Comorbidity in the elderly with diabetes: Identification of areas of potential treatment conflicts

Impacts of medication adherence and home healthcare on the associations between polypharmacy and the risk of severe hypoglycemia among elderly diabetic patients in Taiwan from 2002 to 2012: A nationwide case-crossover study

AIM

To assess how medication adherence and home healthcare support influence the role of polypharmacy in induced hypoglycemia events among elderly diabetic patients.

METHODS

This case-crossover study retrieved records on diabetic patients >=65 years with severe hypoglycemia from 2002 to 2012 in Taiwan. Case period defined as 1-3 days before severe hypoglycemia was compared with a preceding control period of the same length, with an all-washout period of 30 days. Moreover, the modifiable effects of medication adherence and home healthcare service use were evaluated by stratified analysis.

RESULTS

Totally 2,237 patients were identified. Polypharmacy use was associated with the risk of severe hypoglycemia. Patients receiving polypharmacy without home healthcare services (aOR: 1.34; 95 % CI: 1.16-1.54) and those with poor adherence to anti-diabetic medications (aOR: 1.48; 95 % CI: 1.24-1.77) were significantly associated with an elevated risk of severe hypoglycemia. In patients with good adherence, non-home healthcare users being prescribed with polypharmacy had a higher risk of severe hypoglycemia. In the group that received home healthcare services, patients with poor adherence using polypharmacy had a higher risk of severe hypoglycemia.

CONCLUSIONS

Good adherence and receiving home healthcare services were associated with a decreased odds of severe hypoglycemic events in elderly diabetic patients, regardless of the fact whether they were prescribed with polypharmacy.

Association of Drug-Disease Interactions with Mortality or Readmission in Hospitalised Middle-Aged and Older Adults: A Systematic Review and Meta-Analysis

BACKGROUND AND OBJECTIVE

Multimorbidity is common in hospitalised adults who are at increased risk of inappropriate prescribing including drug-disease interactions. These interactions occur when a medicine being used to treat one condition exacerbates a concurrent medical condition and may lead to adverse health outcomes. The aim of this review was to examine the association between drug-disease interactions and the risk of mortality and readmission in hospitalised middle-aged and older adults.

METHODS

A systematic review was conducted on drug-disease interactions in hospitalised middle-aged (45-64 years) and older adults (≥65 years). The study protocol was prospectively registered with PROSPERO (Registration Number: CRD42022341998). Drug-disease interactions were defined as a medicine being used to treat one condition with the potential to exacerbate a concurrent medical condition or that were inappropriate based on a comorbid medical condition. Both observational and interventional studies were included. The outcomes of interest were mortality and readmissions. The databases searched included MEDLINE, CINAHL, EMBASE, Web of Science, SCOPUS and the Cochrane Library from inception to 12 July, 2022. A meta-analysis was performed to pool risk estimates using the random-effects model.

RESULTS

A total of 563 studies were identified and four met the inclusion criteria. All were observational studies in older adults, with no studies identified in middle-aged adults. Most of the studies were at risk of bias because of an inadequate adjustment for covariates and a lack of clarity around individuals lost to follow-up. There were various definitions of drug-disease interactions within these four studies. Two studies assessed drugs that were contraindicated based on renal function, one assessed an individual drug-disease combination, and one was based on the clinical judgement of a pharmacist. There were two studies that showed an association between drug-disease interactions and the outcomes of interest. One reported that the use of diltiazem in patients with heart failure was associated with an increased risk of readmissions. The second reported that the use of medicines contraindicated according to renal function were associated with increased risk of all-cause mortality and a composite of mortality and readmission. Three of the studies (total study population = 5705) were amenable to a meta-analysis, which showed no significant association between drug-disease interactions and readmissions (odds ratio = 1.0, 95% confidence interval 0.80-1.38).

CONCLUSIONS

Few studies were identified examining the risk of drug-disease interactions and mortality and readmission in hospitalised adults. Most of the identified studies were at risk of bias. There is no universal accepted definition of drug-disease interactions in the literature. Further studies are needed to develop a standardised and accepted definition of these interactions to guide further research in this area.

Cardiovascular and mortality benefits of sodium-glucose cotransporter-2 inhibitors and glucagon-like peptide 1 receptor agonists as third-step glucose-lowering medicine in patients with type 2 diabetes: a retrospective cohort analysis

INTRODUCTION

Studies have found that sodium-glucose cotransporter 2 inhibitors (SGLT2) and glucagon-like peptide 1 receptor agonists (GLP1) have cardiovascular benefits for patients with type 2 diabetes (DM2) and atherosclerotic cardiovascular disease (ASCVD), chronic kidney disease (CKD), or heart failure (HF). The literature does not provide evidence specifically for patients with these conditions who are adding one of these medicines to two glucose-lowering medications (ie, as "third-step" therapy). We explored the effects of different third-step medications on cardiovascular outcomes in patients with diabetes and these comorbid conditions. Specifically, we compared third-step SGLT2 or GLP1 to third-step dipeptidyl peptidase-4 inhibitors (DPP4), insulin, or thiazolidinediones (TZD).

RESEARCH DESIGN AND METHODS

We assembled a retrospective cohort of adults at five Kaiser Permanente sites with DM2 and ASCVD, CKD, or HF, initiating third-step treatment between 2016 and 2020. Propensity score weighted Poisson models were used to calculate adjusted rate ratios (ARRs) for all-cause mortality, incident major adverse cardiovascular event (MACE), and incident HF hospitalization in patients initiating SGLT2 or GLP1 compared with DPP4, insulin, or TZD.

RESULTS

We identified 27 542 patients initiating third-step treatment with one or more of these conditions (19 958 with ASCVD, 14 577 with CKD, and 3919 with HF). ARRs for GLP1 and SGLT2 versus DPP4, insulin, and TZD in the patient subgroups ranged between 0.22 and 0.55 for all-cause mortality, 0.38 and 0.81 for MACE, and 0.46 and 1.05 for HF hospitalization. Many ARRs were statistically significant, and all significant ARRs showed a benefit (ARR <1) for GLP1 or SGLT2 when compared with DPP4, insulin, or TZD.

CONCLUSIONS

Third-step SGLT2 and GLP1 are generally associated with a benefit for these outcomes in these patient groups when compared with third-step DPP4, insulin, or TZD. Our results add to evidence of a cardiovascular benefit of SGLT2 and GLP1 and could inform clinical guidelines for choosing third-step diabetes treatment.

The effects of resistance exercises interventions on quality of life and glycemic control in patients with type 2 diabetes: Systematic review and meta-analysis of randomized controlled trials

AIMS

The global burden of diabetes mellitus is escalating rapidly, and the complex comorbidities contribute to a marked decline in patients' quality of life. This review assesses the impact of resistance training on quality of life in type 2 diabetes patients, addressing the ongoing debate over its role in diabetes management and the potential to enhance clinical outcomes.

METHODS

Systematic review and meta-analysis of randomized controlled trials regarding assessing effects from resistance training on quality of life among diabetic patients. We systematically searched PubMed, Medline, Web of Science and Embase and the register of controlled trials searched to February 2021. All included studies were randomized controlled trials in adults with type 2 diabetes that assessed the effect of a resistance training on glycemic control and change in health-related quality of life (HRQOL). The HRQOL was measured by validated questionnaires, covering physical and mental components scores, and pooled standardized effect sizes were calculated. Glycemic control measured by the level of Glycated Hemoglobin (HbA1c), and pooled weighted effect sizes were calculated.

RESULT

9 randomized controlled trials were eligible for the systematic review and our meta-analysis, with 557 participants completed randomized programs data. With random effects meta-analyses model, there was no significant pooled estimate of the standardized mean difference of PCS of quality of life (0.73, 95%CI: -1.19 to 2.65), while in our sensitivity analysis, resistance training had a marginally significantly positive effect on physical components among diabetic patients (0.21, 95%CI: -0.02 to 0.45). Additionally, resistance exercise was non-significantly related with improvement in mental components scores of HRQOL compared with control group (standardized mean difference, (-0.01 (95%CI: -1.25 to 1.23)). With random effects meta-analyses, constructed resistance training intervention did not significantly change the level of HbA1c compared with the control group (-0.22, 95%CI: -0.98 to 0.54) CONCLUSION: The resistance/strength training might have the slight positive effect on the PCS of HRQOL among patients with type 2 diabetes, but was non-significantly beneficial for MCS of HRQOL and glycemic control.

How valid is a prescription-based multimorbidity index (Rx-risk) in predicting mortality in the Outcomes and Multimorbidity In Type 2 diabetes (OMIT) study? A nation-wide registry-based cohort study from Norway

OBJECTIVE

The prescription-based Rx-risk index has previously been developed to measure multimorbidity. We aimed to adapt and evaluate the validity of the Rx-risk index in prediction of mortality among persons with type 2 diabetes.

DESIGN

Registry-based study.

SETTING

Adults with type 2 diabetes in Norway identified within the 'Outcomes and Multimorbidity In Type 2 diabetes' cohort, with linkage to prescriptions from the Norwegian Prescription Database and mortality from the Population Registry.

