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Fan YP, Lai TH, Lai JN, Yang CC. 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. Geriatr Nurs 2024; 58:8-14. [PMID: 38729064 DOI: 10.1016/j.gerinurse.2024.04.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Revised: 04/12/2024] [Accepted: 04/19/2024] [Indexed: 05/12/2024]
Abstract
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.
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Affiliation(s)
- Yu-Pei Fan
- Institute of Public Health, National Yang Ming Chiao Tung University, Taipei, Taiwan, Department of Medical Education; MacKay Memorial Hospital, Taipei, Taiwan
| | - Tzu-Hsuan Lai
- Traditional Chinese Medicine-Acupuncture Program, College of Traditional Chinese Medicine Practitioners and Acupuncturists, Kwantlen Polytechnic University, Richmond, Canada
| | - Jung-Nien Lai
- School of Chinese Medicine, College of Chinese Medicine, China Medical University, Taichung, Taiwan, Departments of Chinese Medicine, China Medical University Hospital, Taichung, Taiwan.
| | - Chen-Chang Yang
- Institute of Public Health, National Yang Ming Chiao Tung University, Taipei, Taiwan, Department of Medical Education; Institute of Environmental and Occupational Health Sciences, National Yang Ming Chiao Tung University School of Medicine, Taipei, Taiwan; Department of Occupational Medicine and Clinical Toxicology, Taipei Veterans General Hospital, Taipei, Taiwan
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2
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O'Neil H, Todd A, Pearce M, Husband A. What are the consequences of over and undertreatment of type 2 diabetes mellitus in a frail population? A systematic review. Endocrinol Diabetes Metab 2024; 7:e00470. [PMID: 38411378 PMCID: PMC10897870 DOI: 10.1002/edm2.470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2023] [Revised: 01/18/2024] [Accepted: 01/21/2024] [Indexed: 02/28/2024] Open
Abstract
AIMS This review aims to identify the evidence base for the consequences of over and undertreatment of type 2 diabetes mellitus in a frail population. METHOD In this systematic review, we searched MEDLINE, Embase, PubMed, CINAHL and the Cochrane Library for studies from January 2001 to 15th August 2022. We included a variety of study types that assessed and reported frailty including patients ≥18 years old. Studies included those that reported the prevalence of over or undertreatment of diabetes mellitus in a frail population and those examining outcomes related to glucose control in frail older people living with diabetes. Data were extracted using a bespoke extraction table using a narrative synthesis approach. RESULTS A total of 4114 articles were identified with 112 meeting inclusion criteria. These included 15,130 participants across the 11 studies with sample sizes ranging from 101 to 11,140. Several areas were identified in the included studies where under or overtreatment of diabetes impacted outcomes for patients. These included hospital admissions, readmissions, length of stay, falls, mortality, cognitive impairment and cardiovascular disease outcomes. CONCLUSION The results showed that there was a high heterogeneity of outcomes between the studies and that many examined small numbers of participants. In this review, both over and undertreatment were shown to increase adverse outcomes in frail older people. Further research around optimal glycaemic control for frail older people living with diabetes is required with the aim to identify ideal target ranges and produce practical clinical guidelines to promote attainment of these.
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Affiliation(s)
- Helen O'Neil
- School of PharmacyNewcastle UniversityNewcastleUK
- South Tyneside and Sunderland NHS Foundation TrustSinderlandUK
- NIHR North East and North Cumbria Applied Research Collaboration (NIHR NENC ARC)NewcastleUK
| | - Adam Todd
- School of PharmacyNewcastle UniversityNewcastleUK
| | - Mark Pearce
- Population Health Sciences Institute, Newcastle UniversityNewcastle upon TyneUK
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3
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Mu Z, Sun M, Wen L, Li P, Gao J, Liu M, Bian H, Wang Z. Effect of hypoglycemia on cognitive performance in older patients with diabetes: A meta-analysis. ANNALES D'ENDOCRINOLOGIE 2024; 85:56-62. [PMID: 37884125 DOI: 10.1016/j.ando.2023.10.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 10/10/2023] [Accepted: 10/16/2023] [Indexed: 10/28/2023]
Abstract
GOALS The goal of this study was to use meta-analysis to compile information from various studies to investigate the existence and severity of cognitive impairment in elderly diabetes patients who have hypoglycemic episodes. MATERIALS AND TECHNIQUES For research studies on the relationship between hypoglycemia and cognitive decline or dementia in persons older than 45 years, we searched the PubMed, EMBASE, Cochrane Library, CNKI, WanFang, CBM and VIP databases for the period 1989 to 2022. We conducted random effects inverse variance on the meta-analysis and used the I2 statistic to assess heterogeneity. RESULT We selected 44 of the 518 studies we retrieved, 7 being appropriate for meta-analysis. Six thousand and forty-five individuals were involved in total. Both types of older diabetic patients with hypoglycemia performed considerably worse on tests of general intelligence than control participants (standardized mean difference, 0.58; 95% CI, 0.88-0.28). Also, elderly type-2 diabetes patients with hypoglycemic episodes had significantly worse memory performance (standardized mean difference, 0.19; 95% CI, 0.29-0.09). Additionally, we found that older type-2 diabetes patients with hypoglycemia had significantly poorer psychomotor function than those without hypoglycemia (standardized mean difference, 0.51; 95% CI, 0.38-0.63).
