Comparative Effectiveness for Glycemic Control in Older Adults with Diabetes

Cardiovascular, Metabolic, and Safety Outcomes with Semaglutide by Baseline Age: Post Hoc Analysis of SUSTAIN 6 and PIONEER 6

INTRODUCTION

The high risk of cardiovascular events in people with type 2 diabetes increases with age. The cardiovascular effects of once-weekly subcutaneous and once-daily oral semaglutide versus placebo in people with type 2 diabetes at high cardiovascular risk were investigated in the SUSTAIN 6 and PIONEER 6 cardiovascular outcomes trials, respectively. It is unknown whether the effects of semaglutide are age dependent.

METHODS

This post hoc analysis evaluated cardiovascular, metabolic, and safety outcomes with semaglutide versus placebo in age subgroups (≤ 60; > 60 to ≤ 65; > 65 to ≤ 70; and > 70 years) pooled from SUSTAIN 6 and PIONEER 6. Major adverse cardiovascular events (composite of cardiovascular death, nonfatal myocardial infarction, and nonfatal stroke), changes from baseline in glycated hemoglobin A1c (HbA1c) and body weight, and adverse events were analyzed.

RESULTS

Semaglutide reduced major adverse cardiovascular events and its components versus placebo across age subgroups (most hazard ratios < 1.0; pinteraction > 0.05). The treatment difference in HbA1c reduction was greater in those aged ≤ 60 years than in older subgroups (pinteraction = 0.01). Reductions in body weight with semaglutide versus placebo were consistent across age subgroups (pinteraction = 0.124). Serious adverse events or severe hypoglycemic episodes did not differ between semaglutide and placebo across age subgroups.

CONCLUSION

Semaglutide consistently reduced major adverse cardiovascular events and body weight versus placebo across age subgroups; its safety profile did not differ with age. These results suggest that relaxing HbA1c targets based solely on age may not always be required for people with type 2 diabetes.

TRIAL REGISTRATION

SUSTAIN 6 (NCT01720446) and PIONEER 6 (NCT02692716) are registered at ClinicalTrials.gov.

Comparison of Type 2 Diabetes Mellitus Control at Home Healthcare and Hospital Clinic Care at King Salman Armed Forces Hospital (2021-2022): A Retrospective Cohort Study

BACKGROUND

Home healthcare represents a great necessity for patients with diabetes mellitus (DM). Although there are numerous studies on geriatric diabetic patients, there are few studies on diabetic home care versus hospital care.

AIM

This study aimed to compare the effect of home healthcare services to hospital care for controlling type 2 diabetes mellitus (T2DM) at King Salman Armed Forces Hospital, Tabuk, Saudi Arabia.

METHODS

This retrospective cohort study included patients with type 2 diabetes mellitus at King Salman Armed Forces Hospital. The home healthcare group included 128 participants who received frequent follow-up visits at home. The hospital care group included 128 participants from the primary care clinic. Glycosylated hemoglobin (HbA1c) was used to measure glycemic control. Logistic regression analysis was done to detect factors related to achieving glycemic control.

RESULTS

Home healthcare care had a greater impact on the reduction of baseline glycosylated hemoglobin levels (p=0.0053). The target glycosylated hemoglobin was achieved by patients who received home healthcare (p=0.020). Using the multivariate regression analysis, home healthcare, married patients, those who can do full daily life activities without assistance, and those who were treated with only insulin had significant correlations to meet the target glycosylated hemoglobin level (odds ratio: 0.814, 0.541, 0.448, and 0.144; 95% confidence intervals: 0.72-0.94, 0.30-0.99, 0.31-0.65, and 0.08-0.25, respectively).

CONCLUSIONS

Home care strategy for patients suffering from type 2 diabetes mellitus provides better glycemic control compared to hospital care. Home care, marriage, doing full daily activities, and insulin treatment are important factors affecting glycemic control.