PARTICIPANTS

We defined a calibration sample of 42 290 adults diagnosed with type 2 diabetes 1950-2013, and a temporal validation sample of 7085 adults diagnosed 2014-2016 to evaluate the index validity over time PRIMARY OUTCOME MEASURE: All-cause mortality METHODS: For the calibration sample, dispensed drug prescriptions in 2013 were used to define 44 morbidity categories. Weights were estimated using regression coefficients from a Cox regression model with 5 year mortality as the outcome and all morbidity categories, age and sex included as covariates. The Rx-risk index was computed as a weighted sum of morbidities. The validity of the index was evaluated using C-statistic and calibration plots.

RESULTS

In the calibration sample, mean (SD) age at start of follow-up and duration of diabetes was 63.8 (12.4) and 10.1 (7.0) years, respectively. The overall C-statistic was 0.82 and varied from 0.74 to 0.85 when stratifying on age groups, sex, level of education and country of origin. In the validation sample, mean (SD) age and duration of diabetes was 59.7 (13.0) and 2.0 (0.8) years, respectively. Despite younger age, shorter duration of diabetes and later time period, the C-index was high both in the total sample (0.84) and separately for men (0.83) and women (0.84).

CONCLUSIONS

The Rx-risk index showed good discrimination and calibration in predicting mortality and thus presents a valid tool to assess multimorbidity among persons with type 2 diabetes.

Characteristics of elderly diabetes patients: focus on clinical manifestation, pathogenic mechanism, and the role of traditional Chinese medicine

Diabetes mellitus has become a major public health issue globally, putting an enormous burden on global health systems and people. Among all diseased groups, a considerable part of patients are elderly, while their clinical features, pathogenic processes, and medication regimens are different from patients of other ages. Despite the availability of multiple therapies and techniques, there are still numerous elderly diabetes patients suffering from poor blood glucose control, severe complications, and drug adverse effects, which negatively affect the quality of life in their golden years. Traditional Chinese Medicine (TCM) has been widely used in the treatment of diabetes for several decades, and its relevant clinical practice has confirmed that it has a satisfactory effect on alleviating clinical symptoms and mitigating the progression of complications. Chinese herbal medicine and its active components were used widely with obvious clinical advantages by multiple targets and signaling pathways. However, due to the particular features of elderly diabetes, few studies were conducted to explore Traditional Chinese Medicine intervention on elderly diabetic patients. This study reviews the research on clinical features, pathogenic processes, treatment principles, and TCM treatments, hoping to provide fresh perspectives on the prevention and management strategies for elderly diabetes.

Factors associated with diabetes concordant comorbidities among adult diabetic patients in Central Ethiopia: a cross-sectional study

Background

Diabetes comorbidities are a serious public health issue that raises the risk of adverse health effects and complicates diabetes management. It also harms emotional health, medication adherence, self-management, and general quality of life. However, evidence is scarce in Ethiopia, particularly in the study area. Thus, this study aimed to estimate the prevalence of diabetes concordant comorbidities and identify factors associated with the presence of concordant comorbidities among adult diabetic patients in central Ethiopia.

Methods

A health facility-based cross-sectional study was conducted among 398 adult diabetic patients. A computer-generated simple random sampling was used to select study participants. Data were collected using a structured data extraction checklist. The collected data were entered into Epi info version 7.2 and exported to SPSS version 27 for analysis. A binary logistic regression model was used to analyze the association between dependent and independent variables. An adjusted odds ratio with the corresponding 95% confidence interval was used to measure the strength of the association and statistical significance was declared at a p-value < 0.05.

Result

The prevalence of diabetes-concordant comorbidities was 41% (95% CI: 36.2-46.0). The multivariable logistic regression model showed that age 41-60 (AOR = 2.86, 95% CI: 1.60-5.13), place of residence (AOR = 2.22, 95% CI: 1.33-3.70), having type two diabetes (AOR = 3.30, 95% CI: 1.21-8.99), and having positive proteinuria (AOR = 2.64, 95% CI: 1.47-4.76) were significantly associated with diabetes concordant comorbidities.

Conclusion

The prevalence of diabetes-concordant comorbidities was relatively high. Age, place of residence, type of diabetes, and positive proteinuria were factors associated with diabetes-concordant comorbidities. Prevention, early identification, and proper management of diabetes comorbidities are crucial.

Hyperglycaemia and Chronic Obstructive Pulmonary Disease

Chronic obstructive pulmonary disease (COPD) may coexist with type 2 diabetes mellitus (T2DM). Patients with COPD have an increased risk of developing T2DM compared with a control but, on the other side, hyperglycaemia and DM have been associated with reduced predicted levels of lung function. The mechanistic relationships between these two diseases are complicated, multifaceted, and little understood, yet they can impact treatment strategy. The potential risks and benefits for patients with T2DM treated with pulmonary drugs and the potential pulmonary risks and benefits for patients with COPD when taking antidiabetic drugs should always be considered. The interaction between the presence and/or treatment of COPD, risk of infection, presence and/or treatment of T2DM and risk of acute exacerbations of COPD (AECOPDs) can be represented as a vicious circle; however, several strategies may help to break this circle. The most effective approach to simultaneously treating T2DM and COPD is to interfere with the shared inflammatory substrate, thus targeting both lung inflammation (COPD) and vascular inflammation (DM). In any case, it is always crucial to establish glycaemic management since the reduction in lung function found in people with diabetes might decrease the threshold for clinical manifestations of COPD. In this article, we examine possible connections between COPD and T2DM as well as pharmacological strategies that could focus on these connections.

COPD and multimorbidity: recognising and addressing a syndemic occurrence

Most patients with chronic obstructive pulmonary disease (COPD) have at least one additional, clinically relevant chronic disease. Those with the most severe airflow obstruction will die from respiratory failure, but most patients with COPD die from non-respiratory disorders, particularly cardiovascular diseases and cancer. As many chronic diseases have shared risk factors (eg, ageing, smoking, pollution, inactivity, and poverty), we argue that a shift from the current paradigm in which COPD is considered as a single disease with comorbidities, to one in which COPD is considered as part of a multimorbid state-with co-occurring diseases potentially sharing pathobiological mechanisms-is needed to advance disease prevention, diagnosis, and management. The term syndemics is used to describe the co-occurrence of diseases with shared mechanisms and risk factors, a novel concept that we propose helps to explain the clustering of certain morbidities in patients diagnosed with COPD. A syndemics approach to understanding COPD could have important clinical implications, in which the complex disease presentations in these patients are addressed through proactive diagnosis, assessment of severity, and integrated management of the COPD multimorbid state, with a patient-centred rather than a single-disease approach.

Impacts of increases and decreases of drugs on rehabilitation outcomes of subacute stroke patients

OBJECTIVE

To examine changes in drugs for subacute stroke patients and elucidate the impact of medications on rehabilitation outcomes.

MATERIALS AND METHODS

A total of 295 subacute stroke patients who were admitted to the convalescent rehabilitation ward between June 2018 and May 2019 were included. Polypharmacy was defined as five or more drugs at admission. The primary outcome was the Functional Independence Measure Total score (FIM-T) at discharge. Multiple regression analysis was performed to examine the relationships between the FIM-T at discharge and drug changes or other factors. This study was conducted in two stages. The first analysis included all stroke patients, and the second analysis included only stroke patients with polypharmacy.

RESULTS

On multiple regression analysis, the number of drugs at admission (β=-0.628) was associated with FIM-T at discharge of all stroke patients. Furthermore, the number of additional drugs during hospitalization (β=-1.964) was associated with FIM-T at discharge in the 176 stroke patients with polypharmacy.

CONCLUSION

This study suggested that the number of drugs at admission and the addition of drugs during hospitalization might have a negative impact on the rehabilitation outcomes of subacute stroke patients.

Inflammaging and Frailty in Immune-Mediated Rheumatic Diseases: How to Address and Score the Issue

Frailty is a new concept in rheumatology that can help identify people more likely to have less favorable outcomes. Sarcopenia and inflammaging can be regarded as the biological foundations of physical frailty. Frailty is becoming more widely accepted as an indicator of ageing and is linked to an increased risk of negative outcomes such as falls, injuries, and mortality. Frailty identifies a group of older adults that seem poorer and more fragile than their age-matched counterparts, despite sharing similar comorbidities, demography, sex, and age. Several studies suggest that inflammation affects immune-mediated pathways, multimorbidity, and frailty by inhibiting growth factors, increasing catabolism, and by disrupting homeostatic signaling. Frailty is more common in the community-dwelling population as people get older, ranging from 7 to 10% in those over 65 years up to 40% in those who are octogenarians. Different parameters have been validated to identify frailty. These primarily relate to two conceptual models: Fried's physical frailty phenotype and Rockwood's cumulative deficit method. Immune-mediated rheumatic diseases (IMRDs), such as rheumatoid arthritis, spondyloarthritis, systemic lupus erythematosus, systemic sclerosis, and vasculitis, are leading causes of frailty in developing countries. The aim of this review was to quantitatively synthesize published literature on the prevalence of frailty in IMRDs and to summarize current evidence on the relevance and applicability of the most widely used frailty screening tools.

