, and physical activity ≥150min/week. HbA1c<7% was substituted for the AHA health factor of fasting blood glucose. Frequencies of each factor were tabulated for the total sample and for each gender. Logistic regression examined variables associated with achievement of each CV health factor. The mean age was 37.14±17years. Mean HbA1c was 7.9±1.5%, and duration was 19.5±13.5years. The majority (54%) were working full or part-time. Achievement of CV health factors in the whole sample ranged from 27% (HbA1c<7%) to 94% nonsmoking. Achievement of some factors varied by gender. Common variables associated with several CV health factors included gender, education, employment, and T1D duration. This young sample exhibited low levels of some CV health factors, especially HbA1c and physical activity. Providers need to routinely assess and advise on management of all CV risk factors to prevent this common diabetes complication.

Associations between explorative dietary patterns and serum lipid levels and their interactions with ApoA5 and ApoE haplotype in patients with recently diagnosed type 2 diabetes

Aims

In patients with type 2 diabetes (T2D), responsiveness of serum lipid concentrations to dietary patterns may vary by genotype. The aims of the present study were to identify explorative dietary patterns and to examine their independent associations with serum lipid levels and interactions with apolipoprotein (Apo)A5 and ApoE variants among patients recently diagnosed with T2D.

Methods

Within a cross-sectional analysis, participants of the German Diabetes Study (n = 348) with mean T2D duration of 6 months were investigated for fasting serum lipid levels, ApoA5 and ApoE genotypes; food consumption frequencies were assessed by a food propensity questionnaire. Dietary patterns were derived using principal component analysis (PCA) and reduced rank regression (RRR), which extracts patterns explaining variation in serum lipid concentrations.

Results

PCA yielded interpretable dietary patterns which were, however, not related to serum lipid levels. Relevance of the RRR patterns varied by genotype: a preferred consumption of fruit gum, fruit juice, and potato dumpling, whilst avoiding fruits and vegetables independently associated with higher triglyceride levels among ApoA5*2. Patients in the highest compared to the lowest tertile of pattern adherence had 99 % higher triglycerides. Lower consumption frequencies of butter, cream cake, French fries, or high-percentage alcoholic beverages were independently related to lower LDL-cholesterol among ApoE2 carriers, with those in the highest compared to the lowest tertile of pattern adherence having 40 % lower LDL-cholesterol (both P_interaction < 0.05).

Conclusions

Our explorative data analyses suggest that associations of dietary patterns with triglycerides and LDL-cholesterol differ by ApoA5 and ApoE haplotype in recently diagnosed T2D.

Trial registration Clinicaltrials.gov: NCT01055093. Date of registration: January 22, 2010 (retrospectively registered). Date of enrolment of first participant to the trial: September 2005

Electronic supplementary material

The online version of this article (doi:10.1186/s12933-016-0455-9) contains supplementary material, which is available to authorized users.

Fasting plasma glucose levels and coronary artery calcification in subjects with impaired fasting glucose

BACKGROUND

Prediabetes is associated with an increased risk of cardiovascular disease (CVD). While the association of impaired glucose tolerance with CVD has been shown in many studies, the relationship between impaired fasting glucose (IFG) and CVD remains unclear.

OBJECTIVES

The purpose of this study was to compare the coronary artery calcium (CAC) scores of participants with normal fasting glucose versus those with IFG, according to fasting plasma glucose (FPG) levels, and to assess whether differences in CAC scores were independent of important confounders.

DESIGN

Retrospective study.

SETTING

Health Promotion Center of the University Hospital (Gyeonggi-do, South Korea), during the period 2010-2014.

PATIENTS AND METHODS

Participants were enrolled from the general population who visited for a medical check-up. CAC was assessed in asymptomatic individuals by multidetector computed tomography. Anthropometric parameters and metabolic profiles were also recorded. Subjects were divided into four fasting glucose groups. Participants with a history of CVD or diabetes mellitus were excluded.

MAIN OUTCOME MEASURES

Correlation between FPG and CAC scores, CAC score categories, and association between CAC score and FPG categories.

RESULTS

Of 1112 participants, 346 (34.2%) had a CAC score > 0. FPG values in the IFG patients were positively but weakly correlated with CAC scores (r=0.099, P=.001). The incidence of CAC differed according to FPG level (P < .001) and in Kruskal-Wallis test the mean CAC score differed by FPG group (P < .001). After adjustment for other factors in a multiple logistic regression analysis, those subjects with FPG >=110 mg/dL had a significantly higher risk of CAC than did subjects with normal fasting glucose (110.