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Affiliation(s)
- Zhenzhen Mu
- Medical College of Yan'an University, Yan'an City, 716000, Shanxi Province, China
| | - Mimi Sun
- Shaanxi Provincial People's Hospital, Xi'an City, Shanxi Province, China
| | - Lian Wen
- Medical College of Yan'an University, Yan'an City, 716000, Shanxi Province, China
| | - Peipei Li
- Medical College of Yan'an University, Yan'an City, 716000, Shanxi Province, China
| | - Jiangmei Gao
- Yan'an University Affiliated Hospital, Xi'an City, Shanxi Province, China
| | - Minli Liu
- Medical College of Yan'an University, Yan'an City, 716000, Shanxi Province, China
| | - Hongyan Bian
- Medical College of Yan'an University, Yan'an City, 716000, Shanxi Province, China.
| | - Zhiguo Wang
- Yan'an University Affiliated Hospital, Xi'an City, Shanxi Province, China
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4
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Golding J, Hope SV, Chakera AJ, Puttanna A. The evolving continuum of dysglycaemia: Non-diabetic hyperglycaemia in older adults. Diabet Med 2023; 40:e15177. [PMID: 37452769 DOI: 10.1111/dme.15177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Revised: 07/06/2023] [Accepted: 07/12/2023] [Indexed: 07/18/2023]
Abstract
Identifying non-diabetic hyperglycaemia (NDH) and intervening to halt the progression to type 2 diabetes has become an essential component of cardiovascular and cerebrovascular risk reduction. Diabetes prevention programs have been instigated to address the increasing prevalence of NDH and type 2 diabetes by targeting lifestyle modifications. Evidence suggests that the risk of progression from NDH to type 2 diabetes declines with age, and that a diagnosis of type 2 diabetes in older adults is not associated with the same risk of adverse consequences as it is in younger age groups. The current definition of NDH is not adjusted based on a person's age. Therefore, there is debate about the emphasis that should be placed upon a diagnosis of NDH in older adults. This article will explore the evidence and current clinical practice surrounding dysglycaemia through the spectrum of different age ranges, and the potential implications this has for older adults.
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Affiliation(s)
- J Golding
- Department of Diabetes and Endocrinology, University Hospitals Sussex NHS Foundation Trust, Brighton, UK
- Department of Medicine, Brighton and Sussex Medical School, Brighton, UK
| | - S V Hope
- College of Medicine and Health, University of Exeter, Exeter, UK
- Department of Healthcare for Older People, Royal Devon University Healthcare NHS Foundation Trust, Exeter, UK
| | - A J Chakera
- Department of Diabetes and Endocrinology, University Hospitals Sussex NHS Foundation Trust, Brighton, UK
- Department of Medicine, Brighton and Sussex Medical School, Brighton, UK
| | - A Puttanna
- Department of Diabetes and Endocrinology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
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5
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Christou MA, Christou PA, Kyriakopoulos C, Christou GA, Tigas S. Effects of Hypoglycemia on Cardiovascular Function in Patients with Diabetes. Int J Mol Sci 2023; 24:ijms24119357. [PMID: 37298308 DOI: 10.3390/ijms24119357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Revised: 05/21/2023] [Accepted: 05/25/2023] [Indexed: 06/12/2023] Open
Abstract
Hypoglycemia is common in patients with type 1 and type 2 diabetes (T1D, T2D), treated with insulin or sulfonylureas, and has multiple short- and long-term clinical implications. Whether acute or recurrent, hypoglycemia significantly affects the cardiovascular system with the potential to cause cardiovascular dysfunction. Several pathophysiological mechanisms have been proposed linking hypoglycemia to increased cardiovascular risk, including hemodynamic changes, myocardial ischemia, abnormal cardiac repolarization, cardiac arrhythmias, prothrombotic and proinflammatory effects, and induction of oxidative stress. Hypoglycemia-induced changes can promote the development of endothelial dysfunction, which is an early marker of atherosclerosis. Although data from clinical trials and real-world studies suggest an association between hypoglycemia and cardiovascular events in patients with diabetes, it remains uncertain whether this association is causal. New therapeutic agents for patients with T2D do not cause hypoglycemia and have cardioprotective benefits, whereas increasing the use of new technologies, such as continuous glucose monitoring devices and insulin pumps, has the potential to reduce hypoglycemia and its adverse cardiovascular outcomes in patients with T1D.