The interplay between diabetes mellitus and chronic obstructive pulmonary disease

Chronic obstructive pulmonary disease (COPD) and diabetes mellitus (DM) are common and chronic disorders. COPD is characterized by persistent respiratory symptoms and airflow limitation due to airway and/or alveolar abnormalities and it is considered currently the fourth leading cause of death worldwide. DM is a systemic disease characterized by a chronic hyperglycemia associated with inflammation and oxidative stress. The relationship between the two conditions is not completely understood and conflicting results are reported in the literature. Many studies have investigated the mechanisms through with the respiratory disease is associated with an increased risk of metabolic condition or whether the incidence risk of COPD in individuals affected by DM is higher. The link between the two chronic conditions has relevant implications in the management of patients affected by the both of them. Respiratory patients should be screened for diabetes mellitus as a frequent comorbidity of lung disease since therapeutic options should be assessed about risk-to-benefit ratios associated with the indication for the steroid use. Furthermore, the role of hyperglycemia on pulmonary function (e.g. infection or inflammatory processes) should be evaluated in DM. Finally, in presence of both diseases potential treatment interactions should be considered. In this overview we explored the common aspects of both clinical chronic illnesses and investigated the interplay between the two conditions.

Age-specific associations between the number of co-morbidities, all-cause mortality and public direct medical costs in patients with type 2 diabetes: A retrospective cohort study

AIM

To evaluate the association between the number of co-morbidities, all-cause mortality and public health system expenditure in patients with type 2 diabetes (T2D) across different age groups.

MATERIALS AND METHODS

A retrospective observational study of T2D patients using electronic health records in Hong Kong was conducted. Patients were stratified by age (< 50, 50-64, 65-79, ≥ 80 years) and the number of co-morbidities (0, 1, 2, 3, ≥ 4), defined using the Charlson Comorbidity Index and prevalent chronic diseases identified in local surveys. The association between the number of co-morbidities, all-cause mortality and direct medical costs was examined using Cox proportional hazard regression and the gamma generalized linear model with log link function.

RESULTS

A total of 262 212 T2D patients with a median follow-up of 10 years were included. Hypertension and dyslipidaemia were the most common co-morbidities in all age groups. After age stratification, cardiovascular diseases dominated the top pair of co-morbidities in the older age groups (65-79 and ≥ 80 years), while inflammatory and liver disease were predominant among younger individuals. Compared with co-morbidity-free T2D patients, the hazard ratios (95% CI) of death for patients aged younger than 50 and 80 years or older with two co-morbidities were 1.31 (1.08-1.59) and 1.25 (1.15-1.36), respectively, and increased to 3.08 (2.25-4.21) and 1.98 (1.82-2.16), respectively, as the number of co-morbidities increased to four or more. Similar trends were observed for medical costs.

CONCLUSIONS

Age-specific co-morbidity patterns were observed for patients with T2D. A greater number of co-morbidities was associated with increased mortality and healthcare costs, with stronger relationships observed among younger patients.

Medication Prescribed Within One Year Preceding Fall-Related Injuries in Ontario Older Adults

Background

Serious injuries secondary to falls are becoming more prevalent due to the worldwide ageing of societies. Several medication classes have been associated with falls and fall-related injuries. The purpose of this study was to describe medication classes and the number of medication classes prescribed to older adults prior to the fall-related injury.

Methods

This population-based descriptive study used secondary administrative health-care data in Ontario, Canada for 2010-2014. Descriptive statistics were reported for Anatomic Therapeutic Chemical 4^th level medication classes. Frequency of medications prescribed to older adults was calculated on different sex, age groups, types of medications, and injures.

Results

Over five years (2010-2014), 288,251 older adults (63.2% females) were admitted to an emergency department for a fall-related injury (40.0% fractures, 12.1% brain injury). In the year before the injury, 48.5% were prescribed statins, 27.2% antidepressants, 25.0% opioids, and 16.6% anxiolytics. Females were prescribed more diuretics, antidepressants, and anxiolytics than males; and people aged 85 years and older had a higher percentage of diuretics, antidepressants, and antipsychotics. There were 36.4% of older adults prescribed 5-9 different medication classes and 41.2% were prescribed 10 or more medication classes.

Discussion

Older adults experiencing fall-related injuries were prescribed more opioids, benzodiazepines, and antidepressants than previously reported for the general population of older adults in Ontario. Higher percentage of females and more 85+ older adults were prescribed with psychotropic drugs, and they were also found to be at higher risk of fall-related injuries. Further associations between medications and fall-related injuries need to be explored in well-defined cohort studies.

The National Programme for Health Care of the Elderly: A Review of its Achievements and Challenges in India

Aging care is critical. Projections for 2020 indicate that India’s older population will comprise 6.57% of the overall population. The best-known newly developed technologies must be provided to the older population. Non-governmental organizations and private institutions are increasingly providing more door-to-door guidance and help. This study evaluated the impact of the National Programme for Health Care of the Elderly (NPHCE) in India and analyzed its achievements and challenges. The program’s key strategies include providing preventive and promotional care and sickness management, empowering geriatric services, and guaranteeing optimal rehabilitation. The NPHCE is an excellent project for caring for a rapidly aging population. This study described the existing programs and schemes related to older people in India, with a focus on the NPHCE and an analysis of the program’s achievements and challenges.

Mechanisms Linking COPD to Type 1 and 2 Diabetes Mellitus: Is There a Relationship between Diabetes and COPD?

Chronic obstructive pulmonary disease (COPD) patients frequently suffer from multiple comorbidities, resulting in poor outcomes for these patients. Diabetes is observed at a higher frequency in COPD patients than in the general population. Both type 1 and 2 diabetes mellitus are associated with pulmonary complications, and similar therapeutic strategies are proposed to treat these conditions. Epidemiological studies and disease models have increased our knowledge of these clinical associations. Several recent genome-wide association studies have identified positive genetic correlations between lung function and obesity, possibly due to alterations in genes linked to cell proliferation; embryo, skeletal, and tissue development; and regulation of gene expression. These studies suggest that genetic predisposition, in addition to weight gain, can influence lung function. Cigarette smoke exposure can also influence the differential methylation of CpG sites in genes linked to diabetes and COPD, and smoke-related single nucleotide polymorphisms are associated with resting heart rate and coronary artery disease. Despite the vast literature on clinical disease association, little direct mechanistic evidence is currently available demonstrating that either disease influences the progression of the other, but common pharmacological approaches could slow the progression of these diseases. Here, we review the clinical and scientific literature to discuss whether mechanisms beyond preexisting conditions, lifestyle, and weight gain contribute to the development of COPD associated with diabetes. Specifically, we outline environmental and genetic confounders linked with these diseases.

Antioxidant Activity, Metal Chelating Ability and DNA Protective Effect of the Hydroethanolic Extracts of Crocus sativus Stigmas, Tepals and Leaves

The present study investigated the antioxidant activity, metal chelating ability and genoprotective effect of the hydroethanolic extracts of Crocus sativus stigmas (STG), tepals (TPL) and leaves (LV). We evaluated the antioxidant and metal (Fe2+ and Cu2+) chelating activities of the stigmas, tepals and leaves of C. sativus. Similarly, we examined the genotoxic and DNA protective effect of these parts on rat leukocytes by comet assay. The results showed that TPL contains the best polyphenol content (64.66 µg GA eq/mg extract). The highest radical scavenging activity is shown by the TPL (DPPH radical scavenging activity: IC50 = 80.73 µg/mL). The same extracts gave a better ferric reducing power at a dose of 50 µg/mL, and better protective activity against β-carotene degradation (39.31% of oxidized β-carotene at a 100 µg/mL dose). In addition, they showed a good chelating ability of Fe2+ (48.7% at a 500 µg/mL dose) and Cu2+ (85.02% at a dose of 500 µg/mL). Thus, the antioxidant activity and metal chelating ability in the C. sativus plant is important, and it varies according to the part and dose used. In addition, pretreatment with STG, TPL and LV significantly (p < 0.001) protected rat leukocytes against the elevation of percent DNA in the tail, tail length and tail moment in streptozotocin- and alloxan-induced DNA damage. These results suggest that C. sativus by-products contain natural antioxidant, metal chelating and DNA protective compounds, which are capable of reducing the risk of cancer and other diseases associated with daily exposure to genotoxic xenobiotics.

Potentially inappropriate prescribing for adults living with diabetes mellitus: a scoping review

BACKGROUND

People living with diabetes often experience multiple morbidity and polypharmacy, increasing their risk of potentially inappropriate prescribing. Inappropriate prescribing is associated with poorer health outcomes.

AIM

The aim of this scoping review was to explore and map studies conducted on potentially inappropriate prescribing among adults living with diabetes and to identify gaps regarding identification and assessment of potentially inappropriate prescribing in this group.

METHOD

Studies that reported any type of potentially inappropriate prescribing were included. Studies conducted on people aged < 18 years or with a diagnosis of gestational diabetes or prediabetes were excluded. No restrictions to language, study design, publication status, geographic area, or clinical setting were applied in selecting the studies. Articles were systematically searched from 11 databases.

RESULTS

Of the 190 included studies, the majority (63.7%) were conducted in high-income countries. None of the studies used an explicit tool specifically designed to identify potentially inappropriate prescribing among people with diabetes. The most frequently studied potentially inappropriate prescribing in high-income countries was contraindication while in low- and middle-income countries prescribing omission was the most common. Software and websites were mostly used for identifying drug-drug interactions. The specific events and conditions that were considered as inappropriate were inconsistent across studies.