Risk factors for cardiovascular disease and mortality events in adults with type 2 diabetes - a 10-year follow-up: Tehran Lipid and Glucose Study

BACKGROUND

To identify risk factors for cardiovascular disease (CVD) and mortality events in patients with type 2 diabetes and to calculate their population attributable fraction among a representative Iranian population.

METHODS

A total of 1198 patients with type 2 diabetes (504 men and 694 women), aged ≥30 years, without prevalent CVD, with a median follow-up of 10 years were included in current study. To examine the association between risk factors and their outcomes, multivariate sex-adjusted Cox proportional hazard regression models were used.

RESULTS

During the study, 281 and 172 participants experienced CVD and all-cause mortality events, respectively. Regarding CVD events, fasting plasma glucose (FPG) level of 7.22-<10 mmol/L [hazard ratio (HR): 1.46, 95% CI 1.12-1.96], FPG level ≥10 mmol/L (HR 2.04, 1.53-2.72), hypertension (HR 1.65, 1.28-2.13), hypercholesterolaemia (HR 1.96, 1.40-2.75) and high waist to hip ratio (HR 1.30, 0.99-1.70; p = 0.051) were significant predictors, and corresponding population attributable fractions were 9.76, 17.84, 23.26, 41.63 and 14.76%, respectively. Considering all-cause mortality events, hypertension (HR 1.70, 1.23-2.36), FPG level ≥10 mmol/L (HR 2.31, 1.55-3.20) and smoking (HR 1.45, 1.03-2.04) were significant predictors, and corresponding population attributable fractions were 25.81, 20.88 and 11.18%, respectively. Meanwhile, being overweight or obese was associated with lower all-cause and CVD mortality events.

CONCLUSIONS

Among modifiable risk factors in patients with type 2 diabetes, hypercholesterolaemia and central adiposity for CVD, smoking for mortality events and hypertension and poor glycaemic control for both outcomes need to be paid most attention by healthcare professionals. Copyright © 2016 John Wiley & Sons, Ltd.

Management of Hypercholesterolemia, Appropriateness of Therapeutic Approaches and New Drugs in Patients with High Cardiovascular Risk

Control of lipid levels is one of the most effective strategies for cardiovascular (CV) event prevention. In fact, many clinical trials have clearly demonstrated that low-density lipoprotein cholesterol (LDL-C) lowering, primarily with statins, reduces major CV events and mortality. The evidence from these trials has been useful in designing the cholesterol treatment guidelines, which are mainly aimed at preventing and managing cardiovascular disease (CVD). However, available data indicate that a large proportion of patients fail to achieve lipid goals, and this is particularly frequent in patients at high or very high CV risk. Furthermore, owing to side effects, a significant percentage of patients cannot tolerate statin treatment. Hence, researchers have focused their attention on novel LDL-C-lowering agents that act via mechanisms distinct from that of statins. Among the new compounds under investigation, the monoclonal antibodies to proprotein convertase subtilisin/kexin type 9 (PCSK9) seem particularly promising, having recently been shown to be well tolerated and highly effective at lowering LDL-C, with a possible effect on the occurrence of CV events. Currently, alirocumab is approved by the US Food and Drug Administration (FDA) as an adjunct to diet and maximally tolerated statin therapy for use in adults with heterozygous familial hypercholesterolemia (FH) or those with atherosclerotic CV disease who require additional LDL-C lowering; it has also been recently approved by the European Medicines Agency (EMA) for use in patients with heterozygous FH, non–familial hypercholesterolemia or mixed dyslipidemia in whom statins are ineffective or not tolerated. Evolocumab is approved by the FDA as an adjunct to diet and maximally tolerated statins for adults with hetero- and homozygous FH and those with atherosclerotic CV disease who require additional lowering of LDL-C, and by the EMA in adults with primary hypercholesterolemia or mixed dyslipidemia, as an adjunct to diet, in combination with a statin or a statin with other lipid lowering therapies in patients unable to reach LDL-C goals with the maximum tolerated dose of a statin; alone or in combination with other lipid lowering therapies in patients who are statin-intolerant, or those for whom a statin is contraindicated. Evolocumab is also indicated in adults and adolescents aged 12 years and over with homozygous familial hypercholesterolemia in combination with other lipid-lowering therapies.

Enhancing Access to Diabetes Self-management Education in Primary Care

Purpose

The purpose of this continuous quality improvement project was to improve access to diabetes self-management education (DSME) and to evaluate the impact on glycemic and weight control by translating an academic medical center’s DSME program, accredited per the Education Recognition Program (ERP) of the American Diabetes Association, into a program offered at primary care clinics (PCCs).

