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Stasinopoulos J, Wood SJ, Bell JS, Manski-Nankervis JA, Hogan M, Sluggett JK. Potential Overtreatment and Undertreatment of Type 2 Diabetes Mellitus in Long-Term Care Facilities: A Systematic Review. J Am Med Dir Assoc 2021; 22:1889-1897.e5. [PMID: 34004183 DOI: 10.1016/j.jamda.2021.04.013] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Revised: 04/08/2021] [Accepted: 04/09/2021] [Indexed: 12/17/2022]
Abstract
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.
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Affiliation(s)
- Jacquelina Stasinopoulos
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, VIC, Australia.
| | - Stephen J Wood
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, VIC, Australia
| | - J Simon Bell
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, VIC, Australia; Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Jo-Anne Manski-Nankervis
- Department of General Practice, Melbourne Medical School, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Carlton, VIC, Australia
| | | | - Janet K Sluggett
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, VIC, Australia; University of South Australia, UniSA Allied Health and Human Performance, Adelaide, SA, Australia; Registry of Senior Australians, South Australian Health and Medical Research Institute, Adelaide, SA, Australia
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Misra A, Sattar N, Tandon N, Shrivastava U, Vikram NK, Khunti K, Hills AP. Clinical management of type 2 diabetes in south Asia. Lancet Diabetes Endocrinol 2018; 6:979-991. [PMID: 30287103 DOI: 10.1016/s2213-8587(18)30199-2] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2016] [Revised: 06/19/2018] [Accepted: 06/19/2018] [Indexed: 02/07/2023]
Abstract
Compared with other ethnic groups, south Asian people with type 2 diabetes tend to develop the disease at a younger age and manifest with higher glycaemia, dyslipidaemia, nephropathy, and cardiovascular diseases. Additionally, specific issues that can affect treatment of type 2 diabetes in south Asia include poor awareness of the disease, delay in diagnosis, inadequate treatment, the use of ineffective and often harmful alternative medicines, and frequent non-compliance with lifestyle recommendations and drug treatment. Disease development at younger ages, delayed diagnosis, and inadequate management result in early development of severe complications and premature mortality. In this Series paper, we describe the challenges associated with the increasing burden of type 2 diabetes in south Asia and discuss ways to improve clinical care of people with the disorder in the region (defined to include Bangladesh, Bhutan, India, Nepal, Pakistan, and Sri Lanka). Treatment of diabetes in south Asia needs to be individualised on the basis of diverse and heterogeneous lifestyle, phenotype, environmental, social, cultural, and economic factors. Aggressive management of risk factors from diagnosis is necessary to reduce the risk of microvascular and macrovascular complications, focusing on provision of basic treatments (eg, metformin, low-cost statins, and blood pressure-lowering drugs) and other interventions such as smoking cessation. Strengthening of the primary care model of care, better referral linkages, and implementation of rehabilitation services to care for patients with chronic complications will be important. Finally, improvement of physicians' skills, provision of relevant training to non-physician health-care workers, and the development and regular updating of national clinical management guidelines will also be crucial to improve diabetes care in the region.
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Affiliation(s)
- Anoop Misra
- Fortis C-DOC Centre of Excellence for Diabetes, Metabolic Diseases, and Endocrinology, New Delhi, India; National Diabetes, Obesity, and Cholesterol Foundation, New Delhi, India; Diabetes Foundation (India), New Delhi, India.
| | - Naveed Sattar
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Nikhil Tandon
- Department of Endocrinology, All India Institute of Medical Sciences, New Delhi, India
| | - Usha Shrivastava
- National Diabetes, Obesity, and Cholesterol Foundation, New Delhi, India
| | - Naval K Vikram
- Department of Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Kamlesh Khunti
- Diabetes Research Centre, University of Leicester, Leicester General Hospital, Leicester, UK
| | - Andrew P Hills
- School of Health Sciences, College of Health and Medicine, University of Tasmania, Launceston, TAS, Australia
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Silbert R, Salcido-Montenegro A, Rodriguez-Gutierrez R, Katabi A, McCoy RG. Hypoglycemia Among Patients with Type 2 Diabetes: Epidemiology, Risk Factors, and Prevention Strategies. Curr Diab Rep 2018; 18:53. [PMID: 29931579 PMCID: PMC6117835 DOI: 10.1007/s11892-018-1018-0] [Citation(s) in RCA: 115] [Impact Index Per Article: 19.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
PURPOSE OF REVIEW Hypoglycemia is the most common and often treatment-limiting serious adverse effect of diabetes therapy. Despite being potentially preventable, hypoglycemia in type 2 diabetes incurs substantial personal and societal burden. We review the epidemiology of hypoglycemia in type 2 diabetes, discuss key risk factors, and introduce potential prevention strategies. RECENT FINDINGS Reported rates of hypoglycemia in type 2 diabetes vary widely as there is marked heterogeneity in how hypoglycemia is defined, measured, and reported. In randomized controlled trials, rates of severe hypoglycemia ranged from 0.7 to 12 per 100 person-years. In observational studies, hospitalizations or emergency department visits for hypoglycemia were experienced by 0.2 (patients treated without insulin or sulfonylurea) to 2.0 (insulin or sulfonylurea users) per 100 person-years. Patient-reported hypoglycemia is much more common. Over the course of 6 months, 1-4% non-insulin users reported need for medical attention for hypoglycemia; 1-17%, need for any assistance; and 46-58%, any hypoglycemia symptoms. Similarly, over a 12-month period, 4-17% of insulin-treated patients reported needing assistance and 37-64% experienced any hypoglycemic symptoms. Hypoglycemia is most common among older patients with multiple or advanced comorbidities, patients with long diabetes duration, or patients with a prior history of hypoglycemia. Insulin and sulfonylurea use, food insecurity, and fasting also increase hypoglycemia risk. Clinical decision support tools may help identify at-risk patients. Prospective trials of efforts to reduce hypoglycemia risk are needed, and there is emerging evidence supporting multidisciplinary interventions including treatment de-intensification, use of diabetes technologies, diabetes self-management, and social support. Hypoglycemia among patients with type 2 diabetes is common. Patient-centered multidisciplinary care may help proactively identify at-risk patients and address the multiplicity of factors contributing to hypoglycemia occurrence.