CONCLUSION

Contraindications, prescribing omissions and dosing problems were the most commonly studied types of potentially inappropriate prescribing. Prescribers should carefully consider the individual prescribing recommendations of medications. Future studies focusing on the development of explicit tools to identify potentially inappropriate prescribing for adults living with diabetes are needed.

Therapeutic approaches targeting molecular signaling pathways common to diabetes, lung diseases and cancer

Diabetes mellitus (DM), is the most common metabolic disease and is characterized by sustained hyperglycemia. Accumulating evidences supports a strong association between DM and numerous lung diseases including chronic obstructive pulmonary disease (COPD), fibrosis, and lung cancer (LC). The global incidence of DM-associated lung disorders is rising and several ongoing studies, including clinical trials, aim to elucidate the molecular mechanisms linking DM with lung disorders, in particular LC. Several potential mechanisms, including hyperglycemia, hyperinsulinemia, glycation, inflammation, and hypoxia, are cited as plausible links between DM and LC. In addition, studies also propose a connection between the use of anti-diabetic medications and reduction in the incidence of LC. However, the exact cause for DM associated lung diseases especially LC is not clear and is an area under intense investigation. Herein, we review the biological links reported between DM and lung disorders with an emphasis on LC. Furthermore, we report common signaling pathways (eg: TGF-β, IL-6, HIF-1, PDGF) and miRNAs that are dysregulated in DM and LC and serve as molecular targets for therapy. Finally, we propose a nanomedicine based approach for delivering therapeutics (eg: IL-24 plasmid DNA, HuR siRNA) to disrupt signaling pathways common to DM and LC and thus potentially treat DM-associated LC. Finally, we conclude that the effective modulation of commonly regulated signaling pathways would help design novel therapeutic protocols for treating DM patients diagnosed with LC.

Corrination of a GLP-1 Receptor Agonist for Glycemic Control without Emesis

Glucagon-like peptide-1 receptor (GLP-1R) agonists used to treat type 2 diabetes mellitus often produce nausea, vomiting, and in some patients, undesired anorexia. Notably, these behavioral effects are caused by direct central GLP-1R activation. Herein, we describe the creation of a GLP-1R agonist conjugate with modified brain penetrance that enhances GLP-1R-mediated glycemic control without inducing vomiting. Covalent attachment of the GLP-1R agonist exendin-4 (Ex4) to dicyanocobinamide (Cbi), a corrin ring containing precursor of vitamin B12, produces a "corrinated" Ex4 construct (Cbi-Ex4). Data collected in the musk shrew (Suncus murinus), an emetic mammal, reveal beneficial effects of Cbi-Ex4 relative to Ex4, as evidenced by improvements in glycemic responses in glucose tolerance tests and a profound reduction of emetic events. Our findings highlight the potential for clinical use of Cbi-Ex4 for millions of patients seeking improved glycemic control without common side effects (e.g., emesis) characteristic of current GLP-1 therapeutics.

Drug utilisation pattern over 3 years in the real-world treatment of type II diabetes

INTRODUCTION

Non-adherence to therapy is very common in patients with type II diabetes, leading to an increase in morbidity and mortality. The development of new oral therapies following metformin has increased the possibilities of treatment but little has been done in terms of improving medication adherence. The goal of the following study is to evaluate adherence and persistence over a period of 3 years in real-world diabetic patients and describe the comorbidities found in the group of patients studied.

MATERIAL AND METHODOLOGY

A non-interventional pharmacological observational study was conducted by examining all therapies from 2011 to 2019 at a local health centre in Pescara (ASL). The medication adherence and persistence over a 3-year period were calculated using the pharmacy-refill method. The identification of the comorbidities was carried out in accordance with the Anatomical Therapeutic Chemical (ATC) Classification system at the fourth level.

RESULTS

A total of 19 600 patients undergoing treatment for type II diabetes from January 2011 to December 2019 were analysed. The absolute adherence value at 3 years was 0.68 ± 0.23. The 3-year persistence curves showed a statistically significant difference (P < .0001). The ATCs with highest figures in the entire study group were: A02BC, B01AC and C10AA with 14 220, 13 934 and 10 858 patients, respectively.

CONCLUSIONS

Adherence to therapy was suboptimal, while persistence curves showed a statistically significant difference, with patients treated with metformin showing better results. Comorbidities analysed showed a greater relevance of heart disease.

T-Helper 17 Cell/Regulatory T-Cell Imbalance in COPD Combined with T2DM Patients

Background

Chronic obstructive pulmonary disease (COPD) is often combined with type 2 diabetes mellitus (T2DM) in clinical, and with poor prognosis. In recent years, research shows that inflammation is a common characteristic of COPD and T2DM. T-helper 17 cell (Th17)/regulatory T-cell (Treg) balance controls inflammation and may be important in the pathogenesis of COPD combined with T2DM patients. This study investigated the characteristics of Th17, Treg and related inflammatory factors in COPD combined with T2DM patients and the potential mechanism.

Methods

Application of flow cytometry technology, real-time fluorescent quantitative PCR and ELISA to detect the changes in peripheral blood of Th17 and Treg number and the expression of key transcription factors and related cytokines in COPD combined T2DM patients were performed.

Results

Patients with COPD combined with T2DM revealed significant increase in peripheral Th17, Th17 related cytokines (IL-17A, IL-17F, IL-21, IL-23, IL-6) and transcription factor (RORγt) levels and significant decrease in Treg, Treg-related cytokines (IL-10, TGFβ1) and transcription factor (Foxp3) as compared with patients with COPD, T2DM and healthy controls.

Conclusion

Th17/Treg functional imbalance exists in patients with COPD combined with T2DM, indicating a potential role of Th17/Treg imbalance in the formation and progression of COPD combined with T2DM.

Potential Overtreatment and Undertreatment of Type 2 Diabetes Mellitus in Long-Term Care Facilities: A Systematic Review

OBJECTIVE

To investigate the prevalence, outcomes, and factors associated with potential glycemic overtreatment and undertreatment of type 2 diabetes mellitus (T2DM) in long-term care facilities (LTCFs).

DESIGN

Systematic review.

SETTING AND PARTICIPANTS

Residents with T2DM and aged ≥60 years living in LTCFs.

MEASURES

Articles published between January 2000 and September 2020 were retrieved following a systematic search of MEDLINE, EMBASE, Cochrane Library, CINAHL plus, and gray literature. Inclusion criteria were the reporting of (1) potential overtreatment and undertreatment quantitatively defined (implicitly or explicitly) based on hemoglobin A1c (HbA1c) and/or blood glucose; (2) prevalence, outcomes, and associated factors of potential glycemic overtreatment and undertreatment; and (3) the study involved residents of LTCFs.

RESULTS

Fifteen studies were included. Prevalence of potential overtreatment (5%-86%, n = 15 studies) and undertreatment (1.4%-35%, n = 8 studies) varied widely among facilities and geographical locations, and according to definitions used. Prevalence of potential overtreatment was 16%-74% when defined as treatment with a glucose-lowering medication in a resident with ≥1 hypoglycemia risk factor or serious comorbidity, together with a HbA1c <7% (n = 10 studies). Potential undertreatment was commonly defined as residents on glucose-lowering medication having HbA1c >8.5% and the prevalence 1.4%-14.8% (n = 6 studies). No studies prospectively measured resident health outcomes from overtreatment and undertreatment. Potential overtreatment was positively associated with use of oral glucose-lowering medications, dementia diagnosis or dementia severity, and/or need for assistance with activities of daily living (n = 2 studies). Negative association was found between potential overtreatment and use of insulin/combined insulin and oral glucose-lowering medication. No studies reported factors associated with potential undertreatment.

CONCLUSIONS AND IMPLICATIONS

The prevalence of potential glycemic overtreatment and undertreatment varied widely among residents with T2DM depending on the definition(s) used in each study. Longitudinal studies examining associations between glycemic management and health outcomes, and the use of consensus definitions of overtreatment and undertreatment are required to establish findings about actual glycemic overtreatment and undertreatment in LTCFs.

Gaseous Mediators as a Key Molecular Targets for the Development of Gastrointestinal-Safe Anti-Inflammatory Pharmacology

Non-steroidal anti-inflammatory drugs (NSAIDs) represent one of the most widely used classes of drugs and play a pivotal role in the therapy of numerous inflammatory diseases. However, the adverse effects of these drugs, especially when applied chronically, frequently affect gastrointestinal (GI) tract, resulting in ulceration and bleeding, which constitutes a significant limitation in clinical practice. On the other hand, it has been recently discovered that gaseous mediators nitric oxide (NO), hydrogen sulfide (H₂S) and carbon monoxide (CO) contribute to many physiological processes in the GI tract, including the maintenance of GI mucosal barrier integrity. Therefore, based on the possible therapeutic properties of NO, H₂S and CO, a novel NSAIDs with ability to release one or more of those gaseous messengers have been synthesized. Until now, both preclinical and clinical studies have shown promising effects with respect to the anti-inflammatory potency as well as GI-safety of these novel NSAIDs. This review provides an overview of the gaseous mediators-based NSAIDs along with their mechanisms of action, with special emphasis on possible implications for GI mucosal defense mechanisms.

