Cardiovascular Disease and Risk Management: Standards of Medical Care in Diabetes-2020

Aspirin for primary prevention of cardiovascular disease: a review of recent literature and updated guideline recommendations

INTRODUCTION

Recent clinical trials evaluating the efficacy of aspirin in primary prevention of atherosclerotic cardiovascular disease (ASCVD) have suggested the risk of aspirin may outweigh its benefit in individuals once thought to be candidates for aspirin therapy. These results led to the publication of updated guideline recommendations in 2019 for aspirin use in primary prevention of cardiovascular disease from the American College of Cardiology (ACC) and American Heart Association (AHA).

AREAS COVERED

Recent clinical trials and guidelines relevant to aspirin for primary prevention of ASCVD were identified using PubMed® (July 1, 2016 to April 1, 2019). Studies were limited to randomized, controlled clinical trials. The most current clinical practice guidelines were prioritized.

EXPERT OPINION

Recent clinical trials demonstrated an increased risk of bleeding associated with aspirin use, which often outweighed cardiovascular risk reduction. In light of this new evidence, the ACC/AHA guidelines recommend aspirin for primary prevention in patients 40-70 years of age at a high ASCVD risk and low bleeding risk, who are unable to optimally control modifiable ASCVD risk factors.

Cardiovascular safety outcomes of once-weekly GLP-1 receptor agonists in people with type 2 diabetes

WHAT IS KNOWN AND OBJECTIVE

People with type 2 diabetes (T2D) are at increased risk of cardiovascular disease (CVD), which in turn is associated with increased morbidity and mortality. The impact of glucagon-like peptide-1 receptor agonists (GLP-1 RAs) on cardiovascular (CV) outcomes has been investigated in CV outcomes trials (CVOTs). This review aims to help pharmacists and other healthcare professionals (HCPs) gain a better understanding of such CVOTs in T2D with a primary focus on the once-weekly (QW) GLP-1 RAs.

METHODS

This narrative review mainly focuses on the evaluation of the similarities and differences in the design and results of CVOTs involving currently approved and marketed QW GLP-1 RAs-semaglutide subcutaneous, exenatide extended-release (ER) and dulaglutide. Results from CVOTs of dipeptidyl peptidase-4 inhibitors (DPP4is) and sodium-glucose cotransporter-2 inhibitors (SGLT2is) are also included.

RESULTS AND DISCUSSION

Three CVOTs of QW GLP-1 RAs were identified for inclusion in this review: SUSTAIN 6 (semaglutide), EXSCEL (exenatide ER) and REWIND (dulaglutide), all of which varied in terms of trial design, patient demographics and other baseline characteristics. Results from these CVOTs demonstrated the CV safety of QW GLP-1 RAs compared with standard of care. Additionally, CV and renal benefits were demonstrated for semaglutide and dulaglutide, but not for exenatide ER. The CV safety of four DPP4is and three SGLT2is was demonstrated. None of the DPP4is had a CV or renal benefit, whereas all three SGLT2is were associated with CV and renal benefits.

WHAT IS NEW AND CONCLUSION

This article provides an overview of the results from QW GLP-1 RA CVOTs, including the recently published results for dulaglutide, and places them within the broader T2D treatment landscape to help HCPs make informed decisions in daily practice. The QW GLP-1 RAs with benefits reaching beyond glycaemic control can provide a comprehensive treatment option for people with T2D at high risk of CVD, with CVD or chronic kidney disease.

The efficacy and safety of SGLT2 inhibitors combined with ACEI/ARBs in the treatment of type 2 diabetes mellitus: A meta-analysis of randomized controlled studies

BACKGROUND

The efficacy and safety of the combination therapy with sodium-glucose cotransporter 2 (SGLT2) inhibitors and angiotensin-converting enzyme inhibitors (ACEI)/angiotensin receptor blockers (ARBs) in the treatment of type 2 diabetes mellitus (T2DM) was not clear yet.

RESEARCH DESIGN AND METHODS

A meta-analysis of randomized controlled studies (RCTs) was performed by searching in CENTRAL, Web of Science, PubMed, and Embase.

RESULTS

Eight RCTs involving 6,386 participants were finally enrolled in this meta-analysis. Compared with placebo plus ACEI/ARBs, combined therapy with SGLT2 inhibitors and ACEI/ARBs induced a significant reduction in glycated hemoglobin (HbA1c) level by 0.43% (95% confidence interval [CI]: -0.55, -0.31), fasting plasma glucose level by 16.51 mg/dL (95% CI: -21.94, -11.08); systolic/diastolic blood pressure (BP) by 5.34 mmHg (95% CI: -7.47, -3.21)/1.27 mmHg (95% CI: -1.95, -0.59), respectively; and body weight (BW) by 1.45 kg (95% CI: -2.24, -0.65). Combined therapy was also found to be associated with a lower risk of adverse events. However, a higher risk of genital infections was observed with combination therapy than with placebo.

CONCLUSIONS

This combination therapy showed satisfactory effects on lowering glycemic, BW, and BP in the treatment of T2DM patients. The safety of this combination therapy was also acceptable.

AI-based prediction for the risk of coronary heart disease among patients with type 2 diabetes mellitus

Type 2 diabetes mellitus (T2DM) is one common chronic disease caused by insulin secretion disorder that often leads to severe outcomes and even death due to complications, among which coronary heart disease (CHD) represents the most common and severe one. Given a huge number of T2DM patients, it is thus increasingly important to identify the ones with high risks of CHD complication but the quantitative method is still not available. Here, we first curated a dataset of 1,273 T2DM patients including 304 and 969 ones with or without CHD, respectively. We then trained an artificial intelligence (AI) model using randomly selected 4/5 of the dataset and use the rest data to validate the performance of the model. The result showed that the model achieved an AUC of 0.77 (fivefold cross-validation) on the training dataset and 0.80 on the testing dataset. To further confirm the performance of the presented model, we recruited 1,253 new T2DM patients as totally independent testing dataset including 200 and 1,053 ones with or without CHD. And the model achieved an AUC of 0.71. In addition, we implemented a model to quantitatively evaluate the risk contribution of each feature, which is thus able to present personalized guidance for specific individuals. Finally, an online web server for the model was built. This study presented an AI model to determine the risk of T2DM patients to develop to CHD, which has potential value in providing early warning personalized guidance of CHD risk for both T2DM patients and clinicians.

Predicting the Development of Myocardial Infarction in Middle-Aged Adults with Type 2 Diabetes: A Risk Model Generated from a Nationwide Population-Based Cohort Study in Korea

BACKGROUND

Most of the widely used prediction models for cardiovascular disease are known to overestimate the risk of this disease in Asians. We aimed to generate a risk model for predicting myocardial infarction (MI) in middle-aged Korean subjects with type 2 diabetes.

METHODS

A total of 1,272,992 subjects with type 2 diabetes aged 40 to 64 who received health examinations from 2009 to 2012 were recruited from the Korean National Health Insurance database. Seventy percent of the subjects (n=891,095) were sampled to develop the risk prediction model, and the remaining 30% (n=381,897) were used for internal validation. A Cox proportional hazards regression model and Cox coefficients were used to derive a risk scoring system. Twelve risk variables were selected, and a risk nomogram was created to estimate the 5-year risk of MI.

RESULTS

During 7.1 years of follow-up, 24,809 cases of MI (1.9%) were observed. Age, sex, smoking status, regular exercise, body mass index, chronic kidney disease, duration of diabetes, number of anti-diabetic medications, fasting blood glucose, systolic blood pressure, total cholesterol, and atrial fibrillation were significant risk factors for the development of MI and were incorporated into the risk model. The concordance index for MI prediction was 0.682 (95% confidence interval [CI], 0.678 to 0.686) in the development cohort and 0.669 (95% CI, 0.663 to 0.675) in the validation cohort.

CONCLUSION

A novel risk engine was generated for predicting the development of MI among middle-aged Korean adults with type 2 diabetes. This model may provide useful information for identifying high-risk patients and improving quality of care.

Cost of macrovascular complications in people with diabetes from a public healthcare perspective: a retrospective database study in Brazil

Aims: To evaluate costs in patients with diabetes who experienced a macrovascular complication from a Brazilian public healthcare system perspective.Materials and methods: A retrospective, observational study that utilized the database of the Brazilian Unified Health System (DATASUS). Data for direct medical costs (hospitalization and outpatient) were extracted for patients with diabetes and a macrovascular complication (1 January 2012-31 December 2018) and converted to US Dollars (2019 USD). Mixed-effects logistic regression explored associations between demographic and clinical characteristics with the incurrence of high direct medical costs.Results: In total, 1,668 (0.2%) patients with diabetes met study inclusion criteria and experienced a macrovascular complication, either alone (N = 1,193) or together with a microvascular complication (N = 475). Median [95% CI] annual costs (USD/patient) were 130.5 [90.7; 264.2] at baseline, increasing to 334.0 [182.2; 923.5] in the first year after the complication. The odds of incurring high costs were significantly elevated in the first and second year (vs. baseline), and in patients who experienced a macrovascular and microvascular complication (vs. macrovascular alone) (all p < 0.001).Limitations: The DATASUS database does not cover primary care (it covers secondary and tertiary care), adding a selection bias to the sample. Additionally, our findings may not be representative of the entire Brazilian population given that approximately 75% of the population of Brazil depend exclusively on the SUS, while the remaining 25% have some access to private healthcare.Conclusions: This study has demonstrated higher medical costs from the perspective of the Brazilian public healthcare system in patients with diabetes after experiencing a macrovascular complication, either alone or in conjunction with a microvascular complication, in comparison with costs before the complication(s). In addition to providing up-to-date cost estimates, our findings highlight the need to implement strategies to reduce the cardiovascular risk in Brazilian patients with diabetes and drive cost savings.

