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Koto R, Nakajima A, Miwa T, Sugimoto K. Multimorbidity, Polypharmacy, Severe Hypoglycemia, and Glycemic Control in Patients Using Glucose-Lowering Drugs for Type 2 Diabetes: A Retrospective Cohort Study Using Health Insurance Claims in Japan. Diabetes Ther 2023:10.1007/s13300-023-01421-5. [PMID: 37195511 DOI: 10.1007/s13300-023-01421-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Accepted: 05/03/2023] [Indexed: 05/18/2023] Open
Abstract
INTRODUCTION This study aimed to understand the actual status of multimorbidity and polypharmacy among patients with type 2 diabetes using glucose-lowering drugs, and to assess the effects of patient characteristics on severe hypoglycemia and glycemic control. METHODS We designed a retrospective cohort study using health insurance claims and medical checkup data in Japan from April 2016 to February 2021 and identified patients with type 2 diabetes who were prescribed glucose-lowering drugs. We analyzed data on patient characteristics, including multimorbidity and polypharmacy, calculated the incidence rate for severe hypoglycemic events, applied a negative binomial regression model to explore factors that affected severe hypoglycemia, and analyzed the status of glycemic control in the subcohort for which HbA1c data were available. RESULTS Within the analysis population (n = 93,801), multimorbidity was present in 85.5% and mean ± standard deviation for oral drug prescriptions was 5.6 ± 3.5 per patient, while for those aged 75 years or older these numbers increased to 96.3% and 7.1 ± 3.5, respectively. The crude incidence rate for severe hypoglycemia was 5.85 (95% confidence interval 5.37, 6.37) per 1000 person-years. Risk factors for severe hypoglycemia included younger and older age, prior severe hypoglycemia, use of insulin, sulfonylurea, two-drug therapy including sulfonylurea or glinides, three-or-more-drug therapy, excessive polypharmacy, and comorbidities including end-stage renal disease (ESRD) requiring dialysis. Subcohort analysis (n = 26,746) showed that glycemic control is not always maintained according to guidelines. CONCLUSION Patients with type 2 diabetes, particularly older patients, experienced high multimorbidity and polypharmacy. Several risk factors for severe hypoglycemia were identified, most notably younger age, ESRD, history of severe hypoglycemia, and insulin therapy. TRIAL REGISTRATION The University Hospital Medical Information Network Clinical Trials Registry (UMIN000046736).
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Affiliation(s)
- Ruriko Koto
- Medical Science Department, Teijin Pharma Limited, 2-1, Kasumigaseki 3-Chome, Chiyoda-Ku, Tokyo, 100-8585, Japan.
| | - Akihiro Nakajima
- Pharmaceutical Development Administration Department, Teijin Pharma Limited, Tokyo, Japan
| | - Tetsuya Miwa
- Medical Science Department, Teijin Pharma Limited, 2-1, Kasumigaseki 3-Chome, Chiyoda-Ku, Tokyo, 100-8585, Japan
| | - Ken Sugimoto
- General and Geriatric Medicine, Kawasaki Medical School, Okayama, Japan
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Tasci I. The role of glycated haemoglobin in clinical decision-making of diabetes overtreatment. Diabet Med 2023; 40:e15021. [PMID: 36536605 DOI: 10.1111/dme.15021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Revised: 11/29/2022] [Accepted: 12/02/2022] [Indexed: 12/24/2022]
Affiliation(s)
- Ilker Tasci
- Department of Internal Medicine, Gulhane Faculty of Medicine & Training and Research Hospital, University of Health Sciences Turkey, Ankara, Turkey
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Christiaens A, Henrard S, Boland B, Sinclair AJ. Overtreatment of older people with type 2 diabetes-a high impact frequent occurrence in need of a new definition. Diabet Med 2023; 40:e14994. [PMID: 36300647 DOI: 10.1111/dme.14994] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Accepted: 10/19/2022] [Indexed: 01/17/2023]
Abstract
BACKGROUND Diabetes overtreatment is a frequent and major issue in older people with type 2 diabetes but its definition is often inconsistent and may be misleading. This critical review has aimed at examining the definitions of diabetes overtreatment in older people used in research studies. METHODS Studies addressing diabetes overtreatment in people aged 65 or older were identified by searching the PubMed database according to an extensive search equation. RESULTS Twenty-two research studies providing a definition of diabetes overtreatment in people aged were found. Overall, 12 different definitions of diabetes overtreatment were used. All studies defined overtreatment according to a HbA1c threshold (varying from <42 mmol/mol [<6.0%] to <64 mmol/mol [<8%]). Amongst them, 2 definitions had no consideration about glucose-lowering (GL) treatment, 6 required the prescribing of ≥1 GL agent(s), and 4 the prescribing of ≥1 GL agent(s) inducing the high risk of hypoglycaemia (i.e., sulfonylurea(s) or insulin(s)). Only 4 definitions (four studies) were individualised, using varying HbA1c thresholds according to patients' age or health status. CONCLUSIONS Definitions of diabetes overtreatment are heterogeneous across research studies, which is confusing. A standardised definition, based on the individual risk of hypoglycaemia and/or its complications must be promoted in order to bring clarity and greater insight into this field, as well as to improve the quality of management of diabetes in older patients.