Combination therapies with thiazolidinediones are associated with a lower risk of acute exacerbations in new-onset COPD patients with advanced diabetic mellitus: a cohort-based case-control study

BACKGROUND

The effects of oral antihyperglycaemic drugs (OADs) for type 2 diabetes mellitus (T2DM) on the outcomes of co-existing chronic obstructive pulmonary disease (COPD) patients are not well studied. We examined the association of combinational OADs and the risk of acute exacerbations of COPD (AECOPD) in T2DM patients with co-existing COPD.

METHODS

A cohort-based case-control study was conducted using data from the National Health Insurance Research Database of Taiwan. Among new-onset COPD-T2DM patients, 65,370 were prescribed metformin and 2nd-line OADs before the date of COPD onset. Each AECOPD case was matched to 4 randomly selected controls according to the propensity score estimated by the patient's baseline characteristics. Conditional logistic regression analysis was performed to estimate the association between AECOPD risk and OAD use.

RESULTS

Among COPD-T2DM patients, 3355 AECOPD cases and 13,420 matched controls were selected. Of the patients treated with a double combination of oral OADs (n = 12,916), those treated with sulfonylurea (SU) and thiazolidinediones (TZD) had a lower AECOPD risk than the patients who received metformin (MET) and SU, with an adjusted odds ratio (OR) of 0.69 (95% confidence interval [CI] 0.51-0.94, P = 0.02). Of the patients with a triple combination of oral OADs (n = 3859), we found that those treated with MET, SU and TZD had a lower risk of AECOPD (adjusted OR 0.81 (0.68-0.96, P = 0.01) than a combination of MET, SU and α-glucosidase inhibitors (AGIs) regardless of the level of COPD complexity.

CONCLUSION

Combination therapies with TZD were associated with a reduced risk of AECOPD in advanced T2DM patients with co-existing COPD.

Influencing factors and their relationships of risk perception and decision-making behaviour of polypharmacy in patients with chronic diseases: a qualitative descriptive study

OBJECTIVES

In order to understand the influencing factors of the medication-taking behaviour in patients with chronic diseases, reveal the deep-seated causes underlying the phenomenon of polypharmacy, explore the formation rules of the risk perception of polypharmacy and how risk perception affect the medication decision-making behaviour of patients with chronic diseases.

DESIGN

A qualitative descriptive design was used. Study data were collected through semi-structured interviews with patients and physicians. We used the grounded theory approach to refine influencing factors, followed by interpretative structural modelling that analysed the interaction between these factors.

SETTING

Patients from two hospitals, two nursing homes and two communities. Physicians from two community hospitals in Wuhan, China.

PARTICIPANTS

Patients with chronic diseases with high willingness to cooperate and good communication ability. Physicians with rich experience in the treatment of chronic diseases.

RESULTS

Twenty-nine interviews were conducted (20 patients and 9 physicians). A total of 35 influencing factors of the medication-taking behaviours in patients with chronic diseases were extracted from the interview data, further integrated into 10 integrated influencing factors and ultimately clustered into three aspects: 'medication benefit', 'medication risk' and 'medication strategy'. Medication risk can be divided into four specific dimensions: economic risk, physical risk, psychosocial risk and time risk. 10 integrated influencing factors constituted the interpretative structural model of the medication decision-making behaviours in patients with chronic diseases.

CONCLUSIONS

The causes underlying the medication decision-making behaviour of patients with chronic diseases are complex, involving a series of influencing factors such as their risk perception of the medication-taking behaviour. In order to alleviate the adverse effects of polypharmacy on patients' health and medical costs, further safety measures should be proposed to improve the medication-taking behaviour in patients with chronic diseases based on the relationship and internal mechanism of the influencing factors of the medication decision-making behaviour.

Characteristics associated with polypharmacy in people with type 2 diabetes: the Dutch Diabetes Pearl cohort

AIM

To describe the prevalence and characteristics of polypharmacy in a Dutch cohort of individuals with type 2 diabetes.

METHODS

We included people with type 2 diabetes from the Diabetes Pearl cohort, of whom 3886 were treated in primary care and 2873 in academic care (secondary/tertiary). With multivariable multinomial logistic regression analyses stratified for line of care, we assessed which sociodemographic, lifestyle and cardiometabolic characteristics were associated with moderate (5-9 medications) and severe polypharmacy (≥10 medications) compared with no polypharmacy (0-4 medications).

RESULTS

Mean age was 63 ± 10 years, and 40% were women. The median number of daily medications was 5 (IQR 3-7) in primary care and 7 (IQR 5-10) in academic care. The prevalence of moderate and severe polypharmacy was 44% and 10% in primary care, and 53% and 29% in academic care respectively. Glucose-lowering and lipid-modifying medications were most prevalent. People with severe polypharmacy used a relatively large amount of other (i.e. non-cardiovascular and non-glucose-lowering) medication. Moderate and severe polypharmacy across all lines of care were associated with higher age, low educational level, more smoking, longer diabetes duration, higher BMI and more cardiovascular disease.

CONCLUSIONS

Severe and moderate polypharmacy are prevalent in over half of people with type 2 diabetes in primary care, and even more in academic care. People with polypharmacy are characterized by poorer cardiometabolic status. These results highlight the significance of polypharmacy in type 2 diabetes.

Drug-drug interactions and inappropriate medicines impact on glycemic control and kidney function in older adults with diabetes-attending specialty care institution

PURPOSE

To describe and assess the impact of polypharmacy, and its potential adverse reactions; serious clinically relevant drug-drug interactions (DDIs) and inappropriate medicines (PIMs) on glycemic target, and kidney function in a sample of older adults with type 2 diabetes (T2D).

METHODS

Cross-sectional study was performed in a real-world database including 444 elderly people with T2D from the Portuguese Diabetes Association, aged ≥ 65 years, and registered in 2018. DDIs were analyzed using Micromedex drug-interaction platform and PIMs identified using STOPP criteria version-2.

RESULTS

Polypharmacy was identified in 43.6% of patients. This group of patients has shown to be more females (50 vs. 39.6%, P=0.0208), higher HbA1c targets (P=0.0275), longer diabetes duration (66.4 vs. 54.4%, P=0.0019), more hypertensive (87 vs. 62.9%, P<0.0001), using more insulin (38.1 vs. 26%, P=0.0062), sulfonylureas (37.1 vs. 15.6%, P<0.0001), GLP-1 receptor-agonists (9.7 vs. 3.6%, P=0.0077), metformin-DPP-4 inhibitors (41.2 vs. 29.2%, P=0.0081), and SGLT2 inhibitors (19 vs. 9.6%, P=0.0040). A total of 8.7% of patients had potentially serious clinically relevant DDIs, mainly due to interacting medicine pairs dexamethasone and fluoroquinolones. Furthermore, 23.4% had PIMs, and cardiovascular medicines accounted for largest therapeutic group associated. Polypharmacy found to be associated with twofold greater odds of having HbA1c ≤8%, whereas PIMs associated with 2.5-fold greater odds of having HbA1c ≤9%, and 5.5-folds greater odds of having severe kidney function.

CONCLUSIONS

These findings suggested that there is a potential association between polypharmacy and PIMs and altered glycemic control, and PIMs with the deterioration of kidney function.

Antipsychotic Polypharmacy Is Associated With Adverse Drug Events in Psychiatric Inpatients: The Japan Adverse Drug Events Study

BACKGROUND

Antipsychotic (AP) polypharmacy (APP), the coprescription of more than 1 AP, is frequently practiced in psychiatric inpatients and is considered to be a risk factor for adverse drug events (ADEs). However, the association between APP and ADEs among psychiatric inpatients has not been well investigated.

METHODS

The Japan Adverse Drug Events (JADE) study was a series of cohort studies conducted in several clinical settings. In particular, the JADE study for psychiatric inpatients was a retrospective cohort study of 448 psychiatric inpatients with a cumulative 22,733 patient-days. We investigated the relationship between APP, defined as a concurrent prescription of 2 or more APs and ADEs. We also assessed the relationship between potential risk factors for ADEs due to APs.

RESULTS

Among the 448 patients included in this study, 106 patients (24%) had APP and the remaining 342 patients were prescribed 1 AP or none. Risperidone was the most frequent drug (25%, 109/442 AP prescriptions) used, and levomepromazine was most frequently prescribed as a concurrent medication with other APs (91%, 29/32). The median number of ADEs among the patients with APP was significantly higher than in those without APP (P = 0.001). Antipsychotic polypharmacy was a risk factor for the occurrence of first (adjusted hazard ratio, 1.54; 95% confidence interval, 1.15-2.04) and second (adjusted hazard ratio, 1.99; 95% confidence interval, 1.40-2.79) ADEs.

CONCLUSIONS

Antipsychotic polypharmacy was a risk factor for the occurrence of single and multiple ADEs. Antipsychotic polypharmacy should be conservatively and minimally practiced.

Diabetes Concordant Comorbidities and Associated Factors Among Adult Diabetic Out-Patients at Hiwot Fana Specialized University Hospital, Harar, Eastern Ethiopia: a Cross-Sectional Study

BACKGROUND

Nowadays diabetic comorbidities constitute a major public health problem in Ethiopian context. However, there is a dearth in epidemiology and risk factors of diabetic comorbidity in Ethiopia, particularly in the study setting. Therefore, this study was conducted to determine the prevalence and identify factors associated with concordant diabetic comorbidities among diabetic out-patients at Hiwot Fana Specialized University Hospital (HFSUH), EasternEthiopia.