Methods

Certified diabetes educators from the medical center trained PCC registered dietitian nutritionists, registered nurses, and social workers to provide DSME in their community-based clinic. Main outcomes of this retrospective, pretest/posttest, observational project were to evaluate enrollment in DSME classes and change in A1C and weight as patients underwent a combined intervention of diabetes education classes with or without consultation and support from a PCC registered dietitian nutritionist or registered nurse.

Results

PCC DSME was associated with increased enrollment in DSME classes and a significant reduction of A1C and weight at 3 and 6 months post-DSME. Greatest A1C and weight reductions were observed in patients with newly diagnosed diabetes. Reductions were also seen in patients with diabetes duration ≥10 years, participants taking insulin, and those with depression.

Conclusions

PCC DSME availability increased access to group diabetes education and resulted in reduced A1C and weight for participants. This model was successful in translating an established academic accredited DSME-ERP into a PCC. Results have implications for increasing access to diabetes education programs and improving diabetes control for patients not located near major hospital-based DSME programs.

Heat shock protein-70 and hypoxia inducible factor-1α in type 2 diabetes mellitus patients complicated with retinopathy

PURPOSE

To elucidate the role of heat shock protein-70 (HSP70) and hypoxia inducible factor-1α (HIF-1α) in diabetic retinopathy (DR) patients.

DESIGN AND METHODS

A comparative study was done on the serum level of both HSP70 and HIF-1α in 50 patients with type 2 diabetes mellitus (T2DM) without DR, 50 patients with T2DM and DR and 70 healthy control subjects.

RESULTS

HSP70 and HIF-1α were significantly increased in T2DM patients compared to controls and increased in patients with T2DM & DR compared to T2DM patients without DR (p < 0.0001). HSP70 did not differ among the patients with different stages of DR, while HIF-1α increased significantly in grades 3 and 4 DR patients compared to grades 1 and 2 DR patients. A strong correlation was found between HIF-1α and the development of DR (r = 0.835, p = 0.00) but not with HSP70. HIF-1α can be used as a predictor for development of DR but not HSP70.

CONCLUSIONS

Our study was the first that investigated both HSP70 and HIF-1α in humans and was the first that measured their levels in serum of patients with DR. The study suggested that HSP70 might have a protective function in T2DM patients rather than a therapeutic function. HIF-1α had an upper hand in the development and progression of DR. Induction of HSP70 and blockage of HIF-1α could lead to the development of novel prophylactic and therapeutic strategies for DR and potentially other diabetic complications.

HDL Cholesterol as a Residual Risk Factor for Vascular Events and All-Cause Mortality in Patients With Type 2 Diabetes

OBJECTIVE

To evaluate whether low HDL cholesterol (HDL-c) levels are a risk factor for cardiovascular disease and mortality in patients with type 2 diabetes and whether it remains a residual risk factor when attaining low LDL cholesterol (LDL-c) treatment goals or when LDL-c is treated with intensive lipid-lowering therapy.

RESEARCH DESIGN AND METHODS

We performed a prospective cohort study of 1,829 patients with type 2 diabetes included in the Second Manifestations of ARTerial disease (SMART) cohort. Cox proportional hazard models were used to evaluate the risk of HDL-c on cardiovascular events and all-cause mortality. Analyses were performed in strata of LDL-c levels (<2.0, 2.0-2.5, and >2.5 mmol/L) and lipid-lowering therapy intensity and were adjusted for age, sex, BMI, smoking, alcohol, LDL-c, triglycerides, systolic blood pressure, estimated glomerular filtration rate, glucose, and HbA1c.

RESULTS

A total of 335 new cardiovascular events and 385 deaths occurred during a median follow-up of 7.0 years (interquartile range 3.9-10.4). No relation was found between plasma HDL-c and cardiovascular events (hazard ratio [HR] 0.97, 95% CI 0.93-1.01) or all-cause mortality (HR 0.99, 95% CI 0.96-1.03). Subgroup analysis supported effect modification by plasma LDL-c levels. In patients with LDL-c levels <2.0 mmol/L, higher HDL-c was related to higher risk for all-cause mortality (HR 1.14, 95% CI 1.07-1.21). Higher HDL-c was also related to higher risk for cardiovascular events in patients with LDL-c levels <2.0 mmol/L (HR 1.10, 95% CI 1.07-1.21) in contrast to patients with LDL-c levels between 2.0 and 2.5 mmol/L (HR 0.85, 95% CI 0.75-0.95) and >2.5 mmol/L (HR 0.96, 95% CI 0.91-1.00).

CONCLUSIONS

In high-risk patients with type 2 diabetes with LDL-c levels <2.0 mmol/L, higher HDL-c at baseline is unexpectedly related to a higher risk for cardiovascular events and all-cause mortality in contrast to high-risk patients with type 2 diabetes with LDL-c levels between 2.0 and 2.5 mmol/L.