Managing the multifaceted nature of type 2 diabetes using once-weekly injectable GLP-1 receptor agonist therapy

WHAT IS KNOWN AND OBJECTIVE

As a highly prevalent chronic condition associated with complications and high mortality rates, it is important for pharmacists to have a comprehensive understanding of the impact of type 2 diabetes (T2D) and available treatment options. The use of injectable glucagon-like peptide 1 receptor agonists (GLP-1 RAs) is recommended as an effective and convenient treatment regimen for improving glycaemic control in individuals with T2D, with a good safety profile; however, the wider extent of its potential benefits often are unknown to clinical pharmacists. The objective of this article is to provide an overview of the impact of T2D on individuals and to discuss the multifaceted role of once-weekly (QW) GLP-1 RAs in addressing these challenges.

METHODS

This is a narrative review of the published literature regarding the use of injectable GLP-1 RAs in managing health complications in people with T2D.

RESULTS AND DISCUSSION

Recent findings reveal additional benefits of GLP-1 RAs in managing T2D complications, including atherosclerotic cardiovascular (CV) disease, retinopathy, neuropathy, and nephropathy. Dulaglutide and semaglutide have been shown to provide additional CV benefit in patients at high risk of CV events compared with standard of care/placebo and may offer renal protection in patients with chronic kidney disease. Cost-effectiveness studies, taking into consideration these different complications, have shown that QW GLP-1 RAs were cost-effective compared with other therapies. GLP-1 RAs may also help to improve overall health-related quality of life, reducing the risk of depression and 'diabetes distress', and limiting the risk of hypoglycaemia.

WHAT IS NEW AND CONCLUSION

From the literature, this appears to be the first review of the evidence supporting the multifaceted role of QW GLP-1 RAs in T2D, with particular emphasis on their use in comorbid conditions, as well as associated potential financial and well-being benefits. The results suggest that QW GLP-1 RAs may be an attractive treatment option for improving glycaemic control in T2D, especially in individuals with (or at risk of) additional comorbidities or health complications.

Legacy effect of intensive glucose control on major adverse cardiovascular outcome: Systematic review and meta-analyses of trials according to different scenarios

BACKGROUND

Early and intensive glycaemic control provides long-term protection against the development of microvascular complications, a phenomenon defined legacy effect. Whether a legacy effect of high glucose exists also on macrovascular endpoints is uncertain.

METHODS AND FINDINGS

We performed a systematic review of both randomized clinical trials (RCT)s and observational studies pertinent to the research question. We searched PubMed, Embase, Scopus and the Cochrane database up to January 31th 2020. Eligibility criteria for RCTs were: 1 - efficacy assessment of intensive glucose lowering treatment vs a less-stringent/conventional treatment; 2 - the inclusion of a post-active phase, observational follow-up; 3 - enrolment of patients with T1DM, pre-diabetes, and T2DM; and 4 - data report on major adverse cardiovascular events (MACE) incidence, which was the primary endpoint of this meta-analysis. We performed multiple meta-analyses of the available RCTs according to different scenarios considering the type of diabetes, diabetes duration, the presence of previous cardiovascular events, follow-up extension, and the incidence of MACE recorded only during the observational, post-active phase of the trials. Results from observational studies reporting the association between HbA1c levels during the first year after diabetes diagnosis and subsequent MACE incidence were also collected and are reported narratively. We included data from 7 RCTs and 40,346 patients. The intensive glucose-lowering approach significantly decrease the incidence of MACE compared with conventional treatment (OR 0.86, CI 0.77-0.96; p = 0.007) when considering all the available studies, with a more consistent effect (OR 0.73, CI 0.56-0.94; p = 0.01) in the case of RCTs enrolling patients with diabetes duration <10 years, and an even more pronounced protection (OR 0.64, 48 CI 0.48, 0.86; p = 0.003) when analysing only RCTs enrolling patients without previous cardiovascular events at baseline. Considering only RCTs with a post-trial follow-up >10 years also yielded a relevant beneficial effect of the intensive approach (OR 0.71, CI 0.57, 0.88; p = 0.002). On the other hand, no effect was observed (OR 0.99, CI 0.92, 1.06; p = 0.81) when considering only the events recorded during the post-active, observational phases of the trials. Observational studies showed that HbA1c values >6.5% or 7% during the first year of diabetes diagnosis are associated with a higher incidence of late MACE with increased risk ranging from 19 up to 64%, according to the different study design and HbA1c stratification.

CONCLUSIONS

These results support the recommendation regarding glucose-lowering treatment intensification in order to decrease the probability of having a macrovascular event in patients with short diabetes duration, no prevalent cardiovascular diseases, and long life-expectancy. On the other side, data from RCTs do not support the existence of a protective legacy effect on the macrovasculature beyond the period of intensive glycaemic treatment.

Cardiac Computed Tomography for Personalized Management of Patients With Type 2 Diabetes Mellitus

The incidence and prevalence of type 2 diabetes mellitus are increasing in the United States and worldwide. The individual-level risk of atherosclerotic cardiovascular disease events in primary prevention populations with type 2 diabetes mellitus is highly heterogeneous. Accurate risk stratification in this group is paramount to optimize the use of preventive therapies. Herein, we review the use of the coronary artery calcium score as a decision aid in individuals with type 2 diabetes mellitus without clinical atherosclerotic cardiovascular disease to guide the use of preventive pharmacotherapies, such as aspirin, lipid-lowering mediations, and cardiometabolic agents. The magnitude of expected risk reduction for each of these therapies must be weighed against its cost and potential adverse events. Coronary artery calcium has the potential to improve risk stratification in select individuals beyond clinical and laboratory risk factors, thus providing a more granular assessment of the expected net benefit with each therapy. In patients with diabetes mellitus and stable chest pain, coronary computed tomography angiography increases the sensitivity for coronary artery disease diagnoses compared with functional studies because of the detection of nonobstructive atherosclerosis. Most importantly, this anatomic approach may improve cardiovascular outcomes by increasing the use of evidence-based preventive therapies informed by plaque burden. We therefore provide an updated discussion of the pivotal role of coronary computed tomography angiography in the workup of stable chest pain in patients with diabetes mellitus in the context of recent landmark trials, such as PROMISE trial (Prospective Multicenter Imaging Study for Evaluation of Chest Pain), SCOT-HEART trial (Scottish Computed Tomography of the Heart), and ISCHEMIA trial (International Study of Comparative Health Effectiveness with Medical and Invasive Approaches). Finally, we also outline the current role of coronary computed tomography angiography in acute chest pain presentations.

Cardiometabolic medicine - the US perspective on a new subspecialty

The high prevalence of cardiovascular disease and worldwide diabetes epidemic has created an ever-increasing burden on the healthcare system. This calls for the creation of a new medicine subspecialty: cardiometabolic medicine. Using information from review articles listed on PubMed and professional society guidelines, the authors advocate for a cardiometabolic medicine specialization training program. The curriculum would integrate relevant knowledge and skills of cardiology and endocrinology as well as content of other disciplines essential to the optimal care of cardiometabolic patients, such as epidemiology, biostatistics, behavioral science and psychology. Cardiometabolic medicine should be seen as an opportunity for life-long learning, with core concepts introduced in medical school and continuing through CME courses for practicing physicians. To improve care for complex patients with multiple co-morbidities, a paradigm shift must occur, transforming siloed education, and treatment and training to interdisciplinary and collaborative work.

Individualized Therapy for Hypothyroidism: Is T4 Enough for Everyone?

CONTEXT

It is well recognized that some hypothyroid patients on levothyroxine (LT4) remain symptomatic, but why patients are susceptible to this condition, why symptoms persist, and what is the role of combination therapy with LT4 and liothyronine (LT3), are questions that remain unclear. Here we explore evidence of abnormal thyroid hormone (TH) metabolism in LT4-treated patients, and offer a rationale for why some patients perceive LT4 therapy as a failure.

EVIDENCE ACQUISITION

This review is based on a collection of primary and review literature gathered from a PubMed search of "hypothyroidism," "levothyroxine," "liothyronine," and "desiccated thyroid extract," among other keywords. PubMed searches were supplemented by Google Scholar and the authors' prior knowledge of the subject.

EVIDENCE SYNTHESIS

In most LT4-treated patients, normalization of serum thyrotropin levels results in decreased serum T3/T4 ratio, with relatively lower serum T3 levels; in at least 15% of the cases, serum T3 levels are below normal. These changes can lead to a reduction in TH action, which would explain the slower rate of metabolism and elevated serum cholesterol levels. A small percentage of patients might also experience persistent symptoms of hypothyroidism, with impaired cognition and tiredness. We propose that such patients carry a key clinical factor, for example, specific genetic and/or immunologic makeup, that is well compensated while the thyroid function is normal but might become apparent when compounded with relatively lower serum T3 levels.