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Affiliation(s)
- Richard Silbert
- Department of Medicine Residency Program, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Alejandro Salcido-Montenegro
- Division of Endocrinology, Department of Internal Medicine, University Hospital "Dr. José E. González", Universidad Autonoma de Nuevo Leon, Av. Francisco I. Madero y Av. Gonzalitos s/n, Mitras Centro, 64460, Monterrey, Nuevo León, Mexico
- Plataforma INVEST Medicina UANL-KER Unit Mayo Clinic, "Dr. Jose E. González" University Hospital, Autonomous University of Nuevo Leon, 64460, Monterrey, Nuevo Leon, Mexico
| | - Rene Rodriguez-Gutierrez
- Division of Endocrinology, Department of Internal Medicine, University Hospital "Dr. José E. González", Universidad Autonoma de Nuevo Leon, Av. Francisco I. Madero y Av. Gonzalitos s/n, Mitras Centro, 64460, Monterrey, Nuevo León, Mexico
- Plataforma INVEST Medicina UANL-KER Unit Mayo Clinic, "Dr. Jose E. González" University Hospital, Autonomous University of Nuevo Leon, 64460, Monterrey, Nuevo Leon, Mexico
- Knowledge and Evaluation Research Unit in Endocrinology, Mayo Clinic, Rochester, MN, 55905, USA
| | - Abdulrahman Katabi
- Evidence-Based Practice Center, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Rozalina G McCoy
- Division of Community Internal Medicine, Department of Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
- Division of Health Care Policy and Research, Department of Health Sciences Research, Mayo Clinic, Rochester, MN, 55905, USA.
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Chandrakumar A, Dilip C, Suriyaprakash TNK, Thomas L, Surendran R. Incidence and risk factors of hypoglycemia among Type 2 diabetic patients in a South Indian hospital. Diabetes Metab Syndr 2016; 10:S22-S25. [PMID: 26806327 DOI: 10.1016/j.dsx.2016.01.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2015] [Accepted: 01/09/2016] [Indexed: 02/03/2023]
Abstract
AIM The study was aimed at assessing the cumulative incidence of hypoglycemia and precipitating risk factors among type 2 diabetes mellitus in-patients of a tertiary care hospital in South India. METHODS The prospective cross sectional study spanning 14 months was conducted in a tertiary care hospital in Kerala. All T2DM patients who were administered any form of insulin during the length of hospital stay was monitored for assessing the hypoglycemic episodes. Any patient with a GRBS value less than 70mg/dL was defined to be hypoglycemic as per the ADA guidelines. The statistical analysis of collected data was performed using SPSS 18 for windows version. RESULTS Of the 1650 subjects enrolled in the study, 204 subjects developed hypoglycemia. The sample composed of 60.8% females and 39.2% males and the difference was significant with p=0.02. A significant positive correlation was observed between HbA1c values and GRBS value, with a 2 tailed Pearson correlation coefficient of 0.027. On stratifying as per the modality of insulin dose prescribed, 72.5% of the hypoglycemic patients were found to have been administered fixed dose insulin. CONCLUSION The cumulative incidence of institutional hypoglycemia among type 2 diabetic inpatients was gauged as 12.36%; among which, 26.96% had asymptomatic episodes.
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Affiliation(s)
- Abin Chandrakumar
- Department of Pharmacy Practice, Al Shifa College of Pharmacy, Poonthavanam, Kizhattur P.O, Perinthalmanna, Kerala, 679325.
| | - C Dilip
- Department of Pharmacy Practice, Al Shifa College of Pharmacy, Poonthavanam, Kizhattur P.O, Perinthalmanna, Kerala, 679325
| | - T N K Suriyaprakash
- Department of Pharmaceutics, Al Shifa College of Pharmacy, Poonthavanam, Kizhattur P.O, Perinthalmanna, Kerala, 679325
| | - Levin Thomas
- Department of Pharmacy Practice, Al Shifa College of Pharmacy, Poonthavanam, Kizhattur P.O, Perinthalmanna, Kerala, 679325
| | - Reshma Surendran
- Department of Pharmacy Practice, Al Shifa College of Pharmacy, Poonthavanam, Kizhattur P.O, Perinthalmanna, Kerala, 679325
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