Vascular Disease in Young Indians (20-40 years): Role of Hypertension

Hypertension (HTN) being one of the important risk factors for cardiovascular disease (CVD) is a significant health concern, especially in India. With age, prevalence of HTN, especially systolic HTN increases. Special attention needs to be directed to HTN in young ages (20-40 years) due to lower awareness, need for early treatment and better control of HTN. HTN in the age group of 20-40 years needs critical reappraisal. Given the high prevalence of HTN in the general population in India, in this review we attempt to provide current evidence and expert opinion on epidemiology, aetiopathogenesis and treatment of HTN in young (20-40 years) Indians.

Pharmacologic Therapy of Type 2 Diabetes

Type 2 diabetes (T2DM) is a common condition. Treatment of diabetes and related complications can be complex. In addition to lifestyle changes, medications play an important role in controlling patients' blood glucose levels and preventing complications. From an individual and societal standpoint, it is also an expensive disease. Medical spending attributed to diabetes per individual is significant. With appropriate therapy, patients can lead full, healthy lives with the disease, so making informed decisions regarding pharmacotherapy for T2DM is clearly of great importance.

Association between statins and infections among patients with diabetes: a cohort and prescription sequence symmetry analysis

Purpose

A previous meta‐analysis of randomized trials did not confirm findings from observational studies that suggested that statins reduce the risk of infection. However, animal experiments indicate that statins may be more effective in reducing the risk and/or the severity of infection among patients with diabetes. Hence, we evaluated the effect of statins on antibiotic prescriptions (a proxy for infections) among patients with drug‐treated type 2 diabetes using two confounding‐reducing observational designs.

Methods

We conducted a prescription sequence symmetry analysis and a cohort study using the IADB.nl pharmacy prescription database. For the prescription sequence symmetry analysis, a sequence ratio was calculated. The matched cohort study, comparing the time to first antibiotic prescription between periods that statins are initiated and non‐use periods, was analyzed using stratified Cox regression.

Results

Prescription sequence symmetry analysis of 4684 patients with drug‐treated type 2 diabetes resulted in an adjusted sequence ratio of 0.86 (95% confidence interval [CI]: 0.81 to 0.91). Corresponding figures for the cohort analysis comparing 9852 statin‐initiation with 4928 non‐use periods showed similar results (adjusted hazard ratio: 0.88, 95%CI: 0.83 to 0.95).

Conclusions

These findings suggest that statins are associated with a reduced risk of infections among patients with drug‐treated type 2 diabetes. © 2016 The Authors. Pharmacoepidemiology and Drug Safety Published by John Wiley & Sons Ltd.

Shared care management of patients with type 2 diabetes across the primary and secondary healthcare sectors: study protocol for a randomised controlled trial

BACKGROUND

The prevalence of type 2 diabetes (T2D) is growing globally and hospital-based outpatient clinics are burdened with increasing numbers of patients. To ensure high quality treatment and care, it is necessary to structurally reorganise the management of patients with T2D. The objective of this study is to test if T2D patients (who are at intermediate risk of or are already having incipient diabetic complications) jointly managed by a hospital-based outpatient clinic and general practitioners (shared care programme) have a non-inferior outcome compared to an established programme in a specialised (hospital based) outpatient diabetes clinic.

METHODS

The study is designed as a randomised controlled trial. The shared care model will be tested during a period of 3 years, with data collection at baseline and at 12, 24 and 36 months. All patients will be offered four medical visits a year; the shared care intervention consists of one annual comprehensive check-up at the outpatient clinic and three quarterly visits at the general practitioners' office. The control group will be followed with four quarterly visits at the outpatient clinic, including an annual comprehensive check-up. In the outpatient clinic, the patients will be treated by a specialised diabetes team, including an endocrinologist. On the basis of a predefined stratification model, we will recruit patients stratified to be at intermediate risk of or already having incipient diabetic complications. We plan to include 140 patients. The primary outcome is glycated haemoglobin. Other outcome measures include (1) the proportion of patients who meet the Danish standard indicators reflecting quality of care; (2) quality of life measured by Short Form 36; and (3) the functionality of the patients' families measured by Family Assessment Measure III. The experiences of the patients and families when participating in the shared care program will be explored by collecting dyadic interviews.

DISCUSSION

This study will evaluate the quality of a shared care programme for patients with T2D, and provide evidence about advantages and disadvantages compared with a programme in a specialised outpatient clinic. The results may provide important information on how to organise the care for patients with T2D in the future.

TRIAL REGISTRATION

This trial was registered with Clinicaltrials.gov on 21 October 2015, registration number: NCT02586545 .