CONCLUSIONS

After excluding other explanations, physicians should openly discuss and consider therapy with LT4 and LT3 with those hypothyroid patients who have persistent symptoms or metabolic abnormalities despite normalization of serum thyrotropin level. New clinical trials focused on symptomatic patients, genetic makeup, and comorbidities, with the statistical power to identify differences between monotherapy and combination therapy, are needed.

Influence of Renin-Angiotensin System Inhibitors on Lower-Respiratory Tract Infections in Type 2 Diabetes: The Fremantle Diabetes Study Phase II

OBJECTIVE

To determine whether ACE inhibitors (ACEi) and angiotensin receptor blockers (ARB) protect against lower-respiratory tract infections complicating type 2 diabetes.

RESEARCH DESIGN AND METHODS

Of 1,732 participants with diabetes recruited to the longitudinal observational Fremantle Diabetes Study Phase II (FDS2) between 2008 and 2011, 1,482 had confirmed type 2 diabetes (mean age 65.8 years and median diabetes duration 9.0 years; 51.6% were male). All were followed for hospitalizations for or with, or deaths from, pneumonia/influenza, ascertained from validated administrative data linkage from study entry to end of 2016. Cox regression and competing risk regression were used to identify independent predictors of this outcome.

RESULTS

Two-thirds of participants (n = 982) were taking an ACEi and/or ARB at study entry (498 [33.6%] ACEi, 408 [27.5%] ARB, 76 [5.1%] both). During 9,511 person-years of follow-up (mean ± SD 6.4 ± 2.0 years), 174 participants had incident pneumonia/influenza (156 hospitalizations and 18 deaths without hospitalization). In Cox regression analysis, baseline ACEi/ARB use was independently associated with a reduced risk of incident pneumonia/influenza (cause-specific hazard ratio [HR] 0.64 [95% CI 0.45, 0.89], P = 0.008). Allowing for the competing risk of death did not change this finding (subdistribution HR 0.67 [0.48, 0.95], P = 0.024), and similar reductions were seen for ACEi, ARB alone, and ACEi/ARB combination therapy. There was no significant change in use of ACEi/ARB during follow-up [interaction with ln(time), P = 0.70]. Other significant predictors of incident pneumonia/influenza were previously reported, clinically plausible variables.

CONCLUSIONS

ACEi/ARB reduce the risk of pneumonia/influenza in people with type 2 diabetes.

Lipid-lowering treatment and low-density lipoprotein cholesterol target achievement in patients with type 2 diabetes and acute coronary syndrome

BACKGROUND

Patients with type 2 diabetes mellitus characteristically display an atherogenic lipid profile with high triglyceride concentrations, low high-density lipoprotein cholesterol (HDL-C) concentrations and low-density lipoprotein cholesterol (LDL-C) concentrations not always elevated. It is unclear if patients with diabetes who present with an acute coronary syndrome (ACS) receive different or more-potent lipid-lowering therapy (LLT).

AIMS

To investigate lipid abnormalities in patients with and without type 2 diabetes hospitalised for an ACS, and use of LLT before admission and 4 months after the event.

METHODS

Patients were included in the observational DYSIS II study if they were hospitalised for an ACS and had a full lipid profile.

RESULTS

Of 3803 patients, diabetes was documented in 1344 (54.7%). Compared to patients without diabetes, those with diabetes had a lower mean LDL-C (101.2 vs. 112.0mg/dL; 2.6 vs. 2.9mmol/L; P<0.0001), with a greater proportion attaining concentrations<70mg/dL (1.8mmol/L) (23.9% vs. 16.0%; P<0.0001) and<55mg/dL (1.4mmol/L) (11.3% vs. 7.3%; P<0.0001), a higher mean triglyceride concentration (139.0 vs. 121.0mg/dL; 1.6 vs. 1.4mmol/L; P<0.0001) and a lower HDL-C concentration. LLT was more commonly given to patients with diabetes (77.5% vs. 58.8%; P<0.0001); there were no differences in types of therapy prescribed. Four months after hospitalisation, most patients from both groups were being treated with LLT (predominantly statin monotherapy).

CONCLUSIONS

Despite the different lipid profiles, the type of LLT prescribed did not vary depending on the presence or absence of type 2 diabetes. There was no difference in LLT in patients with and without diabetes at 4-month follow-up, except for fibrates, which were used in 2% of patients with and 1% of patients without diabetes. Statin monotherapy of intermediate potency was the predominant treatment in both groups.

Admission fasting plasma glucose is associated with in-hospital outcomes in patients with acute coronary syndrome and diabetes: findings from the improving Care for Cardiovascular Disease in China - Acute Coronary Syndrome (CCC-ACS) project

Background

The discrepancy between glycosylated hemoglobin (HbA_1c) and fasting plasma glucose (FPG) in clinical practice may be related to factors such as acute stress, renal dysfunction, and anemia, and its relationship with in-hospital outcomes is uncertain. The aim of this study was to investigate the association between the type of discrepancy between HbA_1c and FPG and in-hospital outcomes in patients with acute coronary syndrome (ACS) and diabetes.

Methods

The Improving Care for Cardiovascular Disease in China - Acute Coronary Syndrome (CCC-ACS) project is a national, hospital-based quality improvement project with an ongoing database. Patients with ACS, diabetes and complete HbA_1c and FPG values at admission were included. The consistent group included patients with HbA_1c < 6.5% and FPG < 7.0 mmol/L or HbA_1c ≥ 6.5% and FPG ≥ 7.0 mmol/L. The discrepancy group included patients with HbA_1c ≥ 6.5% and FPG < 7.0 mmol/L (increased HbA_1c group) or HbA_1c < 6.5% and FPG ≥ 7.0 mmol/L (increased FBG group).

Results

A total of 7762 patients were included in this study. The numbers of patients in the consistent and discrepancy groups were 5490 and 2272 respectively. In the discrepancy group, increased HbA_1c accounted for 77.5% of discrepancies, and increased FPG accounted for 22.5% of discrepancies. After adjusting for confounders, patients in the increased FPG group had a 1.6-fold increased risk of heart failure (OR, 1.62; 95% CI, 1.08–2.44), a 1.6-fold increased risk of composite cardiovascular death and heart failure (OR, 1.63; 95% CI, 1.09–2.43), and a 1.6-fold increased risk of composite major adverse cardiovascular and cerebrovascular events (MACCEs) and heart failure (OR, 1.56; 95% CI, 1.08–2.24) compared to patients in the increased HbA_1c group.

Conclusions

Patients with an increased FPG but normal HbA_1c had a higher risk of in-hospital adverse outcomes than those with increased HbA_1c but normal FPG. This result may indicate that when HbA_1c and FPG are inconsistent in patients with ACS and diabetes, the increased FPG that may be caused by stress hyperglycemia may have a more substantial adverse effect than increased HbA_1c, which may be caused by chronic hyperglycemia. These high-risk patients should be given more attention and closer monitoring in clinical practice.

Trial registry

Clinicaltrial.gov, NCT02306616. Registered 29 November 2014.

SUCCESSFUL REIMPLEMENTATION OF A VERY LOW CARBOHYDRATE KETOGENIC DIET AFTER SGLT2 INHIBITOR ASSOCIATED EUGLYCEMIC DIABETIC KETOACIDOSIS

Objective

We report a case of a successful reimplementation of a very low carbohydrate ketogenic diet (VLCKD) after a case of euglycemic diabetic ketoacidosis (euDKA).

Methods

A 42-year-old female with a history of type 2 diabetes mellitus on a self-administered VLCKD was prescribed a sodium-glucose co-transporter 2 (SGLT2) inhibitor. Two weeks after initiation, she presented with nausea and vomiting and was found to be in euDKA which was treated with fluid resuscitation, insulin infusion, and cessation of the SGLT2 inhibitor. She was discharged on insulin and instructed not to resume a VLCKD.

Results

After discharge, the patient experienced rapid weight gain and deteriorating glycemic control and desired to resume a VLCKD. She was referred to a university-based medical weight loss clinic that specializes in a VLCKD. The patient was monitored with daily contact via the electronic health record's patient portal and serial laboratory testing while her carbohydrate intake was slowly reduced and her insulin titrated off. She has safely remained in ketosis for 2 years without a further episode of euDKA.

Conclusion

As the clinical use of SGLT2 inhibitors and the VLCKD both become increasingly common, it is vital for practitioners to be aware that the combination can lead to euDKA. We present a case of successfully resuming a VLCKD after recovering from euDKA and cessation of SGLT2 inhibitor therapy.

Risks and Impact of Angiotensin-Converting Enzyme Inhibitors or Angiotensin-Receptor Blockers on SARS-CoV-2 Infection in Adults: A Living Systematic Review

BACKGROUND

The role of angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin-receptor blockers (ARBs) in coronavirus disease 2019 (COVID-19) susceptibility, severity, and treatment is unclear.

PURPOSE

To evaluate, on an ongoing basis, whether use of ACEIs or ARBs either increases risk for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection or is associated with worse COVID-19 disease outcomes, and to assess the efficacy of these medications for COVID-19 treatment.

DATA SOURCES

MEDLINE (Ovid) and Cochrane Database of Systematic Reviews from 2003 to 4 May 2020, with planned ongoing surveillance for 1 year; the World Health Organization database of COVID-19 publications and medRxiv.org through 17 April 2020; and ClinicalTrials.gov to 24 April 2020, with planned ongoing surveillance.