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Affiliation(s)
- Antoine Christiaens
- Fund for Scientific Research - FNRS, Brussels, Belgium
- Clinical Pharmacy Research Group (CLIP), Louvain Drug Research Institute (LDRI), Université Catholique de Louvain, Brussels, Belgium
- Institute of Health and Society (IRSS), Université Catholique de Louvain, Brussels, Belgium
- Institut Pierre Louis d'Epidémiologie et de Santé Publique (IPLESP), INSERM, Sorbonne Université, Paris, France
| | - Séverine Henrard
- Clinical Pharmacy Research Group (CLIP), Louvain Drug Research Institute (LDRI), Université Catholique de Louvain, Brussels, Belgium
- Institute of Health and Society (IRSS), Université Catholique de Louvain, Brussels, Belgium
| | - Benoit Boland
- Institute of Health and Society (IRSS), Université Catholique de Louvain, Brussels, Belgium
- Geriatric medicine, Cliniques universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Alan J Sinclair
- Foundation for Diabetes Research in Older People (fDROP), London, UK
- King's College, London, UK
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Albarqouni L, Palagama S, Chai J, Sivananthajothy P, Pathirana T, Bakhit M, Arab-Zozani M, Ranakusuma R, Cardona M, Scott A, Clark J, Smith CF, Effa E, Ochodo E, Moynihan R. Overuse of medications in low- and middle-income countries: a scoping review. Bull World Health Organ 2023; 101:36-61D. [PMID: 36593777 PMCID: PMC9795388 DOI: 10.2471/blt.22.288293] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Revised: 08/09/2022] [Accepted: 08/10/2022] [Indexed: 01/04/2023] Open
Abstract
Objective To identify and summarize the evidence about the extent of overuse of medications in low- and middle-income countries, its drivers, consequences and potential solutions. Methods We conducted a scoping review by searching the databases PubMed®, Embase®, APA PsycINFO® and Global Index Medicus using a combination of MeSH terms and free text words around overuse of medications and overtreatment. We included studies in any language published before 25 October 2021 that reported on the extent of overuse, its drivers, consequences and solutions. Findings We screened 3489 unique records and included 367 studies reporting on over 5.1 million prescriptions across 80 low- and middle-income countries - with studies from 58.6% (17/29) of all low-, 62.0% (31/50) of all lower-middle- and 60.0% (33/55) of all upper-middle-income countries. Of the included studies, 307 (83.7%) reported on the extent of overuse of medications, with estimates ranging from 7.3% to 98.2% (interquartile range: 30.2-64.5). Commonly overused classes included antimicrobials, psychotropic drugs, proton pump inhibitors and antihypertensive drugs. Drivers included limited knowledge of harms of overuse, polypharmacy, poor regulation and financial influences. Consequences were patient harm and cost. Only 11.4% (42/367) of studies evaluated solutions, which included regulatory reforms, educational, deprescribing and audit-feedback initiatives. Conclusion Growing evidence suggests overuse of medications is widespread within low- and middle-income countries, across multiple drug classes, with few data of solutions from randomized trials. Opportunities exist to build collaborations to rigorously develop and evaluate potential solutions to reduce overuse of medications.
