The METABOLIC Study: Multidimensional assessment of health and functional status in older patients with type 2 diabetes taking oral antidiabetic treatment

Sulfonylurea prescription patterns in elderly patients with type 2 diabetes mellitus: A comprehensive analysis of real-world data from pharmacies in Japan

AIMS/INTRODUCTION

The study aim was to investigate sulfonylurea prescription patterns in elderly patients (age ≥65 years) with type 2 diabetes mellitus in Japan. Sulfonylurea use among older adults has been insufficiently examined, despite the associated risks of hypoglycemia.

MATERIALS AND METHODS

This retrospective cross-sectional survey entailed analysis of Japanese pharmacy data, extracted from the Musubi database, for patients (age 20-100 years) prescribed sulfonylureas between November 2022 and October 2023. Dose distribution, adherence to the Diabetes Treatment Guidelines for the Elderly 2023 and coprescription of other diabetes medications were investigated.

RESULTS

Of the total 91,229 patients, 80.1% were prescribed glimepiride, 16.3% gliclazide and 3.6% glibenclamide. In patients aged ≥65 years, exceeding the recommended dose (>1 mg/day for glimepiride, >40 mg/day for gliclazide) was numerically higher for glimepiride (25.0%) than for gliclazide (7.8%). The most common prescribing patterns were quadruple therapy with a sulfonylurea, a dipeptidyl peptidase-4 inhibitor, an sodium-glucose transporter 2 inhibitor and a biguanide in patients aged 65 to <75 years, and dual therapy with a sulfonylurea and a dipeptidyl peptidase-4 inhibitor in patients aged ≥75 years. Unfortunately, glinide was coprescribed for 338 (0.5%) of elderly patients. Insulin was coprescribed for 3,682 (5.6%) of elderly patients.

CONCLUSIONS

Analysis of real-world sulfonylurea prescription data found guideline non-adherence, namely, excessive prescription of glimepiride, use of glibenclamide in elderly patients, and common coprescription with dipeptidyl peptidase-4 inhibitors. These findings might provide an opportunity to reconsider the treatment of patients with type 2 diabetes mellitus who are over-prescribed sulfonylureas to reduce residual risks, such as hypoglycemia.

Association between glycemic control and cardiovascular events in older Japanese adults with diabetes mellitus: An analysis of the Japanese medical administrative database

AIMS/INTRODUCTION

The relationship between glycated hemoglobin (HbA1c) and cardiovascular events in older adults was investigated using a Japanese administrative medical database.

MATERIALS AND METHODS

Anonymized medical data on patients with diabetes mellitus aged ≥65 years for the period from January 2010 to December 2019 were extracted from the EBM Provider database. The primary end-point was a composite of cardiovascular events, whereas the other end-points included severe hypoglycemia and fracture. The association between cardiovascular events and HbA1c at the index date (i.e., approximately 10 months after initial diabetes mellitus diagnosis) was evaluated using the Cox proportional hazards model.

RESULTS

Among the 3,186,751 patients in the database, 3,946 older adults with diabetes mellitus were eligible for inclusion and were subsequently grouped according to HbA1c quartiles at the index date. Cardiovascular events occurred in 142 patients. Patients with HbA1c in the highest quartile had significantly higher risk of hospitalization for cardiovascular disease than those with HbA1c in the lowest quartile (hazard ratio 1.948; 95% confidence interval 1.252-3.031, P = 0.003). However, the events risk was similar across subgroups with HbA1c <7.2%. The incidence of hypoglycemia and fracture was not significantly associated with the level of glycemic control.

CONCLUSIONS

Among older adults with diabetes mellitus, those with poor glycemic control were at higher risk for cardiovascular events compared with those with better glycemic control. However, strict glycemic control had no effect on cardiovascular risk in patients with HbA1c <7.2%.

Development and Validation of a Self-Administered Multidimensional Prognostic Index to Predict Negative Health Outcomes in Community-Dwelling Persons

The multidimensional prognostic index (MPI) is a comprehensive geriatric assessment (CGA)-based tool that accurately predicts negative health outcomes in older subjects with different diseases and settings. To calculate the MPI several validated tools are assessed by health care professionals according to the CGA, whereas self-reported information by the patients is not available, but it could be of importance for the early identification of frailty. We aimed to develop and validate a self-administered MPI (SELFY-MPI) in community-dwelling subjects. For this reason, we enrolled 167 subjects (mean age = 67.3, range = 20–88 years, 51% = men). All subjects underwent a CGA-based assessment to calculate the MPI and the SELFY-MPI. The SELFY-MPI included the assessment of (1) basic and instrumental activities of daily living, (2) mobility, (3) memory, (4) nutrition, (5) comorbidity, (6) number of medications, and (7) socioeconomic situation. The Bland–Altman methodology was used to measure the agreement between MPI and SELFY-MPI. The mean MPI and SELFY-MPI values were 0.147 and 0.145, respectively. The mean difference was +0.002 ± standard deviation of 0.07. Lower and upper 95% limits of agreement were −0.135 and +0.139, respectively, with only 5 of 167 (3%) of observations outside the limits. Stratified analysis by age provided similar results for younger (≤65 years old, n = 45) and older subjects (>65 years, n = 122). The analysis of variances in subjects subdivided according to different year decades showed no differences of agreement according to age. In conclusion, the SELFY-MPI can be used as a prognostic tool in subjects of different ages.