STUDY SELECTION

Observational studies and trials in adults that examined associations and effects of ACEIs or ARBs on risk for SARS-CoV-2 infection and COVID-19 disease severity and mortality.

DATA EXTRACTION

Single-reviewer abstraction confirmed by another reviewer, independent evaluation by 2 reviewers of study quality, and collective assessment of certainty of evidence.

DATA SYNTHESIS

Two retrospective cohort studies found that ACEI and ARB use was not associated with a higher likelihood of receiving a positive SARS-CoV-2 test result, and 1 case-control study found no association with COVID-19 illness in a large community (moderate-certainty evidence). Fourteen observational studies, involving a total of 23 565 adults with COVID-19, showed consistent evidence that neither medication was associated with more severe COVID-19 illness (high-certainty evidence). Four registered randomized trials plan to evaluate ACEIs and ARBs for treatment of COVID-19.

LIMITATION

Half the studies were small and did not adjust for important confounding variables.

CONCLUSION

High-certainty evidence suggests that ACEI or ARB use is not associated with more severe COVID-19 disease, and moderate-certainty evidence suggests no association between use of these medications and positive SARS-CoV-2 test results among symptomatic patients. Whether these medications increase the risk for mild or asymptomatic disease or are beneficial in COVID-19 treatment remains uncertain.

PRIMARY FUNDING SOURCE

None. (PROSPERO: registration number pending).

The 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA Guidelines on the Management of Blood Cholesterol in Diabetes

The American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines recently published its 2018 recommendations on management of LDL cholesterol (LDL-C) in people with diabetes. For primary prevention, moderate-intensity statin therapy is recommended for those aged 40-75 years, with a preference for high-intensity statin treatment for older subjects and for those with higher estimated risk or risk-enhancing factors following a patient-clinician discussion. Statin therapy may be reasonable in adults <40 years or >75 years of age where there is less evidence for benefit. For people with diabetes and established atherosclerotic cardiovascular disease, high-intensity statin therapy is recommended. The majority of these subjects have very high risk, and an LDL-C goal of <70 mg/dL is recommended. If this target is not achieved, ezetimibe and/or a proprotein convertase subtilisin/kexin type 9 inhibitor may be added.

Lipid management for cardiovascular risk reduction in type 1 diabetes

PURPOSE OF REVIEW

To review the recent evidence for lipid management in type 1 diabetes (T1D) for cardiovascular risk reduction.

RECENT FINDINGS

Individuals with T1D are at increased risk for cardiovascular morbidity and mortality, with atherosclerosis beginning as early as adolescence. Elevated low-density lipoprotein cholesterol (LDL-C), triglycerides, and lipoprotein (a) are associated with increased cardiovascular risk in T1D. Although high-density lipoprotein cholesterol (HDL-C) in T1D is often normal or higher than in nondiabetic controls, HDL in T1D has structural alterations, which make it proatherogenic rather than cardioprotective. Similarly, although LDL-C is not particularly elevated in T1D, LDL still contributes to cardiovascular risk. Studies in individuals with diabetes have primarily included T2D participants, with a much smaller number of T1D participants; such studies have shown that lipid-lowering therapies, such as statins, ezetimibe, and proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors reduce LDL-C levels and cardiovascular events in both those with and without diabetes. Individuals with T1D have increased cholesterol absorption, suggesting that ezetimibe may be particularly effective in T1D. Results of the REDUCE-IT trial show cardiovascular risk reduction from high-dose omega-3 fatty acid (Icosapent Ethyl) therapy in patients with diabetes (primarily type 2 diabetes), independent of triglyceride lowering, but similar data in T1D are currently lacking.

SUMMARY

Individuals with T1D are at high risk of cardiovascular disease, necessitating close lipid monitoring and management from adolescence through adulthood.

Relationship between improvement of glycaemic control and reduction of major cardiovascular events in 15 cardiovascular outcome trials: A meta-analysis with meta-regression

AIM

In order to disclose relations between reduction of haemoglobin A1c (HbA1c) levels and risk of major cardiovascular events (MACE), we performed a meta-analysis with metaregression of all cardiovascular outcome trials (CVOTs) so far published in patients with type 2 diabetes (T2D).

MATERIALS AND METHODS

An electronic search up to February 10, 2020 was conducted to determine eligible trials. Pooled summary estimates and 95% confidence intervals (CI) were calculated according to the random effects model using the Paule-Mandel method; restricted maximum likelihood estimators were used to estimate model parameters in the metaregression.

RESULTS

The 15 CVOTs included evaluated 138,250 patients. In the pooled analysis, the risk of MACE was significantly reduced by 9% (hazard ratio, HR = 0.91, 0.87-0.95, P <0.001) as compared with placebo, with significant heterogeneity between trials (I² = 44%, P = 0.060) There was a robust relation between the reduction in achieved HbA1c at the end of the trial and the HR reduction for MACE (beta = -0.3169, P = 0.029), explaining most (78%) of the between-study variance; this relation was totally driven by the risk reduction of non-fatal stroke only, which explained 100% of between-study variance, and apparently restricted to the class of glucagon-like peptide 1 receptor agonists (GLP-1RAs). There was no relation between the reduction in achieved HbA1c and the HR for heart failure (variance explained = 0%) or all-cause mortality (variance explained = 6%).

CONCLUSION

The blood glucose reduction observed in CVOTs may play some role in reducing the risk of non-fatal stroke, at least during treatment with GLP-1RAs, without affecting the other two components of MACE.

Primary Care Physicians' Knowledge of the Cardiovascular Effects of Diabetes Medications: Findings from an Online Survey

Introduction

Cardiovascular (CV) outcomes trial (CVOT) results have led to changes in indications for some glucose-lowering agents, with recommendations based on the presence of comorbidities.

Objective

This study aimed to understand internal medicine (IM) and family medicine (FM) physicians’ knowledge of CVOTs and beliefs about type 2 diabetes mellitus (T2DM) medications, excluding insulin, for CV disease risk reduction.

Methods

WebMD, LLC, fielded a 23-item online survey from September 18 to 20, 2018, to 47,534 Medscape members (US IM and FM physicians) who were invited to participate via e-mail (quota = 500).

Results

Of the 702 physicians who responded, 503 were eligible and completed the survey. Overall, 39% of respondents were not familiar with the 2018 American Diabetes Association treatment recommendations for those with T2DM and atherosclerotic CV disease. Respondents reported they were most familiar with TECOS (42%), LEADER (39%), EMPA-REG OUTCOME (33%), and CANVAS (30%). Many respondents did not know which CVOT showed superiority for major adverse CV events (26%) or CV mortality (31%). When provided with a list of seven treatment priorities, 33% of respondents ranked using T2DM medications with CV benefits as least important.

Conclusions

Findings from this 2018 survey suggest that there are knowledge gaps among IM and FM physicians regarding the results from CVOTs, with implications for the treatment of patients with T2DM and CV disease.

Graphical Abstract

The association of low-density lipoprotein cholesterol with elevated arterial stiffness in adolescents and young adults with type 1 and type 2 diabetes: The SEARCH for Diabetes in Youth study

AIM

Our aim was to explore the relationship of Low-Density Lipoprotein Cholesterol (LDL-C) with subclinical cardiovascular disease (CVD) in youth with T1D and T2D. We hypothesized the association of LDL-C with elevated arterial stiffness (AS) would be partially accounted by the co-occurrence of other CVD factors.

METHOD

We included 1376 youth with T1D and 157 with T2D from the SEARCH study. CVD risk factors including LDL-C, waist to height ratio (WHtR), mean arterial pressure (MAP), HbA1c, albumin to creatinine ratio (ACR), and insulin sensitivity (IS) score were measured at both visits. At follow up, elevated carotid-femoral AS was defined as levels above 6.8 m/s. Multivariable logistic regression evaluated the odds of elevated AS as a function of the average CVD risk factors.

RESULTS

At follow up, age was 18.0 ± 4.1 and 21.6 ± 3.5 years and duration of diabetes was 7.8 ± 1.9 and 7.7 ± 1.9 years in T1D and T2D, respectively. Elevated AS was found in 8.4% of T1D and 49.0% of T2D participants. Each SD increase in LDL-C was associated with 1.28 increased odds (95% CI 1.05-1.54, P = .013) of elevated AS in youth with T1D. The association was similar but not statistically significant in T2D. WHtR, IS, and MAP were associated with elevated AS in both groups. Adjustment for WHtR or IS attenuated to non-significance the relationship between LDL-C and AS in T1D.

CONCLUSIONS

Obesity and insulin resistance attenuate the association of high LDL-C with AS suggesting they partially account for the adverse effects of LDL-C on cardiovascular health in youth with T1D.