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Affiliation(s)
- Loai Albarqouni
- Institute for Evidence-Based Healthcare, Faculty of Health Sciences and Medicine, Bond University, 14 University Dr, Robina, QLD, 4229, Australia
| | - Sujeewa Palagama
- Institute for Evidence-Based Healthcare, Faculty of Health Sciences and Medicine, Bond University, 14 University Dr, Robina, QLD, 4229, Australia
| | - Julia Chai
- Cumming School of Medicine, University of Calgary, Alberta, Canada
| | | | - Thanya Pathirana
- School of Medicine and Dentistry, Griffith University, Sunshine Coast, Australia
| | - Mina Bakhit
- Institute for Evidence-Based Healthcare, Faculty of Health Sciences and Medicine, Bond University, 14 University Dr, Robina, QLD, 4229, Australia
| | - Morteza Arab-Zozani
- Social Determinants of Health Research Center, Birjand University of Medical Sciences, Birjand, Iran
| | - Respati Ranakusuma
- Clinical Epidemiology and Evidence-Based Medicine Unit, Dr Cipto Mangunkusumo Hospital, Jakarta, Indonesia
| | - Magnolia Cardona
- Institute for Evidence-Based Healthcare, Faculty of Health Sciences and Medicine, Bond University, 14 University Dr, Robina, QLD, 4229, Australia
| | - Anna Scott
- Institute for Evidence-Based Healthcare, Faculty of Health Sciences and Medicine, Bond University, 14 University Dr, Robina, QLD, 4229, Australia
| | - Justin Clark
- Institute for Evidence-Based Healthcare, Faculty of Health Sciences and Medicine, Bond University, 14 University Dr, Robina, QLD, 4229, Australia
| | | | - Emmanuel Effa
- Department of Internal Medicine, University of Calabar, Calabar, Nigeria
| | - Eleanor Ochodo
- Centre for Global Health Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Ray Moynihan
- Institute for Evidence-Based Healthcare, Faculty of Health Sciences and Medicine, Bond University, 14 University Dr, Robina, QLD, 4229, Australia
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Potential Risk of Overtreatment in Patients with Type 2 Diabetes Aged 75 Years or Older: Data from a Population Database in Catalonia, Spain. J Clin Med 2022; 11:jcm11175134. [PMID: 36079064 PMCID: PMC9457074 DOI: 10.3390/jcm11175134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Revised: 08/23/2022] [Accepted: 08/26/2022] [Indexed: 11/17/2022] Open
Abstract
Aim: To assess the potential risk of overtreatment in patients with type 2 diabetes (T2DM) aged 75 years or older in primary care. Methods: Electronic health records retrieved from the SIDIAP database (Catalonia, Spain) in 2016. Variables: age, gender, body mass index, registered hypoglycemia, last HbA1c and glomerular filtration rates, and prescriptions for antidiabetic drugs. Potential overtreatment was defined as having HbA1c < 7% or HbA1c < 6.5% in older patients treated with insulin, sulfonylureas, or glinides. Results: From a total population of 138,374 T2DM patients aged 75 years or older, 123,515 had at least one HbA1c available. An HbA1c below 7.0% was present in 59.1% of patients, and below 6.5% in 37.7%. Overall, 23.0% of patients were treated with insulin, 17.8% with sulfonylureas, and 6.6% with glinides. Potential overtreatment (HbA1c < 7%) was suspected in 26.6% of patients treated with any high-risk drug, 47.8% with sulfonylureas, 43.5% with glinides, and 28.1% with insulin. Using the threshold of HbA1c < 6.5%, these figures were: 21.6%, 24.4%, 17.9%, and 12.3%, respectively. Conclusion: One in four older adults with T2DM treated with antidiabetic drugs associated with a high risk of hypoglycemia might be at risk of overtreatment. This risk is higher in those treated with sulfonylureas or glinides than with insulin.