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Affiliation(s)
- Maria A Christou
- Department of Endocrinology, University of Ioannina Faculty of Medicine, 45500 Ioannina, Greece
| | - Panagiota A Christou
- Department of Endocrinology, University of Ioannina Faculty of Medicine, 45500 Ioannina, Greece
| | - Christos Kyriakopoulos
- Department of Respiratory Medicine, University of Ioannina Faculty of Medicine, 45500 Ioannina, Greece
| | - Georgios A Christou
- Laboratory of Physiology, University of Ioannina Faculty of Medicine, 45500 Ioannina, Greece
| | - Stelios Tigas
- Department of Endocrinology, University of Ioannina Faculty of Medicine, 45500 Ioannina, Greece
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Grajower MM, LeRoith D. Management of Type 2 Diabetes Mellitus in the Very Elderly: One Practice's Experience. Endocr Pract 2023:S1530-891X(23)00334-8. [PMID: 36965656 DOI: 10.1016/j.eprac.2023.03.271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2022] [Revised: 03/12/2023] [Accepted: 03/18/2023] [Indexed: 03/27/2023]
Abstract
OBJECTIVE Type 2 diabetes mellitus (T2DM) affects 25% of adults over age 65. Nevertheless, few clinical trials include patients over age 75. METHODS This case series reports retrospective data on a cohort of 85 patients aged 80 and over (mean 88.1, range 80-104) with T2DM, managed by a single endocrinologist. The practice's computerized data base was searched for all patients 80 years of age and older with a diagnosis of T2DM. RESULTS The major observations were the significant decrease in the use of agents associated with hypoglycemia, (sulfonylureas and insulin), and the beneficial and well-tolerated use of glucagon like peptide-1 receptor analogues (GLP-1 RA). The mean A1c in the entire cohort dropped from 7.6% to 6.6% over a mean of 9 months. Nearly one-half of the cohort were treated with GLP1-RA, reflecting studies demonstrating the safety and efficacy of this class of drugs in less elderly patients. At presentation, 75% were on sulfonylurea and/or insulin; this number was reduced to 27%. Furthermore, none of the patients required short-acting (bolus) insulin to achieve the individualized A1c target. CONCLUSION Patients with T2DM aged 80 and over respond well to GLP1-RA drugs, drastically reducing the need for agents associated with hypoglycemia. The important question, which will require larger and prospective studies, is whether the lowering of A1c, as shown in this paper, and the use of GLP-1 RA specifically, are associated with improved morbidity and mortality in the very elderly.
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Affiliation(s)
- Martin M Grajower
- Albert Einstein College of Medicine, Bronx, NY; Icahn School of Medicine at Mount Sinai, NY, NY.