Efficacy, safety and cardiovascular outcomes of once-daily oral semaglutide in patients with type 2 diabetes: The PIONEER programme

Glucagon-like peptide-1 receptor agonists (GLP-1RAs) are recommended for glycaemic management in patients with type 2 diabetes (T2D). Oral semaglutide, the first oral GLP-1RA, has recently been approved for clinical use, based on the results of the randomized, Phase 3a Peptide InnOvatioN for Early diabEtes tReatment (PIONEER) clinical trials. The PIONEER programme tested oral semaglutide in patients with T2D of duration ranging from 3.5 to 15 years, from monotherapy through to insulin add-on, in global populations and two trials dedicated to Japanese patients. Outcomes (glycated haemoglobin [HbA1c] and body weight reduction, plus other relevant efficacy and safety endpoints) were tested against both placebo and active standard-of-care medications. A separate trial evaluated the cardiovascular safety of oral semaglutide in patients with T2D at high cardiovascular risk. Over periods of treatment up to 78 weeks, oral semaglutide 7 and 14 mg once daily reduced HbA1c and body weight across the spectrum of T2D, and improved other diabetes-related endpoints, such as fasting plasma glucose. Oral semaglutide provided significantly better efficacy than placebo and commonly used glucose-lowering medications from the dipeptidyl peptidase-4 inhibitor (sitagliptin) and sodium-glucose co-transporter-2 inhibitor (empagliflozin) classes, as well as the subcutaneous GLP-1RAs liraglutide and dulaglutide. Oral semaglutide was well tolerated in line with the known safety profile of GLP-1RAs, with transient gastrointestinal events being the most common side effects reported. Cardiovascular safety was demonstrated for oral semaglutide in patients with cardiovascular disease or high cardiovascular risk. The results of the PIONEER programme suggest that oral semaglutide is efficacious and well tolerated for glycaemic control of T2D. The availability of oral semaglutide may help to broaden treatment choice and facilitate adoption of earlier GLP-1RA treatment in the paradigm of T2D management.

goFOODTM: An Artificial Intelligence System for Dietary Assessment

Accurate estimation of nutritional information may lead to healthier diets and better clinical outcomes. We propose a dietary assessment system based on artificial intelligence (AI), named goFOOD^TM. The system can estimate the calorie and macronutrient content of a meal, on the sole basis of food images captured by a smartphone. goFOOD^TM requires an input of two meal images or a short video. For conventional single-camera smartphones, the images must be captured from two different viewing angles; smartphones equipped with two rear cameras require only a single press of the shutter button. The deep neural networks are used to process the two images and implements food detection, segmentation and recognition, while a 3D reconstruction algorithm estimates the food’s volume. Each meal’s calorie and macronutrient content is calculated from the food category, volume and the nutrient database. goFOOD^TM supports 319 fine-grained food categories, and has been validated on two multimedia databases that contain non-standardized and fast food meals. The experimental results demonstrate that goFOOD^TM performed better than experienced dietitians on the non-standardized meal database, and was comparable to them on the fast food database. goFOOD^TM provides a simple and efficient solution to the end-user for dietary assessment.

The Inflammasome in Chronic Complications of Diabetes and Related Metabolic Disorders

Diabetes mellitus (DM) ranks seventh as a cause of death worldwide. Chronic complications, including cardiovascular, renal, and eye disease, as well as DM-associated non-alcoholic fatty liver disease (NAFLD) account for most of the morbidity and premature mortality in DM. Despite continuous improvements in the management of late complications of DM, significant gaps remain. Therefore, searching for additional strategies to prevent these serious DM-related conditions is of the utmost importance. DM is characterized by a state of low-grade chronic inflammation, which is critical in the progression of complications. Recent clinical trials indicate that targeting the prototypic pro-inflammatory cytokine interleukin-1β (IL-1 β) improves the outcomes of cardiovascular disease, which is the first cause of death in DM patients. Together with IL-18, IL-1β is processed and secreted by the inflammasomes, a class of multiprotein complexes that coordinate inflammatory responses. Several DM-related metabolic factors, including reactive oxygen species, glyco/lipoxidation end products, and cholesterol crystals, have been involved in the pathogenesis of diabetic kidney disease, and diabetic retinopathy, and in the promoting effect of DM on the onset and progression of atherosclerosis and NAFLD. These metabolic factors are also well-established danger signals capable of regulating inflammasome activity. In addition to presenting the current state of knowledge, this review discusses how the mechanistic understanding of inflammasome regulation by metabolic danger signals may hopefully lead to novel therapeutic strategies targeting inflammation for a more effective treatment of diabetic complications.

Blood pressure reduction and RAAS inhibition in diabetic kidney disease: therapeutic potentials and limitations

Diabetic kidney disease (DKD) affects approximately one-third of patients with diabetes and taking into consideration the high cardiovascular risk burden associated to this condition a multifactorial therapeutic approach is traditionally recommended, in which glucose and blood pressure control play a central role. The inhibition of renin–angiotensin–aldosterone RAAS system represent traditionally the cornerstone of DKD. Clinical outcome trials have demonstrated clinical significant benefit in slowing nephropathy progression mainly in the presence of albuminuria. Thus, international guidelines mandate their use in such patients. Given the central role of RAAS activity in the pathogenesis and progression of renal and cardiovascular damage, a more profound inhibition of the system by the use of multiple agents has been proposed in the past, especially in the presence of proteinuria, however clinical trials have failed to confirm the usefulness of this therapeutic approach. Furthermore, whether strict blood pressure control and pharmacologic RAAS inhibition entails a favorable renal outcome in non-albuminuric patients is at present unclear. This aspect is becoming an important issue in the management of DKD since nonalbuminuric DKD is currently the prevailing presenting phenotype. For these reasons it would be advisable that blood pressure management should be tailored in each subject on the basis of the renal phenotype as well as related comorbidities. This article reviews the current literature and discusses potentials and limitation of targeting the RAAS in order to provide the greatest renal protection in DKD.

Sodium-glucose cotransporter 2 inhibitors’ mechanisms of action in heart failure

Three major cardiovascular outcome trials (CVOTs) with a new class of antidiabetic drugs - sodium-glucose cotransporter 2 (SGLT2) inhibitors (EMPA-REG OUTCOME trial with empagliflozin, CANVAS Program with canagliflozin, DECLARE-TIMI 58 with dapagliflozin) unexpectedly showed that cardiovascular outcomes could be improved possibly due to a reduction in heart failure risk, which seems to be the most sensitive outcome of SGLT2 inhibition. No other CVOT to date has shown any significant benefit on heart failure events. Even more impressive findings came recently from the DAPA-HF trial in patients with confirmed and well-treated heart failure: Dapagliflozin was shown to reduce heart failure risk for patients with heart failure with reduced ejection fraction regardless of diabetes status. Nevertheless, despite their possible wide clinical implications, there is much doubt about the mechanisms of action and a lot of questions to unravel, especially now when their benefits translated to non-diabetic patients, rising doubts about the validity of some current mechanistic assumptions.The time frame of their cardiovascular benefits excludes glucose-lowering and antiatherosclerotic-mediated effects and multiple other mechanisms, direct cardiac as well as systemic, are suggested to explain their early cardiorenal benefits. These are: Anti-inflammatory, antifibrotic, antioxidative, antiapoptotic properties, then renoprotective and hemodynamic effects, attenuation of glucotoxicity, reduction of uric acid levels and epicardial adipose tissue, modification of neurohumoral system and cardiac fuel energetics, sodium-hydrogen exchange inhibition. The most logic explanation seems that SGLT2 inhibitors timely target various mechanisms underpinning heart failure pathogenesis. All the proposed mechanisms of their action could interfere with evolution of heart failure and are discussed separately within the main text.

Practical guidance for use of oral semaglutide in primary care: a narrative review

As the cornerstone of type 2 diabetes (T2D) management within the community, primary care providers are now faced with the challenge of not only managing diabetes itself, but also preventing hypoglycemia and weight gain associated with intensive disease management, and reducing cardiovascular risk. Glucagon-like peptide-1 receptor agonists (GLP-1RAs) are well established as efficacious treatments for T2D, and the safety/tolerability profile of this drug class is well defined. However, despite their beneficial effects, GLP-1RAs are under-utilized, highlighting the need for novel approaches to increase their use in primary care. Oral semaglutide is the first oral GLP-1RA approved for the treatment of T2D, offering glucose lowering and body weight loss, a low risk of hypoglycemia, and no increase in cardiovascular risk. Oral semaglutide represents an additional treatment option for patients not achieving their glycemic goal despite treatment with metformin, either alone or with other hypoglycemic agents. Oral semaglutide has the potential to increase usage of GLP-1RAs in the primary care setting by addressing clinician and patient concerns about injections, and may facilitate earlier initiation of GLP-1RA therapy in T2D. Due to the formulation of oral semaglutide, clinicians need to be aware of specific considerations in order to ensure optimal use. Such considerations include dosing conditions and use of concomitant medications. This article provides practical guidance on the use of oral semaglutide in the primary care setting, based on evidence from clinical studies, including the phase 3a PIONEER program, and the authors' clinical experience.

Guidelines on multidisciplinary approaches for the prevention and management of diabetic foot disease (2020 edition)

In recent years, as living standards have continued to improve, the number of diabetes patients in China, along with the incidence of complications associated with the disease, has been increasing. Among these complications, diabetic foot disease is one of the main causes of disability and death in diabetic patients. Due to the differences in economy, culture, religion and level of medical care available across different regions, preventive and treatment methods and curative results for diabetic foot vary greatly. In multidisciplinary models built around diabetic foot, the timely assessment and diagnosis of wounds and appropriate methods of prevention and treatment with internal and external surgery are key to clinical practice for this pathology. In 2019, under the leadership of the Jiangsu Medical Association and Chinese Diabetes Society, the writing group for the Guidelines on multidisciplinary approaches for the prevention and management of diabetic foot disease (2020 edition) was established with the participation of scholars from the specialist areas of endocrinology, burn injury, vascular surgery, orthopedics, foot and ankle surgery and cardiology. Drawing lessons from diabetic foot guidelines from other countries, this guide analyses clinical practices for diabetic foot, queries the theoretical basis and grades and gives recommendations based on the characteristics of the pathology in China. This paper begins with assessments and diagnoses of diabetic foot, then describes treatments for diabetic foot in detail, and ends with protections for high-risk feet and the prevention of ulcers. This manuscript covers the disciplines of internal medicine, surgical, nursing and rehabilitation and describes a total of 50 recommendations that we hope will provide procedures and protocols for clinicians dealing with diabetic foot.