Hormones and Aging: An Endocrine Society Scientific Statement

Multiple changes occur across various endocrine systems as an individual ages. The understanding of the factors that cause age-related changes and how they should be managed clinically is evolving. This statement reviews the current state of research in the growth hormone, adrenal, ovarian, testicular, and thyroid axes, as well as in osteoporosis, vitamin D deficiency, type 2 diabetes, and water metabolism, with a specific focus on older individuals. Each section describes the natural history and observational data in older individuals, available therapies, clinical trial data on efficacy and safety in older individuals, key points, and scientific gaps. The goal of this statement is to inform future research that refines prevention and treatment strategies in age-associated endocrine conditions, with the goal of improving the health of older individuals.

Safety of dipeptidyl peptidase-4 inhibitors in older adults with type 2 diabetes: a systematic review and meta-analysis of randomized controlled trials

Registration:

PROSPERO: CRD42020210645

Introduction:

We aimed to assess the safety of dipeptidyl peptidase-4 (DPP-4) inhibitors in older patients with type 2 diabetes with inadequate glycaemic control.

Methods:

We included randomized controlled trials (RCTs) in older (⩾65 years) patients with type 2 diabetes. The intervention group was randomized to treatment with any DPP-4 inhibitors. A systematic search in MEDLINE and Embase was performed in December 2020. For assessing the risk of bias, RoB 2 tool was applied. The quality of evidence was assessed using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach. We pooled outcomes using random effects meta-analyses.

Results:

We identified 16 RCTs that included 19,317 patients with a mean age of greater than 70 years. The mean HbA1c level ranged between 7.1 and 10.0 g/dl. Adding DPP-4 inhibitors to standard care alone may increase mortality slightly [risk ratio (RR) 1.04; 95% confidence interval (CI) 0.89–1.21]. Adding DPP-4 inhibitors to standard care increases the risk for hypoglycaemia (RR 1.08; 95% CI 1.01–1.16), but difference in overall adverse events is negligible. DPP-4 inhibitors added to standard care may reduce mortality compared with sulfonylureas (RR 0.88; 95% CI 0.75–1.04). DPP-4 inhibitors probably reduce the risk for hypoglycaemia compared with sulfonylureas (magnitude of effect not quantifiable because of heterogeneity) but difference in overall adverse events is negligible. There is insufficient evidence on hospitalizations, falls, fractures, renal impairment and pancreatitis.

Conclusion:

There is no evidence that DPP-4 inhibitors in addition to standard care decrease mortality but DPP-4 inhibitors increase hypoglycaemia risk. Second-line therapy in older patients should be considered cautiously even in drugs with a good safety profile such as DPP-4 inhibitors. In case second-line treatment is necessary, DPP-4 inhibitors appear to be preferable to sulfonylureas.

Plain language summary

Safety of dipeptidyl peptidase-4 inhibitors in older adults with type 2 diabetes Introduction: We performed the review to assess the safety of dipeptidyl peptidase-4 (DPP-4) inhibitors in older type 2 diabetes patients with blood sugar outside the normal level. Methods: To answer the question, we searched various electronic databases. We included studies in older (⩾65 years) patients with type 2 diabetes that assessed the safety of DPP-4 inhibitors. The data from the different studies were quantitatively summarized using statistical methods. We assessed the quality of the data to judge the certainty of the findings. Results: We identified 16 studies that included 19,317 patients with a mean age greater than 70 years. The average blood sugar level of patients in the included studies was slightly or moderately increased. Adding DPP-4 inhibitors to standard care alone may increase mortality slightly. Adding DPP-4 inhibitors to standard care increases the risk for hypoglycaemia, but difference in overall adverse events is negligible. DPP-4 inhibitors added to standard care may reduce mortality compared with sulfonylureas. DPP-4s probably reduce the risk of hypoglycaemia compared with sulfonylureas (magnitude of effect not quantifiable because of heterogeneity) but difference in overall adverse events is negligible. There is insufficient evidence on hospitalizations, falls, fractures, renal impairment and pancreatitis. Conclusion: There is no evidence that DPP-4 inhibitors in addition to standard care decrease mortality but DPP-4 inhibitors increase the risk that blood sugar falls below normal. Adding DPP-4 inhibitorss to standard care in older patients should be considered cautiously even in drugs with a good safety profile such as DPP-4 inhibitors. In case additional treatment is necessary, DPP-4 inhibitors appear to be preferable to sulfonylureas.