[The status of glycemic control and hypoglycemia in elderly patients visiting the outpatient department specializing in diabetes]

AIM

The Japan Diabetes Society (JDS)/Japan Geriatrics Society (JGS) Joint Committee reported 'Glycemic Targets for Elderly Patients with Diabetes' in 2016. Based on this recommendation, we aimed to clarify 1) the achievement status of glycemic targets in the elderly and 2) the presence of hypoglycemia in real life among elderly individuals with an HbA1c below the lower limit.

SUBJECTS AND METHODS

[Analysis I] In 326 elderly with diabetes ≥65 years of age visiting the outpatient department specializing in diabetes, the proportions of patients with HbA1c values below the lower limit and the use of drugs potentially associated with severe hypoglycemia (e.g. insulin formulations, sulfonylureas, glinides) were investigated. [Analysis II] Of the patients with HbA1c values below the lower limit, seven were tested for hypoglycemia in real life using a continuous glucose monitoring system (CGM).

RESULTS

[Analysis I] Among the 326 subjects, 235 (72.1%) were using drugs potentially associated with severe hypoglycemia, and 63 (19.3%) had an HbA1c value below the lower limit. [Analysis II] In the seven patients examined using CGM, hypoglycemia was detected in five, all of whom were unaware.

CONCLUSIONS

A considerable number of elderly patients were taking drugs associated with hypoglycemic risks and had an HbA1c value below the lower limit, some of whom actually had hypoglycemia as detected by CGM. Using tools such as CGM, preventive measures against hypoglycemia should be taken.

[State of glycemic control in elderly diabetic patients]

AIM

The Japan Diabetes Society and The Japan Geriatric Society made a joint committee and published a new glycemic target in May 2016. Because reports on the state of glycemic control in elderly diabetic patients are insufficient, we investigated the state of glycemic control in this population before the new glycemic target was established.

METHODS

We enrolled patients older than 65 years of age who had been prescribed antidiabetic drugs and hospitalized in the geriatric department of Nagoya University Hospital from April 1, 2015, to March 31, 2016. We investigated the participants' HbA1c, prescription of antidiabetic drugs carrying risks of severe hypoglycemia (risk drugs) at hospitalization, cognitive function, basic activities of daily living, and instrumental activities of daily living.

RESULTS

A total of 63 patients were enrolled. Thirty-five patients were male, the mean age was 83.1±5.9 years old, and the average HbA1c was 7.6%±1.5%. The numbers of patients assigned to categories I, II, and III were 10, 12, and 41, respectively. For prescription of risk drugs, 6 participants were assigned to category I, 8 to category II, and 22 to category III. Prescription of risk drugs was associated with the HbA1c. Approximately one third of the patients using risk drugs had a lower HbA1c than the target value.

CONCLUSIONS

Risk drugs was not significantly associated with the established categories or age. Many of the patients who were prescribed risk drugs had a lower HbA1c than the target values.

Polypharmacy in elderly patients with type 2 diabetes receiving oral antidiabetic treatment

AIM

Polypharmacy in older diabetics can have detrimental effects linked to poor adherence and the risk of drug interaction or more serious/frequent side effects. The aim of this study was to identify the characteristics associated with polypharmacy in a cohort of elderly diabetic patients being treated with oral hypoglycemic agents.

METHODS

The study population consisted of 1342 diabetic patients consecutively enrolled in 57 diabetes centers in Italy participating in the METABOLIC Study. Patients meeting the following inclusion criteria were enrolled: diagnosis of type 2 diabetes mellitus, age ≥65 years, and receiving oral antidiabetic treatment. Data concerning diabetes duration and complications, the medications the patients were taking, and the number of hypoglycemic events were registered. Multidimensional impairment was assessed using the Multidimensional Prognostic Index.

RESULTS

The mean age of the participants was 73.3 ± 5.5 years. Polypharmacy, defined as being prescribed contemporaneously at least five drugs, was found in 57.1 % of the study population. According to a multivariable logistic model, the female gender was significantly associated with polypharmacy, as were living in Northern Italian regions, diabetes duration longer than 4 years, and having a body mass index ≥30 kg/m(2). Comorbidities, diabetes complications, a better cognitive performance on the Short Portable Mental Status Questionnaire, and being malnourished/at risk of malnourishment according to the mini nutritional assessment were associated with polypharmacy.