Registry number: IPGRP-2020cn124

Endothelial Dysfunction: A Contributor to Adverse Cardiovascular Remodeling and Heart Failure Development in Type 2 Diabetes beyond Accelerated Atherogenesis

Endothelial dysfunction, associated with depressed nitric oxide (NO) bioavailability, is awell-recognized contributor to both accelerated atherogenesis and microvascular complications intype 2 diabetes (DM). However, growing evidence points to the comorbidities-driven endothelialdysfunction within coronary microvessels as a key player responsible for left ventricular (LV)diastolic dysfunction, restrictive LV remodeling and heart failure with preserved ejection fraction(HFpEF), the most common form of heart failure in DM. In this review we have described: (1)multiple cellular pathways which may link depressed NO bioavailability to LV diastolicdysfunction and hypertrophy; (2) hemodynamic consequences and prognostic effects of restrictiveLV remodeling and combined diastolic and mild systolic LV dysfunction on cardiovascularoutcomes in DM and HFpEF, with a focus on the clinical relevance of endothelial dysfunction; (3)novel therapeutic strategies to improve endothelial function in DM. In summary, beyondassociations with accelerated atherogenesis and microvascular complications, endothelialdysfunction supplements the multiple interwoven pathways affecting cardiomyocytes, endothelialcells and the extracellular matrix with consequent LV dysfunction in DM patients. The associationamongst impaired endothelial function, reduced coronary flow reserve, combined LV diastolic anddiscrete systolic dysfunction, and low LV stroke volume and preload reserve-all of which areadverse outcome predictors-is a dangerous constellation of inter-related abnormalities, underlyingthe development of heart failure. Nevertheless, the relevance of endothelial effects of novel drugsin terms of their ability to attenuate cardiovascular remodeling and delay heart failure onset in DMpatients remains to be investigated.

Efficacy and safety of patient-led versus physician-led titration of basal insulin in patients with uncontrolled type 2 diabetes: a meta-analysis of randomized controlled trials

INTRODUCTION

Insulin is the most effective antihyperglycemic treatment and basal insulin is the preferred initial formulation in patients with type 2 diabetes. However, its effects are dose-dependent, so adequate titration is necessary to reach targets. We performed a meta-analysis to compare the efficacy and safety of patient-led versus physician-led titration of basal insulin in patients with uncontrolled type 2 diabetes.

RESEARCH DESIGN AND METHODS

Four databases were searched from database inception through March 2020. Randomized controlled studies with at least 12 weeks of follow-up of patients with type 2 diabetes allocated to patient-led versus physician-led titration of basal insulin were selected. Data on glycemic endpoints (hemoglobin A1c (HbA1c), fasting plasma glucose (FPG), hypoglycemia) and other outcomes (insulin dose, body weight, patient-reported outcomes, adverse events, rescue medication, discontinuation) were extracted. Data were pooled using a random-effects model.

RESULTS

Six studies evaluating 12 409 patients were finally included. Compared with the physician-led performance, patient-led titration was associated with a statistically significant higher basal insulin dose (+6 IU/day), leading to benefits on HbA1c (-0.1%) and FPG (-5 mg/dL), despite a higher risk of any level hypoglycemia (relative risk=1.1) and a slight increase in body weight (+0.2 kg). No difference was found for the other outcomes.

CONCLUSIONS

The present study showed that patient-led titration of basal insulin was not inferior to physician-led titration in patients with uncontrolled type 2 diabetes. Therefore, diabetes self-management education and support programs on basal insulin should be widely adopted in clinical practice and patients provided with tools to self-adjust their dose when necessary.

Cardiometabolic Medicine: Development of a New Subspecialty

CONTEXT

The worldwide rise in the prevalence of cardiometabolic disease, and the introduction of therapeutic options for treating metabolic disease that also lower cardiovascular risk, calls for a restructuring of how we care for patients with cardiometabolic disease. We propose establishment of a new medicine subspecialty, Cardiometabolic Medicine.

EVIDENCE ACQUISITION

This summary is based on a synthesis of published original and review articles identified through PubMed, professional society guidelines, and the authors' knowledge of the fields of metabolism, diabetes, and cardiology.

EVIDENCE SYNTHESIS

The growing prevalence of cardiometabolic disease will continue to be perhaps the greatest challenge in the United States and throughout the world. We have entered an era where a large set of clinical tools are available that help prevent and treat cardiometabolic disease; however, our old models of clinical training and siloed care are barriers to rapid uptake and efficient healthcare delivery and are in need of change.

CONCLUSIONS

Establishing the field of Cardiometabolic Medicine would be a small step in the right direction towards providing the best possible comprehensive care for those with complex cardiometabolic disease.

Use of non-LDL-C lipid-lowering medications in patients with type 2 diabetes

BACKGROUND

A number of non-low-density lipoprotein cholesterol lipid abnormalities are associated with type 2 diabetes and insulin resistance, which may lead practitioners to use medications targeting these abnormal lipid fractions despite a lack of evidence or guideline recommendations.

METHODS AND RESULTS

Among 382 921 US patients with type 2 diabetes (69% with cardiovascular disease, 76% on a statin), 95 995 (26%) were on some nonstatin lipid-lowering medication-19 265 (5%) on niacin, 32 919 (9%) on a fibrate and 69 513 (18%) on fish oil. Use of all three medications was stable over time and higher in patients with cardiovascular disease and with higher triglyceride levels, although even among patients with triglyceride levels <2.3 mmol/L, 6% were on a fibrate and 17% were on fish oil.

CONCLUSION

As clinical trials demonstrate little to no cardiovascular benefit from taking these medications, greater attention is needed to focus the use of lipid-lowering medications to those with proven benefit.

Vanderbilt Health Affiliated Network Statin Outreach Service

Quality Improvement Success Stories are published by the American Diabetes Association in collaboration with the American College of Physicians and the National Diabetes Education Program. This series is intended to highlight best practices and strategies from programs and clinics that have successfully improved the quality of care for people with diabetes or related conditions. Each article in the series is reviewed and follows a standard format developed by the editors of Clinical Diabetes. The following article describes the design and implementation of a pharmacist-led program to improve rates of statin use among appropriate patients in high-risk populations.

Prediction and early detection of cardiovascular disease in South Asians with diabetes mellitus

BACKGROUND

Although diabetes mellitus (DM) is no longer considered "coronary heart disease risk equivalent", the risk remains sufficiently high, necessitating early recognition and management of cardiovascular disease (CVD) in these patients. Despite this understanding, the optimum strategy for prediction and early detection of CVD in DM remains debatable.

METHODS

Major societal guidelines for prediction and evaluation of CVD in subjects with or without DM were reviewed. Available evidence about various risk stratification strategies-their advantages, disadvantages and current role in clinical practice-were extensively reviewed. Special emphasis was placed on evidence from South Asian/Indian populations.

RESULTS

The inconsistency and variability inherent to the clinical risk algorithms, lack of consensus regarding the incremental value of subclinical atherosclerosis imaging and the lack of sufficient data to demonstrate the benefits of recognizing asymptomatic atherosclerotic disease are some of the reasons underlying prevailing uncertainty about the optimum approach for cardiovascular risk assessment in DM. These challenges notwithstanding, an evidence-based cardiovascular risk stratification strategy incorporating clinical risk algorithms, biomarkers, atherosclerosis imaging, and cardiac stress testing is proposed.

CONCLUSIONS

The proposed algorithm should help clinicians in optimizing cardiovascular evaluation and management of their patients with DM. However, this remains a dynamic field; further research into different risk assessment tools, esp. focusing on their impact on improving clinical outcomes, should help refine the evaluation strategy in future.

Evaluation of a Pharmacist-Led Intervention to Improve Statin Use in Persons with Diabetes

BACKGROUND

The Statin Use in Persons with Diabetes (SUPD) measure, developed and endorsed by the Pharmacy Quality Alliance and National Quality Forum, has been adopted by the Centers for Medicare & Medicaid Services as part of the star rating measure set. It was added as a display measure in 2015 and, as of 2019, has become a star measure. Clinical pharmacy specialists (CPS) embedded in the patient-centered medical home (PCMH) are well positioned to review and recommend statin therapy for patients with diabetes in order to improve patient care and health plan performance.

OBJECTIVE

To improve rates of statin prescribing and performance on the SUPD measure in the Denver Health Medical Plan (DHMP) population with diabetes by creating a CPS-led intervention to initiate statin prescriptions in eligible patients.