Trends in the Degree of Control and Treatment of Cardiovascular Risk Factors in People With Type 2 Diabetes in a Primary Care Setting in Catalonia During 2007-2018

Objective

To assess the trends in cardiovascular risk factor control and drug therapy from 2007 to 2018 in subjects with type 2 diabetes mellitus (T2DM).

Materials and Methods

Cross-sectional analysis using yearly clinical data and treatment obtained from the SIDIAP database. Patients aged ≥18 years with a diagnosis of T2DM seen in primary care in Catalonia, Spain.

Results

The number of T2DM patients increased from 299,855 in 2007 to 394,266 in 2018. We also found an increasing prevalence of cardiovascular disease, heart failure, and chronic kidney disease (from 18.4 to 24.4%, from 4.5 to 7.3%, and from 20.2 to 31.3%, respectively). The achievement of glycemic targets (HbA1c<7%) scarcely changed (54.9% to 55.9%). Major improvements were seen in blood pressure (≤140/90 mmHg: from 55% to 71.8%), and in lipid control (low-density lipoprotein cholesterol <100 mg/dl: 33.4% to 48.4%), especially in people with established cardiovascular disease (48.8 to 69.7%). Simultaneous achievement of all three targets improved from 12.5% to 20.1% in the overall population and from 24.5% to 32.2% in those with cardiovascular disease but plateaued after 2013. There was an increase in the percentage of patients treated with any antidiabetic drug (70.1% to 81.0%), especially metformin (47.7% to 67.7%), and DPP4i (0 to 22.6%). The use of SGLT-2 and GLP-1ra increased over the years, but remained very low in 2018 (5.5% and 2.1% of subjects, respectively). There were also relevant increases in the use of statins (38.0% to 49.2%), renin-angiotensin system (RAS) drugs (52.5% to 57.2%), and beta-blockers (14.3% to 22.7%).

Conclusions

During the 2007-2018 period, relevant improvements in blood pressure and lipid control occurred, especially in people with cardiovascular disease. Despite the increase in the use of antidiabetic and cardiovascular drugs, the proportion of patients in which the three objectives were simultaneously achieved is still insufficient and plateaued after 2013. The use of antidiabetic drugs with demonstrated cardio renal benefits (SGLT-2 and GLP-1ra) increased over the years, but their use remained quite low.

The Survival Benefit for Optimal Glycemic Control in Advanced Non-Small Cell Lung Cancer Patients With Preexisting Diabetes Mellitus

Background

Diabetes mellitus (DM) is a frequent comorbidity in patients with cancer. This study aimed to evaluate the prognosis of advanced non-small cell lung cancer (NSCLC) patients with DM and to assess whether an optimal glycemic control improves overall survival (OS).

Methods

A total of 1279 advanced NSCLC patients including 300 (23.5%) with preexisting DM were retrospectively reviewed. The continuous relationship between glycated hemoglobin A1C (HbA1c) level and OS was analyzed by restricted cubic spline (RCS) function. Optimal HbA1c cut-off point was determined using X-tile analysis. Survival was analyzed with the Kaplan–Meier method and compared among groups stratified by diabetes status and HbA1c. Multivariable Cox proportional hazards regression analysis was employed to identify prognostic factors for OS after adjusting for baseline characteristics.

Results

DM and non-DM patients had similar OS (median (95% CI): 22.85 (20.05-26.73) vs. 22.22 (20.35-24.76) months, P=0.950). The multivariate Cox regression analyses showed that DM status was not a prognostic factor for OS (HR: 0.952, 95% CI: 0.808-1.122, P=0.559). However, there existed a non-linear but generally positive relationship between the elevated HbA1c level and increased risk of overall mortality. HbA1c > 6.6% was a negative prognostic factor for OS (HR: 1.593, 95% CI: 1.113-2.280, P=0.011). The median OS (95% CI) for nondiabetic patients, DM patients with HbA1c ≤6.6% and those with HbA1c > 6.6% was 22.22 (20.01-24.43), 25.28 (21.79-28.77) and 15.45 (7.57-23.33) months, respectively. Well-controlled DM patients had a comparable crude OS (HR (95% CI): 0.90 (0.76-1.08), P=0.273] compared to nondiabetic patients while patients with HbA1c>6.6% had a worse crude OS than patients without DM (HR (95% CI): 1.70 (1.24-2.34), P=0.001]. The survival benefit of good HbA1c control was prominent in all subgroups.