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Cigiloglu A, Efendioglu EM, Ozturk ZA. A retrospective study of diabetes treatment in older adults: what should we AIM for? Postgrad Med 2022; 134:693-697. [PMID: 35697060 DOI: 10.1080/00325481.2022.2090175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVES Management of diabetes in elderly individuals requires a complex approach, considering the negative consequences. Glycemic overtreatment and undertreatment are relatively common conditions among this population. This study aimed to determine the potential overtreatment and undertreatment frequencies in older adults and the factors associated with these conditions. METHODS This retrospective study included 405 diabetic older adults aged >65 years. Sociodemographic characteristics, additional comorbidities, medications, HbA1c and fasting glucose levels of the patients have been recorded. RESULTS The median age of the patients was 71 years. The frequency of potential overtreatment and undertreatment has been found to be 20.2% and 17.8%, respectively. Insulin and sulfonylureas were found to be associated with increased risk of potential overtreatment (p = 0.000, OR = 14.91 and p = 0.000, OR = 8.48, respectively) and reduced risk of potential undertreatment (p = 0.001, OR = 0.16 and p = 0.000, OR = 0.05, respectively), while DPP-4 inhibitors were found to be associated with reduced risk of potential undertreatment (p = 0.000, OR = 0.12). CONCLUSION Our study has shown that potential glycemic overtreatment and undertreatment are common problems in diabetic older adults. It was found that agents with a high risk of hypoglycemia, such as insulin and sulfonylureas, were more closely associated with potential overtreatment. In the management of diabetes in the elderly, it should be aimed to choose treatment agents that lead to less negative consequences and to follow up the patients more closely.
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Affiliation(s)
- Ahmet Cigiloglu
- Faculty of Medicine, Department of Internal Medicine, Division of Geriatric Medicine, Gaziantep University, Sahinbey, Turkey
| | - Eyyup Murat Efendioglu
- Faculty of Medicine, Department of Internal Medicine, Division of Geriatric Medicine, Gaziantep University, Sahinbey, Turkey
| | - Zeynel Abidin Ozturk
- Faculty of Medicine, Department of Internal Medicine, Division of Geriatric Medicine, Gaziantep University, Sahinbey, Turkey
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Aubert CE, Chan CL, Terman SW, Hofer TP, Ha JK, Cushman WC, Sussman J, Min L. Evaluating alternative methods of comparing antihypertensive treatment intensity. THE AMERICAN JOURNAL OF MANAGED CARE 2022; 28:e157-e162. [PMID: 35546588 PMCID: PMC10694801 DOI: 10.37765/ajmc.2022.89146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVES To change blood pressure treatment, clinicians can modify medication count or dose. However, existing studies have measured count modification, which may miss clinically important dose change in the absence of count change. This research demonstrates how dose modification captures more information about management than medication count alone. STUDY DESIGN Retrospective cohort study. METHODS We included patients 65 years and older with established primary care at the Veterans Health Administration (July 2011-June 2013). We captured medication count and standardized dose change over 90 to 120 days using a validated pharmacy fill algorithm. We determined frequency of dose change without count change (and vice versa), no change in either, change in same direction ("concordant"), and change in opposite direction ("discordant"). We compared change according to systolic blood pressure (SBP) and compared concordance using a minimum threshold definition of dose change of at least 50% (instead of any change) of baseline dose modification. RESULTS Among 440,801 patients, 64.2% had dose change; 22.0%, count change; 35.6%, no change in either; 42.4%, dose change without count modification; and 0.2%, count change without dose modification. Discordance occurred in 2.1% of observations. Using the minimum threshold definition of change, 68.7% had no change in either dose or count. Treatment was more frequently changed at SBP greater than 140 mm Hg. CONCLUSIONS Measuring change in antihypertensive treatment using medication count frequently missed an isolated dose change in treatment modification and less often misclassified regimen modifications where there was no modification in total dose. In future research, measuring dose modification using our new algorithm would capture change in hypertension treatment intensity more precisely than current methods.