CONCLUSIONS

Polypharmacy, a condition that may lead to many potential detrimental outcomes in older diabetic subjects, was significantly associated with some risk factors that may be useful to identify subjects at risk.

Treatment Patterns and Glycemic Control in Older Adults with Type 2 Diabetes Mellitus Receiving Only Oral Antidiabetes Drugs in China

BACKGROUND

Only a few studies have reported the use of oral antidiabetes drugs (OADs) for treating older adults with type 2 diabetes mellitus (T2DM) in China. This study assessed the status of OAD therapy and relevant factors associated with OAD treatment patterns and glycemic control among older patients.

PATIENTS AND METHODS

We conducted a noninterventional, observational, cross-sectional, multicenter study, which was initiated by the Chinese Diabetes Society, in which 9,872 outpatients with T2DM were recruited who received OADs only. Current antidiabetes treatment regimens and related clinical data were collected from patients' self-reporting and medical records. Participants were divided into two groups: ≥65 years and <65 years. All data were tabulated, and statistical analyses were performed using SPSS version 16 software (SPSS Inc., Chicago, IL).

RESULTS

Insulin secretagogues (52.6%): sulfonylureas (SU) (26.6%) and glinides (26.0%) were commonly used as monotherapy in those ≥65 years. The most popular OAD pattern was dual combination therapy (46.8%), with SU plus glucosidase inhibitors (25.1%) being most common in older participants. Age, diabetes duration, body mass index, achieving the glycemic control targets, and hypoglycemia were influencing factors to those ≥65 years in diverse treatment pattern models (P < 0.05). Older patients receiving OADs with triple or more combination treatment and complications were more likely to have substandard glycemic control (hemoglobin A1c level ≥7%).

CONCLUSIONS

The pattern of OADs alone in older adults with T2DM was significantly different from those <65 years in China. A comprehensive OAD treatment pattern or insulin combination may be necessary for better glycemic control in older patients with multiple combinations of OADs or complications.

Characterisation of potential antidiabetic-related proteins from Pleurotus pulmonarius (Fr.) Quél. (grey oyster mushroom) by MALDI-TOF/TOF mass spectrometry

Pleurotus pulmonarius has been reported to have a potent remedial effect on diabetic property and considered to be an alternative for type 2 diabetes mellitus treatment. This study aimed to investigate the antidiabetic properties of ammonium sulphate precipitated protein fractions from P. pulmonarius basidiocarps. Preliminary results demonstrated that 30% (NH₄)₂SO₄ precipitated fraction (F30) inhibited Saccharomyces cerevisiae α-glucosidase activity (24.18%), and 100% (NH₄)₂SO₄ precipitated fraction (F100) inhibited porcine pancreatic α-amylase activity (41.80%). Following RP-HPLC purification, peak 3 from F30 fraction demonstrated inhibition towards α-glucosidase at the same time with meagre inhibition towards α-amylase activity. Characterisation of proteins using MALDI-TOF/TOF MS demonstrated the presence of four different proteins, which could be implicated in the regulation of blood glucose level via various mechanisms. Therefore, this study revealed the presence of four antidiabetic-related proteins which are profilin-like protein, glyceraldehyde-3-phosphate dehydrogenase-like protein, trehalose phosphorylase-like (TP-like) protein, and catalase-like protein. Hence, P. pulmonarius basidiocarps have high potential in lowering blood glucose level, reducing insulin resistance and vascular complications.

Hypoglycemia is independently associated with multidimensional impairment in elderly diabetic patients

Aim. To identify the characteristics associated with multidimensional impairment, evaluated through the Multidimensional Prognostic Index (MPI), a validated predictive tool for mortality derived from a standardized Comprehensive Geriatric Assessment (CGA), in a cohort of elderly diabetic patients treated with oral hypoglycemic drugs. Methods and Results. The study population consisted of 1342 diabetic patients consecutively enrolled in 57 diabetes centers distributed throughout Italy, within the Metabolic Study. Inclusion criteria were diagnosis of type 2 diabetes mellitus (DM), 65 years old or over, and treatment with oral antidiabetic medications. Data concerning DM duration, medications for DM taken during the 3-month period before inclusion in the study, number of hypoglycemic events, and complications of DM were collected. Multidimensional impairment was assessed using the MPI evaluating functional, cognitive, and nutritional status; risk of pressure sores; comorbidity; number of drugs taken; and cohabitation status. The mean age of participants was 73.3 ± 5.5 years, and the mean MPI score was 0.22 ± 0.13. Multivariate analysis showed that advanced age, female gender, hypoglycemic events, and hospitalization for glycemic decompensation were independently associated with a worse MPI score. Conclusion. Stratification of elderly diabetic patients using the MPI might help to identify those patients at highest risk who need better-tailored treatment.