| | - Derek LeRoith
- Albert Einstein College of Medicine, Bronx, NY; Icahn School of Medicine at Mount Sinai, NY, NY
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7
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Sugimoto T, Noma H, Kuroda Y, Matsumoto N, Uchida K, Kishino Y, Saji N, Niida S, Sakurai T. Time trends (2012-2020) in glycated hemoglobin and adherence to the glycemic targets recommended for elderly patients by the Japan Diabetes Society/Japan Geriatrics Society Joint Committee among memory clinic patients with diabetes mellitus. J Diabetes Investig 2022; 13:2038-2046. [PMID: 36124721 DOI: 10.1111/jdi.13897] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Revised: 07/25/2022] [Accepted: 08/17/2022] [Indexed: 11/28/2022] Open
Abstract
AIMS/INTRODUCTION To investigate the changes in the glycated hemoglobin (HbA1c) levels and the relative status of the glycemic control related to the new glycemic targets recommended by the Japan Diabetes Society/Japan Geriatrics Society Joint Committee in 2016 in patients with diabetes mellitus visiting a memory clinic from 2012 to 2020. MATERIALS AND METHODS This cross-sectional study included 1,436 patients aged ≥65 years with diabetes. Patients were categorized into three categories as follows: category I, intact cognitive function and activities of daily living (ADL); category II, mild cognitive deficits or impaired instrumental ADL; and category III, moderate to severe cognitive impairment or impaired basic ADL. Trends in HbA1c levels, glycemic control status (optimally/poorly/excessively controlled) and proportion of individuals receiving drugs potentially associated with severe hypoglycemia among all patients and categories (I, II or III) from 2012 to 2020 were examined using linear, logistic and multinominal logistic regression models adjusted for confounding factors. RESULTS Between 2012 and 2020, the HbA1c levels, as well as the proportion of patients with poor glycemic control, increased, whereas the proportion of patients with excessive glycemic control and those receiving drugs potentially associated with severe hypoglycemia decreased. CONCLUSIONS Increased levels of HbA1c and decreased proportions of individuals under excessive glycemic control might reflect recent treatment strategies that avoid hypoglycemia in older patients. Given the adverse complications associated with hyperglycemia, more flexible and individualized glycemic targets based on comprehensive assessments, including vascular complications and comorbidities, might be necessary.
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Affiliation(s)
- Taiki Sugimoto
- Department of Prevention and Care Science, Research Institute, National Center for Geriatrics and Gerontology, Obu, Japan.,Center for Comprehensive Care and Research on Memory Disorders, Hospital, National Center for Geriatrics and Gerontology, Obu, Japan
| | - Hisashi Noma
- Department of Data Science, The Institute of Statistical Mathematics, Tokyo, Japan
| | - Yujiro Kuroda
- Department of Prevention and Care Science, Research Institute, National Center for Geriatrics and Gerontology, Obu, Japan
| | - Nanae Matsumoto
- Center for Comprehensive Care and Research on Memory Disorders, Hospital, National Center for Geriatrics and Gerontology, Obu, Japan
| | - Kazuaki Uchida
- Center for Comprehensive Care and Research on Memory Disorders, Hospital, National Center for Geriatrics and Gerontology, Obu, Japan.,Department of Public Health, Graduate School of Health Sciences, Kobe University, Kobe, Japan
| | - Yoshinobu Kishino
- Center for Comprehensive Care and Research on Memory Disorders, Hospital, National Center for Geriatrics and Gerontology, Obu, Japan.,Department of Cognition and Behavior Science, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Naoki Saji
- Center for Comprehensive Care and Research on Memory Disorders, Hospital, National Center for Geriatrics and Gerontology, Obu, Japan
| | - Shumpei Niida
- National Center for Geriatrics and Gerontology, Research Institute, Obu, Japan
| | - Takashi Sakurai
- Department of Prevention and Care Science, Research Institute, National Center for Geriatrics and Gerontology, Obu, Japan.,Center for Comprehensive Care and Research on Memory Disorders, Hospital, National Center for Geriatrics and Gerontology, Obu, Japan.,Department of Cognition and Behavior Science, Nagoya University Graduate School of Medicine, Nagoya, Japan
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8