METHODOLOGY

A hospital-based cross-sectional study was conducted by reviewing medical record charts of adult diabetic outpatients. Bivariable and multivariable logistic regression analysis was carried out by using STATA version 16.0. To measure the strength of association an Adjusted Odds Ratio (AOR) with 95% Confidence Interval (CI) was used. Moreover, variables with p-value ≤ 0.05 were considered as statistically significant with the outcome variable.

RESULTS

In this study, it is found that the overall prevalence of concordant comorbidity among adult diabetic out-patients was 55.8% (95% CI: 50.3-61.3). Moreover, more than two-third of patients, 72.73% were diagnosed for type two diabetic mellitus (T2DM). Among specified comorbidities about 42.3% were hypertension, 21.63% were obesity, and 13% were multi-morbidity. Age ≥ 55 years (AOR: 7.52, 95% CI: 1.24, 45.75), T2DM (AOR: 9.01, 95% CI: 1.50, 54.04), 2-5 years duration of treatments (AOR: 0.23, 95 CI: 0.078, 0.691), and poor glycemic control (AOR: 4.4 1, 95% CI: 2.34, 8.32) were factors significantly associated with concordant diabetic comorbidity.

CONCLUSION

From the study conducted, the higher prevalence of concordant comorbidity among diabetic patients was investigated. Furthermore, older in age, T2DM, prolonged duration of treatment, and poor glycemic control were factors associated with diabetic comorbidities. Early detection and appropriate treatment of diabetic comorbidities are very important for better patient's quality of life and functionality.

Proton pump inhibitors and the risk of Alzheimer's disease and non-Alzheimer's dementias

Proton pump inhibitors (PPIs) are among the most prescribed medications. Previous epidemiological studies have presented contradictory results about PPIs and the risk of dementia. Our objective was to investigate the association between the use of PPIs and an increasing risk of incident AD or non-AD dementias. A community-based retrospective cohort study was conducted based on the data available from 1st January 2002 to 31st December 2015 in the Catalan health service (CatSalut) system. This cohort included all PPI users (N = 36,360) and non-users (N = 99,362). A lag window of 5 years was considered between the beginning of the PPI treatment and the diagnosis of dementia. PPI use was not associated with the risk of AD (adjusted odds ratio (OR) 1.06) (95% CI 0.93–1.21; p = 0.408). A weakly but significantly increased risk of non-AD dementias was observed among PPI users (adjusted OR 1.20, 95% CI 1.05–1.37; p = 0.007). A higher dose of PPIs was not associated with an increased risk of either AD or non-AD dementias (OR 1.20; 95% CI 0.91–1.61 and OR 0.95; 95% CI 0.74–1.22, respectively). Regarding the number of PPIs used, we observed an increased risk of AD (OR 1.47; 95% CI 1.18–1.83) and non-AD dementias (OR 1.38; 95% CI 1.12–1.70) in users of two types of PPIs compared with those who used only one type. We did not find a higher incidence of AD among PPI users, but a weak increase in the risk of non-AD dementias among PPI users was observed.

Comorbidity in an Older Population with Type-2 Diabetes Mellitus: Identification of the Characteristics and Healthcare Utilization of High-Cost Patients

Objectives: Little is known about the specific comorbidities contributing to higher costs in patients with type-2 diabetes mellitus (T2DM), particularly in older cases. We aimed to evaluate the prevalence, type, and cost of comorbidities occurring in older T2DM patients versus older non-T2DM patients, and the factors associated with high cost (HC) T2DM patients. Methods: Retrospective cohort study using information from the Campania Region healthcare database. People aged ≥65 years who received ≥2 prescriptions for antidiabetic drugs were identified as "T2DM patients." Comorbidities among T2DM and non-T2DM groups were assessed through the RxRiskV Index (modified version). T2DM individuals were classified according to the total cost distribution as HC or "non-high cost." Two sub-cohorts of HC T2DM patients were assessed: above 90th and 80th percentile of the total cost. Age- and sex-adjusted logistic regression models were created. Results: Among the T2DM cohort, concordant and discordant comorbidities occurred significantly more frequently than in the non-T2DM cohort. Total mean annual cost per T2DM patient due to comorbidities was €7,627 versus €4,401 per non-T2DM patient. Among T2DM patients identified as being above 90th and 80th percentiles of cost distribution, the total annual costs were >€19,577 and >€2,563, respectively. The hospitalization cost was higher for T2DM cases. Strongest predictors of being a HC T2DM patient were having ≥5 comorbidities and renal impairment. Conclusion: HC patients accrued >80% of the total comorbidities cost in older T2DM patients. Integrated care models, with holistic and patient-tailored foci, could achieve more effective T2DM care.

Polypharmacy, potentially serious clinically relevant drug-drug interactions, and inappropriate medicines in elderly people with type 2 diabetes and their impact on quality of life

The aim of the study is to investigate the patterns of polypharmacy, clinical-relevant drug-drug interactions (DDIs), and potentially inappropriate medicines (PIMs), and whether polypharmacy, potential serious clinically-relevant DDIs, or PIMs can be associated with low quality of life (QoL) index scores of older adults with type 2 diabetes (T2D). A cross-sectional study was conducted using data of 670 elderly T2D sub-cohort from a nationwide pharmacy-based intensive monitoring study of inception cohort of T2D in Portugal. 72.09% were found on polypharmacy (≥5 medicines). Participants on polypharmacy were mostly females (P = .0115); more obese (P = .0131); have more comorbid conditions (P < .0001); more diabetes complications (P < .0001); and use more of glucose lowering drugs (P = .0326); insulin (P < .0001); chronic medicines (P < .0001); and have higher diabetes duration (P = .0088) than those without polypharmacy. 10.59% of the participants were found to have potential serious clinically relevant DDIs. The most frequent drug-combinations were angiotensin-converting enzyme (ACE) inhibitors with angiotensin-receptor blockers (ARBs), aspirin with Selective serotonin reuptake inhibitors (SSRIs), and clopidogrel with calcium channel blockers. PIMs are found in 36.11% of the participants. The most common PIMs were benzodiazepines, long-acting sulfonylureas, and iron overdose. The adjusted multivariate models show that Polypharmacy, PIMs, and potential serious clinically relevant DDIs were associated with lower QoL index scores (OR 1.80 95% CI 1.15-2.82), (OR 1.57 95% CI 1.07-2.28), and (OR 1.34 95% CI 0.73-2.48) respectively. The study shows that polypharmacy, potential serious clinical-relevant DDIs, and PIMs may correlate with risk of reduced health related QoL outcome of older adults with T2D.

Respiratory outcomes of metformin use in patients with type 2 diabetes and chronic obstructive pulmonary disease

Few studies investigated the respiratory outcomes of metformin use in patients with coexistent type 2 diabetes mellitus (T2DM) and chronic obstructive pulmonary disease (COPD). We want to compare the long-term respiratory endpoints of metformin use and nonuse in patients with T2DM and COPD. This retrospective cohort study enrolled patients with T2DM and COPD from Taiwan’s National Health Insurance Program between January 1, 2000, and December 31, 2012. Main outcomes were hospitalized bacterial pneumonia, hospitalization for COPD, noninvasive positive pressure ventilation (NIPPV), invasive mechanical ventilation (IMV), and lung cancer. In total, 20,644 propensity score-matched metformin users and nonusers were assessed. The adjusted hazard ratios (95% confidence intervals) of metformin use relative to nonuse for bacterial pneumonia, hospitalization for COPD, NIPPV, IMV, and lung cancer were 1.17 (1.11–1.23), 1.34 (1.26–1.43), 0.99 (0.89–1.10), 1.10 (1.03–1.17), and 1.12 (0.96–1.30). Metformin use also exhibited significant dose–response relationship with respect to the risks of bacterial pneumonia, hospitalization for COPD and IMV. Consistent results were found in the sensitivity test. This nationwide cohort study demonstrated that in patients with T2DM and COPD, metformin use was associated with higher risks of pneumonia, hospitalization for COPD, and IMV. If patients with COPD use metformin, vigilance with regard to their pulmonary condition may be required.

Small airway remodeling in diabetic and smoking chronic obstructive pulmonary disease patients

Diabetes mellitus can reinforce the small airway dysfunction of chronic obstructive pulmonary disease (COPD) patients. The epithelial-mesenchymal transition (EMT) that is associated with small airway remodeling is activated in the airway epithelial cells (AECs) of both COPD patients and diabetic patients. Transforming growth factor β (TGF-β) can induce EMT via the TGF-β/Smad pathway. We found that the small airway dysfunction and airflow limitations were worse in COPD patients with a history of smoking or diabetes than in simple COPD patients, and were even worse in COPD patients with both histories. Pulmonary ventilation tests in rats confirmed these findings. EMT and the TGF-β/Smad pathway were activated in the AECs of rats with COPD or diabetes, and the combination of COPD and diabetes amplified those effects, as indicated by downregulation of Zo1 and upregulation of vimentin, TGF-β and Smad4 in immunohistochemical experiments. Twenty-four-hour treatment with 25 mM glucose and/or 1% cigarette smoke extract upregulated vimentin, TGF-β, Smad2/3/4 and p-Smad2/3, but downregulated Zo1 in AECs. Suppressing the TGF-β/Smad pathway prevented EMT activation and small airway remodeling following cigarette smoke exposure and hyperglycemia. Thus, cigarette smoke and high glucose exposure induces EMT via the TGF-β/Smad pathway in AECs.