METHODS

Between February 1, 2018, and December 31, 2018, DHMP patients who met SUPD measure criteria (aged ≥ 40 and ≤ 75 years, dispensing events for at least 2 diabetes mellitus medication fills, and no statin prescribed) were identified by the health plan chart review and contacted by CPS as appropriate. For patients eligible and agreeable to statin therapy, the CPS initiated the statin prescription. Descriptive statistics were used to summarize outreach and statin prescribing data. Prescription drug event data were also collected from the health plan to verify SUPD measure performance.

RESULTS

At the start of 2018, DHMP's performance on the SUPD measure was 65.7% (Medicare Advantage Part D national average was 68.5%). Of the 326 patients whose charts were reviewed and who were contacted, 275 (84.4%) were eligible for statin initiation, and of these, 115 (41.8%) were prescribed statin therapy. The increase in statin prescribing and dispensing increased DHMP's performance on the SUPD measure to 87.1% at the end of 2018, which correlates with a 5-star rating based on the 2019 cut points.

CONCLUSIONS

CPS embedded in the PCMH setting are well positioned to participate in and positively affect population health initiatives such as the SUPD measure. Appropriate prescribing of statin therapy by CPS for patients included in the SUPD measure ensures that they are on key medication therapy for mitigating atherosclerotic cardiovascular disease and may improve a health plan's Medicare star rating.

DISCLOSURES

This was an unfunded, investigator-initiated project. Anderson owns stock in Merck & Co. All other authors have no conflicts of interest to disclose.

Generalizability of sodium-glucose co-transporter-2 inhibitors cardiovascular outcome trials to the type 2 diabetes population: a systematic review and meta-analysis

Background

Cardiovascular outcome trials of sodium-glucose co-transporter-2 inhibitors (SGLT2i CVOTs) found the agents to be associated with clinical benefits in terms of cardiovascular and renal outcomes. We performed a meta-analysis to assess and compare the overall prevalence of eligibility for the enrollment criteria of CANVAS, DECLARE-TIMI 58, EMPA-REG OUTCOME, and VERTIS-CV among unselected patients with type 2 diabetes.

Methods

This meta-analysis was registered in PROSPERO (CRD42020172032). PubMed, CENTRAL, Scopus and Web of Science were researched in March 2020. Studies evaluating the prevalence of eligibility for each SGLT2i CVOT were selected. Endpoints were estimated using a random-effects model.

Results

Five studies, evaluating 1,703,519 patients with type 2 diabetes, were included. Overall, the prevalence of eligible patients according to the enrollment criteria of CANVAS, DECLARE-TIMI 58, EMPA-REG OUTCOME, and VERTIS-CV was 36.4%, 49.5%, 17.0% and 19.0%, respectively. In head-to-head comparisons, DECLARE-TIMI 58 was associated with the highest odds of eligibility (1.74 versus CANVAS, 5.15 versus EMPA-REG OUTCOME and 4.81 versus VERTIS-CV), followed by CANVAS and EMPA-REG OUTCOME/VERTIS-CV. A high heterogeneity was found for all the outcomes.

Conclusions

The present review showed that a considerable number of patients counseled in clinical practice could have been eligible for SGLT2i CVOTs. Particularly, dapagliflozin was shown to be the SGLT2i with the largest generalizability of findings from its CVOT according to the odds ratio of eligibility for the enrollment criteria among unselected patients with type 2 diabetes. Further country- or region-specific studies are needed to confirm the applicability of our results.

Apolipoprotein B and non-high-density lipoprotein cholesterol reveal a high atherogenicity in individuals with type 2 diabetes and controlled low-density lipoprotein-cholesterol

Background

Lipid-lowering therapy is guided by Low-density-lipoprotein cholesterol (LDL-c) levels, although the cardiovascular disease (CVD) risk could be better reflected by other lipid parameters. This study aimed at comparing a comprehensive lipid profile between patients with type 2 diabetes mellitus (T2DM) with LDL-c concentration within and above target.

Methods

A comprehensive lipid profile was characterized in 96 T2DM patients. The European Society of Cardiology/European Atherosclerosis Society (ESC/EAS) 2016 and 2019 Guidelines for the Management of Dyslipidemias were used to define LDL-c targets.

Results

In this population, only 28.1 and 16.7% of patients had mean LDL-c levels within target, as defined by the 2016 and 2019 guidelines, respectively. Applying the 2016 guidelines criteria, in patients with LDL-c within target, 22, 25 and 44% presented non-high-density lipoprotein cholesterol (non-HDL-c), Apolipoprotein B (ApoB) and oxidized LDL-c levels above the recommended range, respectively, whereas according to the 2019 guidelines criteria, 50, 39 and 44% of the patients with LDL-c within target had elevated high-density lipoprotein cholesterol (HDL-c), ApoB and oxidized LDL-c levels, respectively. LDL-c was strongly correlated with non-HDL-c (r = 0.850), ApoB (r = 0.656) and oxidized LDL-c (r = 0.508). Similarly, there was a strong correlation between non-HDL-c with both ApoB (r = 0.808) and oxidized LDL-c (r = 0.588).

Conclusions

These findings emphasize the limitations of only considering LDL-c concentration for cardiovascular (CV) risk assessment. Targeting only LDL-c could result in missed opportunities for CV risk reduction in T2DM patients. These data suggest that non-HDL-c, ApoB and oxidized LDL-c levels could be considered as an important part of these patients’ evaluation allowing for a more accurate estimation of CV risk and hopefully better management of these high-risk patients.

Recent Updates on Vascular Complications in Patients with Type 2 Diabetes Mellitus

It is well known that patients with type 2 diabetes mellitus (T2DM) are at an increased risk of morbidity and mortality from atherosclerotic cardiovascular (CV) complications. Previously, the concept that diabetes mellitus (DM) is a "coronary artery disease (CAD) risk equivalent" was widely accepted, implying that all DM patients should receive intensive management. However, considerable evidence exist for wide heterogeneity in the risk of CV events among T2DM patients and the concept of a "CAD risk equivalent" has changed. Recent guidelines recommend further CV risk stratification in T2DM patients, with treatment tailored to the risk level. Although imaging modalities for atherosclerotic cardiovascular disease (ASCVD) have been used to improve risk prediction, there is currently no evidence that imaging-oriented therapy improves clinical outcomes. Therefore, controversy remains whether we should screen for CVD in asymptomatic T2DM. The coexistence of T2DM and heart failure (HF) is common. Based on recent CV outcome trials, sodium glucose cotransporter-2 inhibitors and glucagon like peptide-1 receptor agonists are recommended who have established ASCVD, indicators of high risk, or HF because of their demonstrated benefits for CVD. These circumstances have led to an increasing emphasis on ASCVD and HF in T2DM patients. In this review, we examine the literature published within the last 5 years on the risk assessment of CVD in asymptomatic T2DM patients. In particular, we review recent guidelines regarding screening for CVD and research focusing on the role of coronary artery calcium, coronary computed tomography angiography, and carotid intima-media thickness in asymptomatic T2DM patients.

Metformin and cardiorenal outcomes in diabetes: A reappraisal

The guidance issued to the pharmaceutical industry by the US Food and Drug Administration in 2008 has led to the publication of a series of randomized, controlled cardiovascular outcomes trials with newer therapeutic classes of glucose-lowering medications. Several of these trials, which evaluated the newer therapeutic classes of sodium-glucose co-transporter-2 inhibitors and glucagon-like peptide-1 receptor agonists, have reported a reduced incidence of major adverse cardiovascular and/or renal outcomes, usually relative to placebo and standard of care. Metformin was the first glucose-lowering agent reported to improve cardiovascular outcomes in the UK Prospective Diabetes Study (UKPDS) and thus became the foundation of standard care. However, as this clinical trial reported more than 20 years ago, differences from current standards of trial design and evaluation complicate comparison of the cardiovascular profiles of older and newer agents. Our article revisits the evidence for cardiovascular protection with metformin and reviews its effects on the kidney.

The medical transition of young adults with type 1 diabetes (T1D): a retrospective chart review identifies areas in need of improvement

BACKGROUND

The transition process from pediatric to adult care in individuals with T1D has long-term ramifications on health outcomes. Recognition of differences in care delivery and changes made in management during this time may improve the process. We hypothesized that pediatric providers would be less likely to address T1D-related comorbidities than their adult counterparts, highlighting opportunities to strengthen care.

METHODS

A retrospective chart review of patients aged 16-21 years diagnosed with T1D before age 18 was performed. Data on diagnosis, screening, and management of hypertension, dyslipidemia, microalbuminuria, retinopathy, and neuropathy were collected for 1 year before and 1 year after transition to adult care. The 'ADA Standards of Medical Care in Diabetes' were used to determine adherence to the above parameters. Data before and after transition was compared by Fischer's Exact and Exact McNemar tests.

RESULTS

Complete medical records for 54 subjects were reviewed before and after transition from pediatric to adult care providers within a single academic medical system (52% male; 78% Caucasian). Transition to adult care occurred at a mean age of 18 years. Mean length of transition was 7.8 months with no significant change in an individual's HbA1c over that time. Over the transition period, there was no difference in diagnoses of hypertension or the use of anti-hypertensive. Adherence to lipid and retinopathy screening was similar across the transition period; however, adherence to microalbuminuria screening was higher after the transition to adult providers (p = 0.01). Neuropathy screening adherence was overall poor but also improved after transition (p < 0.001).