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Daly SL, Gabbe BJ, Climie RE, Ekegren CL. Association between type 2 diabetes and long-term outcomes in middle-aged and older trauma patients. J Trauma Acute Care Surg 2022; 92:185-192. [PMID: 34137744 DOI: 10.1097/ta.0000000000003317] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Diabetes is associated with increased hospital complications and mortality following trauma. However, there is limited research on the longer-term recovery of trauma patients with diabetes. The aim of this study was to explore the association between type 2 diabetes (T2D) and in-hospital and 24-month outcomes in major trauma patients. METHODS In this cohort study using the Victorian State Trauma Registry, middle-aged and older adults (≥45 years) with major trauma were followed up at 24 months postinjury. Logistic regression (univariable and multivariable) analyses were used to determine the association between diabetes status and 24-month patient-reported outcomes. In-hospital outcomes were compared between groups using χ2 tests. RESULTS Of the 11,490 participants who survived to hospital discharge, 8,493 survived to 24 months postinjury and were followed up at that time point: 953 people (11%) with and 7540 (89%) without T2D. People with T2D had a higher in-hospital death rate (19%) compared with people without T2D (16%; p < 0.001). After adjusting for confounders, people with T2D had poorer outcomes 24 months postinjury than people without T2D, with respect to functional recovery (Glasgow Outcome Scale Extended) (adjusted odds ratio [AOR], 0.58; 95% confidence interval [CI], 0.48-0.69) and return to work/study (AOR, 0.51; 95% CI, 0.37-0.71]). People with T2D experienced higher odds of problems with mobility (AOR, 1.92; 95% CI, 1.60-2.30), self-care (AOR, 1.94; 95% CI, 1.64, 2.29), usual activities (AOR, 1.50; 95% CI, 1.26-1.79), pain and discomfort (AOR, 1.75; 95% CI, 1.49-2.07), anxiety and depression (AOR, 1.45; 95% CI, 1.24, 1.70), and self-reported disability (AOR, 1.51; 95% CI, 1.28-1.79) than people without T2D. CONCLUSION Major trauma patients with T2D have a poorer prognosis than patients without T2D, both during their hospital admission and 24 months postinjury. Patients with T2D may need additional health care and support following trauma to reach their recovery potential. LEVEL OF EVIDENCE Prognostic, level III.
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Affiliation(s)
- Stuart L Daly
- From the School of Public Health and Preventive Medicine (S.L.D., B.J.G., C.L.E.), Monash University; Emergency Medicine (S.L.D., C.L.E.), Alfred Health, Melbourne, VIC, Australia; Health Data Research UK (B.J.G.), Swansea University, Swansea, UK; Farr Institute (B.J.G.), Swansea University Medical School, Swansea University, Swansea, UK; Baker Heart and Diabetes Institute (R.E.C., C.L.E.), Melbourne; Menzies Institute for Medical Research (R.E.C.), University of Tasmania, Hobart, Tasmania, Australia; and Rehabilitation, Ageing and Independent Living (RAIL) Research Centre (C.L.E.), Monash University, Melbourne, VIC, Australia
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López-Rubio C, Koponen M, Lampela P, Taipale H, Tanskanen A, Bell JS, Tolppanen AM, Hartikainen S. Changes in the use of diabetes drugs among community-dwelling people with Alzheimer's disease. BMC Geriatr 2021; 21:701. [PMID: 34911481 PMCID: PMC8672592 DOI: 10.1186/s12877-021-02694-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Accepted: 11/29/2021] [Indexed: 11/10/2022] Open
Abstract
Background Type 2 diabetes is common in persons with Alzheimer’s disease (AD). Management of diabetes in persons with AD is challenging due to changing goals of care and susceptibility to adverse drug events including hypoglycemia. The aim of this study was to investigate the prevalence of diabetes drug use from 5 years before to 5 years after the time of AD diagnosis among persons with and without AD. Methods This was a nationwide register-based study of persons with and without AD and diabetes in Finland. We analyzed data from the Medication Use and Alzheimer’s disease (MEDALZ) study that included 70,718 community-dwelling people diagnosed with AD from 2005 to 2011. The study population included 8418 persons with AD and 6666 matched persons without AD who were diagnosed with diabetes 5 years before AD diagnosis (index date). We defined the prevalence of diabetes drug use in three-month evaluation periods from 5 years before until 5 years after the index date. Results Nearly all people with diabetes (94% in both cohorts) used one or more diabetes drugs on the index date. The most prevalent drug metformin was used by 60.9% of people with AD and 59.1% of people without AD. The next most prevalent drugs were sulfonylureas and insulin. The prevalence of diabetes drug use was similar in people with and without AD but began to decline 1 year after AD diagnosis in the AD cohort compared to non-AD cohort. Conclusions The decline in diabetes drug use after AD diagnosis may be attributed to clinicians and patients seeking to avoid serious adverse drug events including hypoglycemia. In addition, the findings may reflect personalized glycemic control and unintentional weight loss in persons with AD reducing the need for diabetes drugs. Supplementary Information The online version contains supplementary material available at 10.1186/s12877-021-02694-w.