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Affiliation(s)
- Carole E Aubert
- Department of General Internal Medicine, Bern University Hospital, Freiburgstrasse, 3010 Bern, Switzerland.
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Sonmez A, Sabbour H, Echtay A, Rahmah AM, Alhozali AM, al Sabaan FS, Haddad FH, Iraqi H, Elebrashy I, Assaad SN, Bayat Z, Osar Siva Z, Hassanein M. Current gaps in management and timely referral of cardiorenal complications among people with type 2 diabetes mellitus in the Middle East and African countries: Expert recommendations. J Diabetes 2022; 14:315-333. [PMID: 35434900 PMCID: PMC9366572 DOI: 10.1111/1753-0407.13266] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Revised: 03/05/2022] [Accepted: 03/13/2022] [Indexed: 12/11/2022] Open
Abstract
The upsurge of type 2 diabetes mellitus is a major public health concern in the Middle East and North Africa (MENA) and Africa (AFR) region, with cardiorenal complications (CRCs) being the predominant cause of premature morbidity and mortality. High prevalence of cardiometabolic risk factors, lack of awareness among patients and physicians, deficient infrastructure, and economic constraints lead to a cascade of CRCs at a significantly earlier age in MENA and AFR. In this review, we present consensus recommendations by experts in MENA and AFR, highlighting region-specific challenges and potential solutions for management of CRCs. Health professionals who understand sociocultural barriers can significantly increase patient awareness and encourage health-seeking behavior through simple educational tools. Increasing physician knowledge on early identification of CRCs and personalized treatment based on risk stratification, alongside optimum glycemic control, can mitigate therapeutic inertia. Early diagnosis of high-risk people with regular and systematic monitoring of cardiorenal parameters, development of region-specific care pathways for timely referral to specialists, followed by guideline-recommended care with novel antidiabetics are imperative. Adherence to guideline-recommended care can catalyze utilization of sodium glucose cotransporter 2 inhibitors and glucagon-like peptide 1 receptor agonists with demonstrated cardiorenal benefits-thus paving the way for overcoming care gaps in a cost-effective manner. Leveraging digital technology like electronic medical records can help generate real-world data and provide insights on voids in adoption of newer antidiabetic medications. A patient-centric approach, collaborative care among physicians from different specialties, alongside involvement of policy makers are key for improving patient outcomes and quality of care in MENA and AFR.
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Affiliation(s)
- Alper Sonmez
- Department of Endocrinology and MetabolismGulhane School of Medicine, University of Health SciencesAnkaraTurkey
| | - Hani Sabbour
- Heart & Vascular Institute Cleveland ClinicAbu DhabiUAE
- Brown University Warren Alpert School of MedicineProvidenceRhode IslandUSA
| | - Akram Echtay
- School of MedicineLebanese UniversityHadathLebanon
| | - Abbas Mahdi Rahmah
- National Centre for DiabetesCollege of Medicine, Al‐Mustansriya UniversityBaghdadIraq
| | | | | | - Fares H. Haddad
- Endocrine & Diabetes, Abdali Hospital/Endocrine & Diabetes ClinicAmmanJordan
| | - Hinde Iraqi
- Faculty of Medicine and PharmacyMohammed V UniversityRabatMorocco
| | | | | | - Zaheer Bayat
- Division of Endocrinology and Metabolism, Department of Internal MedicineHelen Joseph HospitalRossmore, JohannesburgSouth Africa
| | | | - Mohamed Hassanein
- Dubai Hospital, DHADubaiUAE
- Gulf Medical UniversityAjmanUAE
- Cardiff UniversityCardiffUK
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Al-Musawe L, Torre C, Guerreiro JP, Rodrigues AT, Raposo JF, Mota-Filipe H, Martins AP. Overtreatment and undertreatment in a sample of elderly people with diabetes. Int J Clin Pract 2021; 75:e14847. [PMID: 34516684 DOI: 10.1111/ijcp.14847] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Accepted: 09/10/2021] [Indexed: 12/29/2022] Open
Abstract