Conclusion

Impaired glycemic level negatively affects survival for patients with advanced NSCLC while proper glycemic control with HbA1c ≤6.6% improves the OS.

Identification and prevalence of frailty in diabetes mellitus and association with clinical outcomes: a systematic review protocol

INTRODUCTION

Diabetes mellitus is common and growing in prevalence, and an increasing proportion of people with diabetes are living to older age. Frailty is, therefore, becoming an important concept in diabetes. Frailty is associated with older age and describes a state of increased susceptibility to decompensation in response to physiological stress. A range of measures have been used to quantify frailty. This systematic review aims to identify measures used to quantify frailty in people with diabetes (any type); to summarise the prevalence of frailty in diabetes; and to describe the relationship between frailty and adverse clinical outcomes in people with diabetes.

METHODS AND ANALYSIS

Three electronic databases (Medline, Embase and Web of Science) will be searched from 2000 to November 2019 and supplemented by citation searching of relevant articles and hand searching of reference lists. Two reviewers will independently review titles, abstracts and full texts. Inclusion criteria include: (1) adults with any type of diabetes mellitus; (2) quantify frailty using any validated frailty measure; (3) report the prevalence of frailty and/or the association between frailty and clinical outcomes in people with diabetes; (4) studies that assess generic (eg, mortality, hospital admission and falls) or diabetes-specific outcomes (eg, hypoglycaemic episodes, cardiovascular events, diabetic nephropathy and diabetic retinopathy); (5) cross-sectional and longitudinal observational studies. Study quality will be assessed using the Newcastle-Ottawa Scale for observational studies. Clinical and methodological heterogeneity will be assessed, and a random effects meta-analysis performed if appropriate. Otherwise, a narrative synthesis will be performed.

ETHICS AND DISSEMINATION

This manuscript describes the protocol for a systematic review of observational studies and does not require ethical approval.

PROSPERO REGISTRATION NUMBER

CRD42020163109.

Prevalence of type 2 diabetes and their complications among home health care patients at Al-Kharj military industries corporation hospital

INTRODUCTION

The diabetes mellitus type 2 is a result of hyperglycemia due to insulin resistance caused by insufficient secretion of insulin from the beta cells of pancreas. The detection and controlling of diabetes mellitus type 2 (DMT2) at primary health-care centers in Saudi Arabia is well justified and widely practiced. The knowledge and awareness of DMT2 patients should be increased through the determination of its prevalence which may decrease the rates of comorbidities.

METHODS

A questionnaire of 159 patients registered at Home Care Center at Family and Community Medicine Department, Al-Kharj Military Industries Corporation Hospital, Saudi Arabia was used. Hemoglobin A1C (HbA1C) percentage and blood pressure were measured for all participants. Statistical analysis was performed for all data.

RESULTS

A total of 36.5% of cases were males and 63.5% were females with a mean age of 77.6 years. 94.3% of participants had DMT2 where 3.8% had type 1. 74.2% of cases experienced only one to two complications other than diabetes where 20.8% had more than three diseases. 47.2% of cases had HbA1C% <7.5% where 29 cases had HbA1C% ranged from 7.5% to 8% and about 32.8% of patients had poor glycemic control with HbA1C >8%. 81.1% of cases had hypertension, while 25.8% suffered from Stroke complication, 8.8% of patients had a congestive cardiac failure, 7.5% had ischemic heart disease, and 6.3% suffered from chronic kidney disease. The treatment goals, HbA1C 7.5--8%, have been achieved for about 64% of DMT2 patients where 51 patients still had uncontrolled DMT2 with HbA1C >8%.

CONCLUSION

Despite the majority of cases had good glycemic control, more attention should be paid to those over 65 years as they commonly had more morbidities that definitely affect their treatment regimes. Patients should be involved in different home health care programs to increase their awareness and knowledge of the possible risk factors and diabetes comorbidities.