Type 2 Diabetes and Chronic Conditions Disparities in Medicare Beneficiaries in the State of Michigan

BACKGROUND

This study aimed to describe the prevalence of type 2 diabetes and combinations of multiple chronic conditions (MCCs) that are leading causes of death (LCD) and confirm that disparities exist between groups based on race and sex.

MATERIALS AND METHODS

We conducted a retrospective cohort study using 2012 Medicare claims data from beneficiaries with type 2 diabetes over the age of 65 in the state of Michigan.

RESULTS

Female beneficiaries have type 2 diabetes and 1 or more MCCs that are LCD more often than males. Most type 2 diabetes patients have diabetes alone without MCCs, while a large proportion have at least 1 additional chronic condition that is a LCD. One in 3 patients have 3 or more chronic conditions. The most prevalent type 2 diabetes coexisting MCCs are congestive heart failure (CHF), chronic obstructive pulmonary disease and chronic kidney disease. Asian/Pacific Islanders have the highest prevalence of type 2 diabetes without MCCs, and the highest prevalence of diabetes plus CHF. While fewer black beneficiaries have diabetes alone or 1 additional MCC, the prevalence of 3 or more MCCs in blacks generally exceeds the prevalence in other races. In beneficiaries with newly diagnosed type 2 diabetes, chronic obstructive pulmonary disease and CHF are the first new chronic conditions to be diagnosed after an initial type 2 diabetes diagnosis.

CONCLUSIONS

Race and sex disparities occur in the prevalence of type 2 diabetes and MCCs that are LCD in Medicare beneficiaries in the state of Michigan.

Type 2 diabetes in older patients: an analysis of the DPV and DIVE databases

BACKGROUND

The clinical profile differs between old and young patients with type 2 diabetes mellitus (T2DM). We explored, based on a large real-world database, patient and disease characteristics and actual treatment patterns by age.

METHODS

The analysis was based on the DIVE and DPV registries of patients with T2DM. Patients were analyzed by age groups 50-59 (middle-young), 60-69 (young-old), 70-79 (middle-old), 80-89 (old), and 90 years or more (oldest-old).

RESULTS

A total of 396,719 patients were analyzed, of which 17.7% were 50-59 years, 27.7% 60-69 years, 34.3% 70-79 years, 18.3% 80-89 years and 2.0% at least 90 years. We found that (a) T2DM in old and oldest-old patients was characterized much less by the presence of metabolic risk factors such as hypertension, obesity, dyslipidemia and smoking than in younger patients; (b) the HbA1c was much lower in oldest-old than in middle-young patients (7.2 ± 1.6% versus 8.0 ± 2.2%; p < 0.001), but it was associated with higher proportions of patients with severe hypoglycemia (7.0 versus 1.6%; p < 0.001); (c) this was potentially associated with the higher and increasing rates of insulin use in older patients (from 17.6% to 37.6%, p < 0.001) and the particular comorbidity profile of these patients, for example, chronic kidney disease (CKD); (d) patients with late diabetes onset had lower HbA1c values, lower bodyweight and less cardiovascular risk factors; (e) patients with a longer diabetes duration had a considerable increase in macrovascular and even more microvascular complications.

CONCLUSION

In very old patients there is a need for frequent careful routine assessment and a tailored pharmacotherapy in which patient safety is much more important than blood-glucose-lowering efficacy.

Type 2 diabetes complications and comorbidity in Sub-Saharan Africans

BACKGROUND

Context-specific evidence of the spectrum of type 2 diabetes (T2D) burden is essential for setting priorities and designing interventions to reduce associated morbidity and mortality. However, there are currently limited data on the burden of T2D complications and comorbidity in sub-Saharan Africa (SSA).

METHODS

T2D complications and comorbidities were assessed in 2,784 participants with diabetes enrolled from tertiary health centres and contextualised in 3,209 individuals without diabetes in Nigeria, Ghana and Kenya. T2D complications and comorbidities evaluated included cardiometabolic, ocular, neurological and renal characteristics.

FINDINGS

The most common complications/comorbidities among the T2D participants were hypertension (71%; 95% CI 69-73), hyperlipidaemia (34%; 95% CI 32-36), and obesity (27%; 95% CI 25-29). Additionally, the prevalence of cataracts was 32% (95% CI 30-35), diabetic retinopathy 15% (95% CI 13-17), impaired renal function 13% (95% CI 12-15), and erectile dysfunction (in men) 35% (95% CI 32-38). T2D population-attributable fraction for these comorbidities ranged between 6 and 64%.

INTERPRETATION

The burden of diabetes complications and comorbidity is substantial in SSA highlighting the urgent need for innovative public health strategies that prioritise promotion of healthy lifestyles for prevention and early detection of T2D. Also needed are strategies to strengthen health care system capacities to provide treatment and care for diabetes complications.

Comparison of the cohort selection performance of Australian Medicines Terminology to Anatomical Therapeutic Chemical mappings

OBJECTIVE

Electronic health records are increasingly utilized for observational and clinical research. Identification of cohorts using electronic health records is an important step in this process. Previous studies largely focused on the methods of cohort selection, but there is little evidence on the impact of underlying vocabularies and mappings between vocabularies used for cohort selection. We aim to compare the cohort selection performance using Australian Medicines Terminology to Anatomical Therapeutic Chemical (ATC) mappings from 2 different sources. These mappings were taken from the Observational Medical Outcomes Partnership Common Data Model (OMOP-CDM) and the Pharmaceutical Benefits Scheme (PBS) schedule.

MATERIALS AND METHODS

We retrieved patients from the electronic Practice Based Research Network data repository using 3 ATC classification groups (A10, N02A, N06A). The retrieved patients were further verified manually and pooled to form a reference standard which was used to assess the accuracy of mappings using precision, recall, and F measure metrics.

RESULTS

The OMOP-CDM mappings identified 2.6%, 15.2%, and 24.4% more drugs than the PBS mappings in the A10, N02A and N06A groups respectively. Despite this, the PBS mappings generally performed the same in cohort selection as OMOP-CDM mappings except for the N02A Opioids group, where a significantly greater number of patients were retrieved. Both mappings exhibited variable recall, but perfect precision, with all drugs found to be correctly identified.

CONCLUSION

We found that 1 of the 3 ATC groups had a significant difference and this affected cohort selection performance. Our findings highlighted that underlying terminology mappings can greatly impact cohort selection accuracy. Clinical researchers should carefully evaluate vocabulary mapping sources including methodologies used to develop those mappings.

Significant EHR Feature-Driven T2D Inference: Predictive Machine Learning and Networks

Background: Electronic health records (EHR) play an important role for the redefinition of phenotypes in view of the wealth and heterogeneity of information now available from disparate data sources. A recent cross-sectional retrospective study has described the potential of EHR toward type 2 diabetes mellitus (T2D) screening when ad hoc models are used. About 10,000 US patients have been analyzed through a variety of inference techniques applied to all records with a variable degree of completeness. The analyses conducted in the reference study have indicated that EHR phenotypes significantly improved T2D detection.

Methods: With these US patients and the T2D data evidenced in the above study, we propose an integrative inference approach that leverages the prediction power of EHR features selected by two well-known methods, Random Forests and Lasso. The goal is 2-fold: reducing the Big Data redundancies potentially harmful to the predictive learning task and exploiting the interconnectivity of EHR features. A mutual information (MI) network is the inference tool used to identify communities useful to prioritize significant T2D features underlying the similarity between patients.

Results: Endowed with a different degree of granularity, the communities detected after the application of both methods were centered especially on T2D comorbidities and risk factors. As such, they appear very relevant for assessment of two main issues, T2D disease burden, and prevention.

Conclusions: Our analytical approach offers a solution for managing the EHR scale factor in a complex disease context. EHR are rich sources of phenotypic diversity through which novel stratifications of patients are expected. To enable these results, both pre-screening of variables and calibration of risk prediction methods become necessary steps in EHR analyses. We have presented networks identifying major T2D communities. The specific significance assigned to comorbidities and risk factors in relation to T2D can be inferred with accuracy from just a suitably reduced number of EHR features.

Defining Dysbiosis for a Cluster of Chronic Diseases

The prevalence of many chronic diseases has increased over the last decades. It has been postulated that dysbiosis driven by environmental factors such as antibiotic use is shifting the microbiome in ways that increase inflammation and the onset of chronic disease. Dysbiosis can be defined through the loss or gain of bacteria that either promote health or disease, respectively. Here we use multiple independent datasets to determine the nature of dysbiosis for a cluster of chronic diseases that includes urinary stone disease (USD), obesity, diabetes, cardiovascular disease, and kidney disease, which often exist as co-morbidities. For all disease states, individuals exhibited a statistically significant association with antibiotics in the last year compared to healthy counterparts. There was also a statistically significant association between antibiotic use and gut microbiota composition. Furthermore, each disease state was associated with a loss of microbial diversity in the gut. Three genera, Bacteroides, Prevotella, and Ruminococcus, were the most common dysbiotic taxa in terms of being enriched or depleted in disease populations and was driven in part by the diversity of operational taxonomic units (OTUs) within these genera. Results of the cross-sectional analysis suggest that antibiotic-driven loss of microbial diversity may increase the risk for chronic disease. However, longitudinal studies are needed to confirm the causative effect of diversity loss for chronic disease risk.