AIMS In older adults with type 2 diabetes (T2D), overtreatment remains prevalent and undertreatment ignored. The main objective is to estimate the prevalence and examine factors associated with potential overtreatment and undertreatment. METHOD Observational study conducted within an administrative database of older adults with T2D who registered in 2018 at the Portuguese Diabetes Association. Participants were categorized either as potentially overtreated (HbA1c ≤ 7.5%), appropriately on target (HbA1c ≥7.5 to ≤9%), or potentially undertreated (HbA1c > 9%). RESULTS The study included 444 participants: potential overtreatment and undertreatment were found in 60.5% and 12.6% of the study population. Taking the patients on target as a comparator, the group of potentially overtreated showed to be more men (61.3% vs 52.2%), less-obese (34.1% vs 39.2), higher cardiovascular diseases (13.7% vs 11%), peripheral vascular diseases (16.7% vs 12.8%), diabetic foot (10% vs 4.5%), and severe kidney disease (5.2% vs 4.5%). Conversely, the potentially undertreated participants were more women (64.2% vs 47.7%), obese (49% vs 39.2%), had more dyslipidemia (69% vs 63.1%), peripheral vascular disease (14.2% vs 12.8%), diabetic foot (8.9% vs 4.5%), and infections (14.2% vs 11.9%). The odds of potential overtreatment were mostly decreased by 59% of women, 73.5% in those with retinopathy, and 86.3% in insulin, 65.4% sulfonylureas, and 66.8% in SGLT2 inhibitors users. Contrariwise, an increase in the odds of potential undertreatment was more than 4.8 times higher in insulin, and more than 3.1 times higher in sulfonylureas users. CONCLUSION Potential overtreatment and undertreatment in older adults with T2D in routine clinical practice should guide the clinicians to balance the use of newer oral antidiabetic agents considering its safety profile regarding hypoglycemia.
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Affiliation(s)
| | - Carla Torre
- Faculty of Pharmacy, University of Lisbon, Lisbon, Portugal
| | | | | | - Joao Filipe Raposo
- Nova Medical School, New University of Lisbon, Lisbon, Portugal
- Portuguese Diabetes Association (APDP), Lisbon, Portugal
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Ambrož M, de Vries ST, Hoogenberg K, Denig P. Older Age, Polypharmacy, and Low Systolic Blood Pressure Are Associated With More Hypotension-Related Adverse Events in Patients With Type 2 Diabetes Treated With Antihypertensives. Front Pharmacol 2021; 12:728911. [PMID: 34630105 PMCID: PMC8497792 DOI: 10.3389/fphar.2021.728911] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Accepted: 09/06/2021] [Indexed: 01/30/2023] Open
Abstract
Background and Aims: Low systolic blood pressure (SBP) levels while being treated with antihypertensives may cause hypotension-related adverse events (hrAEs), especially in the elderly, women, and frail patients. We aimed to assess the association between the occurrence of hrAEs and low SBP levels, age, sex, and polypharmacy among patients with type 2 diabetes (T2D) treated with antihypertensives. Methods: In this cohort study, we used the Groningen Initiative to ANalyse Type 2 diabetes Treatment (GIANTT) database which includes patients managed for T2D in primary care from the north of the Netherlands. Patients treated with ≥1 antihypertensive drug and ≥1 SBP measurement between 2012 and 2014 were included. The outcome was the presence of an hrAE, i.e. postural hypotension, dizziness, weakness/tiredness, and syncope in 90 days before or after the lowest recorded SBP level. Age (≥70 vs. <70 years), sex (women vs. men), polypharmacy (5–9 drugs or ≥10 drugs vs. <5 drugs), and SBP level (<130 or ≥130 mmHg) were included as determinants. Logistic regression analyses were conducted for age, sex and polypharmacy, including the SBP level and their interaction, adjusted for confounders. Odds ratios (OR) with 95% confidence intervals (CI) are presented. Results: We included 21,119 patients, 49% of which were ≥70 years old, 52% were women, 57% had polypharmacy, 61% had an SBP level <130 mmHg and 5.4% experienced an hrAE. Patients with an SBP level <130 mmHg had a significantly higher occurrence of hrAEs than patients with a higher SBP level (6.2 vs. 4.0%; ORs 1.41, 95%CI 1.14–1.75, 1.43, 95%CI 1.17–1.76 and 1.33, 95%CI 1.06–1.67 by age, sex, and polypharmacy, respectively). Older patients (OR 1.29, 95%CI 1.02–1.64) and patients with polypharmacy (OR 5–9 drugs 1.27, 95%CI 1.00–1.62; OR ≥10 drugs 2.37, 95% CI 1.67–3.37) were more likely to experience an hrAE. The association with sex and the interactions between the determinants and SBP level were not significant. Conclusion: Low SBP levels in patients with T2D treated with antihypertensives is associated with an increase in hrAEs. Older patients and those with polypharmacy are particularly at risk of hrAEs. Age, sex, and polypharmacy did not modify the risk of hrAEs associated with a low SBP level.