Prevalence of prediabetes and type 2 diabetes in two non-random populations aged 44-77 years in the Faroe Islands

AIMS

The prevalence of type 2 diabetes is increasing worldwide but little known about the status in the Faroe Islands. The aim was therefore to determine the prevalence of type 2 diabetes mellitus and prediabetes in two non-random populations aged 44-77 years.

METHODS

This cross-sectional survey was conducted between 2011 and 2012 and included two sub-populations, namely 518 Septuagenarians aged 74-77 years (84% of the invited) and 401 Mark aged 44-73 years (87% of the invited). Subjects were screened for glycosylated haemoglobin, type A1c, non-fasting random plasma glucose, fasting plasma glucose followed by an oral glucose tolerance test. The screening was based on a diagnostic algorithm that included screening, diagnostic and confirmatory steps.

RESULTS

Each group was analysed separately. In the Septuagenarian group 20.4% had type 2 diabetes, with 5.2% being newly detected and a total of 59% had prediabetes. In the Mark group 4.1% had diabetes, with 2.1% being newly detected and 22.3% had prediabetes. Diabetes increased with age and was significantly more prevalent among men. Women had lower mean fasting plasma glucose concentrations and men had lower values for 2-hours plasma glucose. Significant predictors associated with diabetes mellitus included obesity (BMI ≥ 30, abnormal waist/hip ratio and vegetable consumption.

CONCLUSIONS

Among the Faroese populations studied, the prevalence of type 2 diabetes increased with age and was more prevalent among men. The detected prevalence was comparable to other Nordic countries for all age-groups.

Temporal trends in optimal diabetic care and complications of elderly type 2 diabetes patients in Thailand: A nationwide study

BACKGROUND

This study aimed to assess the nationwide trends in optimal diabetic care and complications of elderly type 2 diabetes mellitus (T2DM) patients over a 6-year period in Thailand.

METHODS

T2DM patients aged 65 years or older who received medical care at public hospitals in Thailand from 2010 to 2015 were included. The optimal T2DM care in elderly patients was defined as (1) blood pressure (BP) < 140/90, (2) hemoglobin A1C (HbA1c) < 7%, (3) low-density lipoprotein cholesterol (LDL-C) < 100 mg/dL, (4) use of antiplatelet medications, and (5) use of angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin II receptor blockers (ARBs) in hypertensive patients. T2DM treatment-related complications included hospital admissions due to dysglycemia.

RESULTS

A total of 54 295 elderly T2DM patients were enrolled in this study. From 2010 to 2015, there was an increasing trend in the achievement of BP control and use of antiplatelet medications (P for trend < 0.01), whereas there was a decreasing trend in the achievement of HbA1c and LDL-C control among elderly T2DM patients (P for trend < 0.001). There was an increasing trend in the use of ACEI/ARB among elderly T2DM patients with hypertension (P for trend < 0.001). Hospital admissions due to dysglycemia decreased over the study period (P for trend < 0.001).

CONCLUSION

There has been a trend change for diabetic care among elderly T2DM patients in Thailand. Further studies are needed to assess the impact on patient outcomes.

Diabetes and frailty

PURPOSE OF REVIEW

Disability and its preceding condition, frailty, are outstanding issues for achieving healthy aging. Diabetes is a very prevalent chronic disease among older patients that favours frailty status. This review will analyse the relationship between diabetes and frailty in the elderly and summarize the current strategies to improve physical function in diabetic older patients.

RECENT FINDINGS

We have analyzed the current knowledge providing insight on the relationship between frailty and diabetes in older people. Epidemiological evidences and potential mechanisms connecting diabetes with frailty in the aging process have been examined. Finally, the strategies to reduce frailty in aged population with diabetes were discussed.

SUMMARY

Current evidence reveals the high prevalence of diabetes in frail older patients, producing an additional impairment of physical performance in this population. Insulin resistance seems to contribute to this clinical manifestation which is related to the impact of diabetes on skeletal muscle function, on vascular function, and on the hormonal milieu. Exercise, nutritional and educational interventions, and less strict glycaemic control appear as the most effective strategies to reduce frailty in diabetic older people.