The association between polypharmacy and adverse health consequences in elderly type 2 diabetes mellitus patients; a systematic review and meta-analysis

AIM

To summarize the existing literature concerning the association between polypharmacy and adverse health consequences in elderly patients with type 2 diabetes mellitus.

METHODS

We searched four literature databases (PubMed/Medline, ScienceDirect and Web of Science) through April 2019. We included all studies that addressed the association between polypharmacy and all-cause of mortality, glycemic control, macrovacular complications, hospitalization, potentially inappropriate medicines, drug-drug interactions and fall. A statistical program OpenMeta [Analyst] was used. The pooled odds ratios (ORs) and 95% confidence intervals (CIs) were calculated with a random effects model. I² statistics was performed to assess heterogeneity.

RESULTS

Out of sixteen studies, three studies were used for meta-analysis. A statistically significant association was found between polypharmacy and all-cause mortality (OR = 1.622, 95% CI (1.606-1.637) P < 0.001), and myocardial infarction (OR = 1.962, 95% CI (1.942-1.982), P < 0.001. Non-statistically significant association with evidence of moderate heterogeneity was found between polypharmacy and stroke (OR = 1.335; 95% CI (0.532-3.346), P = 0.538, I² = 45%), and hospitalization (OR = 1.723; 95% CI (0.983-3.021), P = 0.057, I² = 57%).

CONCLUSIONS

Pooled risk estimates reveal that polypharmacy is associated with increased all-cause mortality, macrovacular complications and hospitalization using categorical definitions. These findings assert the need for interventions that optimize the balance of benefits and harms in medicines prescribing.

Adherence to Medication, Physical Activity and Diet in Older Adults With Diabetes: Its Association With Cognition, Anxiety and Depression

Background

Adherence to medication, physical activity (PA) and diet in diabetes mellitus (DM) patients is crucial for its good management, avoiding acute and chronic complications. There are several risk factors associated with non-adherence, including cognitive impairment, depression and anxiety. Nevertheless, studies on therapeutic adherence in older patients with DM are scarce. In this context, the present study aimed to analyze whether adherence to medication, PA and diet are associated with cognitive impairment, anxiety and depression. It also aimed to identity predictors of medication non-adherence.

Methods

A cross-sectional study of older patients (≥ 65 years old) with DM was carried out in the Outpatient Department of Internal Medicine Service of CHUSJ-Porto, Portugal. Those unable to communicate were excluded. Cognition (mini-mental state examination), anxiety and depression (hospital anxiety and depression scale) were assessed. Adherence to medication, PA and diet was measured, based on self-reporting patient/family, questionnaires, physician clinical opinion, hemoglobin test and pharmacy records. Patient groups were compared, using the Mann-Whitney or the Kruskal-Wallis test for continuous variables and the Chi-square test for paired categorical variables (significance level of 0.05). The odds ratio (OR) was calculated to identify independent predictors of non-adherence to medication.

Results

The final sample (n = 94) had a mean age of 75.2 years (standard deviation: 6.7) and mostly were female (53.2%), married (63.8%) and with a low education level (61.7%). Also, 22.3% with cognitive impairment, 16% with depression and 23.4% with anxiety were found. Patients non-adherent to medication had higher depression (P = 0.048) and anxiety (P = 0.010), compared to adherents/partial adherents. Patients non-adherent to PA showed higher anxiety (P = 0.035) and depression (P = 0.004), compared to adherents. Non-adherents to PA had more cognitive impairment than adherents (26.3% vs. 0%; P = 0.034). Patients who had insulin prescribed presented a higher risk of non-adherence to medication (OR: 4.041, 95% confidence interval (CI): 1.404 - 11.628; P = 0.010). Also, the risk of non-adherence to medication is higher by an increase of one unit in anxiety (OR: 1.252, 95% CI: 1.046 - 1.499; P = 0.014).

Conclusions

Higher anxiety and depression were associated with non-adherence to medication and to PA. Insulin prescribed and high anxiety scores were predictors of medication non-adherence. This study appears to contribute to the knowledge about the influence of cognitive and psychological factors in therapeutic adherence in these older diabetic patients.

Clinical significance of high-mobility group box-1 (HMGB1) in subjects with type 2 diabetes mellitus (T2DM) combined with chronic obstructive pulmonary disease (COPD)

Background

Simple method to predict type 2 diabetes mellitus (T2DM) combined with chronic obstructive pulmonary disease (COPD) is in great need clinically. This study aims to assess the clinical significance of high‐mobility group box‐1 (HMGB1) in predicting T2DM combined with COPD in Chinese patients with T2DM or COPD.

Methods

Serum concentrations of glycated hemoglobin (HbA1C), fasting plasma glucose (FPG), fasting insulin (FINS), total cholesterol (TC), triglyceride (TG), low‐density lipoprotein cholesterol (LDL‐c), high‐density lipoprotein cholesterol (HDL‐c), C‐reactive protein (CRP), fibrinogen (FIB), HMGB1, white blood cell count (WBC), neutrophil% (NEU%), and lung function text such as forced expiratory volume 1/forced vital capacity (FEV1/FVC) and forced expiratory volume 1% predicted value (FEV1%pred) were measured in 126 T2DM patients, 118 COPD patients, 112 T2DM combined with COPD patients, and 120 healthy controls. Logistic regression was used to estimate the risk factors for T2DM combined with COPD.

Results

High‐mobility group box‐1 elevated in patients with T2DM combined with COPD, significantly higher than other subjects (P < 0.05), and differences in HMGB1 also existed between patients with T2DM or COPD and healthy individuals (P < 0.01). HMGB1 was positively correlated with HOMA‐IR, FBG, and HbA1c (P < 0.01) and negatively correlated with FEV1/FVC and FEV1%pred (P < 0.01). Logistic regression showed that HMGB1 was identified to be independent risk factor for T2DM combined with COPD.

Conclusion

High‐mobility group box‐1 was independent risk factor for T2DM combined with COPD and can be served to predict the occurrence of T2DM combined with COPD.

Why primary obesity is a disease?

Obesity must be considered a real pathology. In the world wide, obesity represent one of the major public health issue associated with increased morbidity and mortality. Overweight or obesity, in fact, significantly increases the risk of contracting diseases, such as: arterial hypertension, dyslipidemia, type 2 diabetes mellitus, coronary heart disease, cerebral vasculopathy, gallbladder lithiasis, arthropathy, ovarian polycytosis, sleep apnea syndrome, and some neoplasms. Despite numerous informative campaigns, unfortunately, the fight against obesity does not seem to work: in the last years, the prevalence continued to increase. The progressive and rapid increase in the incidence of obesity, which has characterized most of the economically advanced countries in the last decade, has been the main stimulus for the research of the mechanisms underlying this pathology and the related disorders. The aims of this review is to provide a revision of the literature in order to define obesity as diseases, secondly to highlight the limits and the inaccuracy of common tools used for the diagnosis of obesity, and as a third thing to strengthen the concept of the complexity of obesity as a disease among political health care providers. Obesity may be viewed as a multifactorial pathology and chronic low-grade inflammatory disease. In fact, people affected by obesity have greater risk of developing comorbility and morbility, respect to healthy. Hence, the absolute therapeutic benefit is directly proportional to the basic risk. So, internationally interest on early diagnosis of obesity is growing to avoid under- and overdiagnosis consequences. Therefore, the consequences are an aggravation of the disease and an increase in obesity related pathology like diabetes, cardiovascular disease, and cancer. The most widely used parameter for diagnosis, body mass index (BMI) is not suitable for assessing the body fat. In fact, several studies demonstrate that BMI alone cannot define obesity, which consists not so much in weight gain as in excess fat mass. The use of suitable tools for the assessment of fat mass percentage combined with clinical and genetic analysis allowed to identify different phenotypes of obesity, which explain the various paradoxes of obesity. It is essential to adopt all possible strategies to be able to combat obesity, ameliorate the suffering of patients, and reduce the social and treatment costs of obesity.

Risk Factors for Developing Comorbid Sleeping Problems: Results of a Survey of 1,925 Women Over 50 With a Chronic Health Condition

Objective: To test the association between sleeping problems and multiple epidemiological factors among women over 50 with a chronic condition. Method: The Medical Outcomes Study Sleep Scale (MOS-SS) was employed to measure sleep problems among 1,925 participants with chronic conditions who also responded to questions about health service use, self-care and demographics. Results: About 43% of women reported sleeping problems. Women were more likely to have a sleeping problem if they reported some difficulties with available income, odds ratio (OR) = 1.61; 95% confidence interval (CI): [1.27, 2.04]; p < .005, or were struggling with available income (OR = 2.84; 95% CI: [2.04, 3.96]; p < .005). Women were less likely to have sleeping problems if they were highly physically active (OR = .63; 95% CI: [0.51, 0.79]; p < .005). Discussion: Medical professionals should be aware of the significant risk of sleeping problems among mid-age and older women with chronic health conditions, particularly those who have financial concerns, are sedentary, or are not highly physically active.