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Affiliation(s)
- Martina Ambrož
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Sieta T de Vries
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Klaas Hoogenberg
- Department of Internal Medicine, Martini Hospital, Groningen, Netherlands
| | - Petra Denig
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
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Sonmez A. Challenges in the Prevention and Management of Diabetic Kidney Diseases. FRONTIERS IN CLINICAL DIABETES AND HEALTHCARE 2021; 2:728320. [PMID: 36994322 PMCID: PMC10012163 DOI: 10.3389/fcdhc.2021.728320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Accepted: 08/06/2021] [Indexed: 11/13/2022]
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Basu S, Shao H, Luo J, Lipska K, Suda KJ, Yudkin JS. Estimates of insulin needs and dispensation given wastage, alternative glycemic targets, and non-insulin therapies in US populations with type 2 diabetes mellitus: A microsimulation study. J Diabetes Complications 2021; 35:107839. [PMID: 33455873 DOI: 10.1016/j.jdiacomp.2020.107839] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Revised: 12/11/2020] [Accepted: 12/16/2020] [Indexed: 11/18/2022]
Abstract
AIMS Registries and health plans estimate insulin need for population health metrics. We sought to identify how such estimates affect population- and individual-level estimates of over- and under-treatment. METHODS We developed a microsimulation comparing estimated insulin need to dispensation using the National Health and Nutrition Examination Survey (NHANES, 2005-2016, N= 2832) and Medical Expenditure Panel Survey (MEPS, 2005-2016, N = 29,615). RESULTS From NHANES, ~21.6% of people with type 2 diabetes would require insulin to achieve a HbA1c target of 7% after maximum titration of two non-insulins (60.7 IU/person/day, or 84,629,833 vials of 1000 IU in the US). From MEPS, we observed 57.4 IU/person/day of insulin dispensed (81,585,842 vials). About 29% of people were dispensed at least two standard deviations less than their estimated need, and 22% at least two standard deviations more than estimated need. Population-level need estimates reduced 39.4% if liberalizing HbA1c targets to 8% for people ≥75 years old. CONCLUSIONS Estimated insulin needs of people with type 2 diabetes in the U.S. are consistent with their dispensed insulin at the population level, but are sensitive to HbA1c targets for older adults, and conceal under- and over-treated subpopulations.
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Affiliation(s)
- Sanjay Basu
- Center for Primary Care, Harvard Medical School, United States of America; Ariadne Labs, Brigham and Women's Hospital and Harvard T.H. Chan School of Public Health, United States of America; Research and Population Health, Collective Health, United States of America; School of Public Health, Imperial College London, UK.
| | - Hui Shao
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, United States of America
| | - Jing Luo
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, United States of America
| | - Kasia Lipska
- Section of Endocrinology, Department of Internal Medicine, Yale University School of Medicine, United States of America
| | - Katie J Suda
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, United States of America; Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Health Care System, United States of America
| | - John S Yudkin
- Institute of Cardiovascular Science, Division of Medicine, University College London, UK
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Jaursch-Hancke C. [Not Available]. MMW Fortschr Med 2020; 162:28. [PMID: 32578102 DOI: 10.1007/s15006-020-0605-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
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