CONCLUSIONS

Overall, there were no significant changes in the diagnosis or management of several T1D-related comorbidities during the transition period in a small cohort of young adults with T1D. The transition length was longer than the recommended 3-months, highlighting an opportunity to improve the process. There was no deterioration of glycemic control over this time, although HbA1c values were above target. Adult providers had significantly higher rates of adherence to screening for microalbuminuria and neuropathy than their pediatric counterparts, but adherence for neuropathy was quite poor overall, indicating a need for practice improvement.

UP Philippine General Hospital Division of Endocrinology, Diabetes & Metabolism Consensus Recommendations for In-Patient Management of Diabetes Mellitus among Persons with COVID-19

Diabetes mellitus (DM) is a known risk factor for morbidity and mortality among patients with COVID-19 based on recent studies. While there are many local and international guidelines on inpatient management of diabetes, the complicated pathology of the virus, the use of glucose-elevating drugs such as glucocorticoids, antivirals and even inotropes, and various other unique problems has made the management of in-hospital hyperglycemia among patients with COVID-19 much more difficult than in other infections. The objective of this guidance is to collate and integrate the best available evidence that has been published regarding in-patient management of diabetes among patients with COVID-19. A comprehensive review of literature was done and recommendations have been made through a consensus of expert endocrinologists from the University of the Philippines-Philippine General Hospital (UP-PGH) Division of Endocrinology, Diabetes and Metabolism. These recommendations are evolving as we continue to understand the pathology of the disease and how persons with diabetes are affected by this virus.

The Evolving Understanding and Approach to Residual Cardiovascular Risk Management

Despite unprecedented advances in treatment of atherosclerotic cardiovascular disease, it remains the leading cause of death and disability worldwide. Treatment of major traditional risk factors, including low-density lipoprotein-cholesterol, serves as the foundation of atherosclerotic risk reduction. However, there remains a significant residual risk of cardiovascular events despite optimal risk factor management. Beyond traditional risk factors, other drivers of residual risk have come to the forefront, including inflammatory, pro-thrombotic, and metabolic pathways that contribute to recurrent events and are often unrecognized and not addressed in clinical practice. This review will explore the evidence linking these pathways to atherosclerotic cardiovascular disease and potential future therapeutic options to attenuate residual cardiovascular risk conferred by these pathways.

Outcomes in adults with systolic blood pressure between 130 and 139 mmHg in Action to Control Cardiovascular Risk in Diabetes Blood Pressure trial and Systolic Blood Pressure Intervention Trial

BACKGROUND

Patients with stage 1 systolic hypertension have increased risk of cardiovascular disease (CVD) events.

METHODS

Using Cox models, we assess the effect of targeting an intensive SBP goal of less than 120 mmHg compared with standard SBP goal of less than 140 mmHg on the risk of CVD events in adults with stage 1 systolic hypertension with diabetes mellitus enrolled in Action to Control Cardiovascular Risk in Diabetes Blood Pressure trial (ACCORD BP) (n = 1901) and without diabetes mellitus enrolled in Systolic Blood Pressure Intervention Trial (SPRINT) (n = 3484) that used identical SBP goal interventions.

OUTCOMES

In ACCORD BP, the primary composite CVD outcome was the first occurrence of myocardial infarction, stroke, or CVD mortality. In SPRINT, the primary composite CVD outcome was the first occurrence of myocardial infarction, other acute coronary syndrome, stroke, heart failure, or CVD mortality.

RESULTS

In SPRINT, targeting an intensive SBP goal significantly reduced the risk of the primary CVD outcome [hazard ratio 0.75 (95% confidence interval, 0.58-0.98); events 1.78 vs. 2.37%/year]. In ACCORD BP, the relationships of SBP goal with the primary CVD outcome was modified by the glycemia goal intervention (interaction P = 0.039). In the standard glycemia subgroup (A1c target 7-7.9%), intensive SBP goal significantly reduced the risk of the primary CVD outcome [hazard ratio 0.61 (0.40-0.94); events 1.63 vs. 2.56%/year]. In the intensive glycemia subgroup (A1c target <6%), the risk of the primary CVD outcome was not significantly different between groups [hazard ratio 1.20 (0.76-1.89); events 1.91 vs. 1.60%/year].

CONCLUSION

Targeting an intensive SBP goal significantly reduced the risk of CVD events in patients with stage 1 systolic hypertension without diabetes and with diabetes on standard glycemia goal.

Postprandial hyperlipidemia as a risk factor in patients with type 2 diabetes

Introduction: Postprandial hyperlipidemia is a common feature of the atherogenic dyslipidemia in patients with type 2 diabetes. Quantification of this with oral fat tolerance tests is not used routinely in clinical practice and abnormal postprandial lipids are usually inferred from non-fasting plasma triglyceride levels. Identifying excessive postprandial hyperlipidemia may help to refine cardiovascular risk assessment but there are no treatments currently available which selectively target postprandial lipids and no large cardiovascular outcome trials using this as the entry criterion.Areas covered: In this review of relevant published material, we summarize the findings from the most important publications in this area.Expert opinion: Postprandial hyperlipidemia appears to contribute to the cardiovascular risk in patients with diabetes. Non-fasting triglyceride levels provide a surrogate marker of postprandial hyperlipidemia but more specific markers such as apoB48 levels may prove to be more reliable. Omega-3 fatty acids, fibrates and ezetimibe can reduce postprandial lipids but may not correct them completely. Several novel treatments have been developed to target hypertriglyceridemia and some of these may be particularly effective in improving postprandial levels. Further clinical trials are needed to establish the role of postprandial lipids in assessment of cardiovascular risk and to identify the most effective treatments.

Combining Glucagon-Like Peptide 1 Receptor Agonists and Sodium-Glucose Cotransporter 2 Inhibitors to Target Multiple Organ Defects in Type 2 Diabetes

Long-term risks of macro- and microvascular complications may be reduced in people with type 2 diabetes who achieve early and sustained glycemic control. Delays in attaining A1C goals are associated with poor long-term cardiovascular (CV) outcomes. Glucagon-like peptide 1 (GLP-1) receptor agonists and sodium-glucose cotransporter 2 (SGLT2) inhibitors are glucose-lowering therapies that act through complementary mechanisms of action with regard to the pathophysiologic defects of type 2 diabetes. Trials of agents in both drug classes have demonstrated improvements in CV and renal outcomes. This review discusses the rationale for combination therapy with a GLP-1 receptor agonist and an SGLT2 inhibitor, including early initiation of this combination in newly diagnosed patients. This combination may lead to timely glycemic control and potentially additive CV and renal benefits. Clinical studies of the combination have shown partially additive effects on A1C reduction, additive effects on weight reduction, and potentially synergistic effects on blood pressure reduction. Long-term studies are needed to determine whether the combination provides an additional effect on CV and renal outcomes compared with agents from either drug class when used alone.

Prevention and management of cardiovascular disease in patients with diabetes: current challenges and opportunities

More than 100 million people in the USA have diabetes or prediabetes and are at high risk for developing cardiovascular disease. Current evidence-based guidelines support a multifactorial approach in patients with diabetes, including lifestyle intervention and pharmacological treatment of hyperglycemia, hypertension, and dyslipidemia. In addition, recent cardiovascular outcome trials demonstrated that sodium-glucose cotransporter-2 inhibitors and glucagon-like peptide 1 receptor agonists improve cardiovascular outcomes in patients with diabetes. Albeit this evidence, over 80% of patients with diabetes do not achieve the recommended treatment goals. Considering the rising burden of cardiovascular complications, there is need to improve the quality of care in patients with diabetes. In this review, we discuss the current quality of health care in patients with diabetes in the USA, identify barriers to achieve guideline-recommended treatment goals and outline opportunities for the improvement in caring for patients with diabetes.

Abdominal aortic aneurysm: a review on the role of oral antidiabetic drugs

INTRODUCTION

A paradoxical negative association between diabetes mellitus and abdominal aortic aneurysm (AAA) prevalence and growth is established. However, so far is not possible to determine whether this protection comes from the disease itself or the medication for Diabetes. The aim of this manuscript is to review the association between oral antidiabetic drugs and AAA incidence and growth.

EVIDENCE ACQUISITION

A search was conducted on PubMed and Scopus databases until December 2019 to identify publications reporting on the association between oral antidiabetic drugs (biguanides/metformin, sulfonylureas(SU), thiazolidinediones(TZD), dipeptidyl-peptidase 4(DPP-4) inhibitors, glucagon-like peptide 1(GLP-1) agonists, sodium-glucose transporter protein-2(SGLT2) inhibitors) and the outcomes AAA incidence and growth. Only data from human studies were considered, with a minimum of 3 months follow-up.

EVIDENCE SYNTHESIS

Six studies enrolling 25,810 patients were included: one reporting on the AAA risk and five reporting on AAA growth. Metformin prescription was associated with a 28% reduction in AAA occurrence, while SU and TZD were associated with a 18% decrease in AAA risk. Regarding AAA enlargement, results were concordant for a slower expansion rate associated with metformin, with a decrease ranging from -0.30 mm/y to -1.30 mm/y, but not consistent for other antidiabetic drugs.

CONCLUSIONS

Metformin seems to be associated with a decrease in AAA risk and enlargement rate. Evidence for the other classes is lacking. Studies evaluating the association between oral antidiabetic drugs and AAA progression, independently of the diabetic status, are needed.