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Affiliation(s)
| | - Marjaana Koponen
- Kuopio Research Centre of Geriatric Care, University of Eastern Finland, Kuopio, Finland.,School of Pharmacy, University of Eastern Finland, PO Box 1627, 70210, Kuopio, Finland.,Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, Victoria, Australia
| | - Pasi Lampela
- Kuopio Research Centre of Geriatric Care, University of Eastern Finland, Kuopio, Finland.,School of Pharmacy, University of Eastern Finland, PO Box 1627, 70210, Kuopio, Finland
| | - Heidi Taipale
- School of Pharmacy, University of Eastern Finland, PO Box 1627, 70210, Kuopio, Finland.,Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.,Department of Forensic Psychiatry, Niuvanniemi Hospital, University of Eastern Finland, Kuopio, Finland
| | - Antti Tanskanen
- Department of Forensic Psychiatry, Niuvanniemi Hospital, University of Eastern Finland, Kuopio, Finland
| | - J Simon Bell
- School of Pharmacy, University of Eastern Finland, PO Box 1627, 70210, Kuopio, Finland.,Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, Victoria, Australia
| | - Anna-Maija Tolppanen
- Kuopio Research Centre of Geriatric Care, University of Eastern Finland, Kuopio, Finland.,School of Pharmacy, University of Eastern Finland, PO Box 1627, 70210, Kuopio, Finland
| | - Sirpa Hartikainen
- Kuopio Research Centre of Geriatric Care, University of Eastern Finland, Kuopio, Finland. .,School of Pharmacy, University of Eastern Finland, PO Box 1627, 70210, Kuopio, Finland.
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10
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Komorita Y, Ohkuma T, Iwase M, Fujii H, Oku Y, Higashi T, Oshiro A, Sakamoto W, Yoshinari M, Nakamura U, Kitazono T. Polypharmacy and bone fracture risk in patients with type 2 diabetes: The Fukuoka Diabetes Registry. Diabetes Res Clin Pract 2021; 181:109097. [PMID: 34678390 DOI: 10.1016/j.diabres.2021.109097] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Revised: 10/06/2021] [Accepted: 10/13/2021] [Indexed: 10/20/2022]
Abstract
AIMS To prospectively investigate the association between the number of prescribed drugs and the fracture risk in patients with type 2 diabetes. METHODS Japanese participants with type 2 diabetes (n = 4,706; 2,755 men, 1,951 postmenopausal women; mean age, 66 years) were followed for a median of 5.3 years and grouped on the basis of the number of prescribed drugs at baseline. The main outcomes were fractures at any anatomic site and fragility fractures (fractures at hip and spine sites). RESULTS During follow-up, any fracture occurred in 662 participants. The overall age- and sex-adjusted fracture incidence rates per 1,000 person-years were 21.2 (0-2 drugs), 28.1 (3-5 drugs), 37.7 (6-8 drugs), and 44.0 (≥9 drugs) (p for trend < 0.001). Compared with 0-2 drugs, the multivariate-adjusted hazard ratios (HRs) (95% confidence intervals [CIs]) for fractures were 1.34 (1.07-1.68) for 3-5 drugs, 1.76 (1.37-2.26) for 6-8 drugs, and 1.71 (1.27-2.31) in ≥ 9 drugs. The multivariate-adjusted HR (95% CI) per increment in drugs was 1.05 (1.02-1.08) (p < 0.001). Similar tendencies were observed for fragility fractures. CONCLUSIONS A greater number of prescribed drugs is associated with an increased bone fracture risk in patients with type 2 diabetes.
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Affiliation(s)
- Yuji Komorita
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Toshiaki Ohkuma
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Masanori Iwase
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan; Diabetes Center, Hakujyuji Hospital, Fukuoka, Japan.
| | - Hiroki Fujii
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Yutaro Oku
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Taiki Higashi
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Ayaka Oshiro
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Wakako Sakamoto
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Masahito Yoshinari
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Udai Nakamura
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan; Diabetes Center, Steel Memorial Yawata Hospital, Kitakyushu, Japan
| | - Takanari Kitazono
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
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11
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Kieu A, Govender RD, Östlundh L, King J. Benefits of the addition of continuous or flash glucose monitoring versus standard practice using self-monitored blood glucose and haemoglobin A1c in the primary care of diabetes mellitus: a systematic review protocol. BMJ Open 2021; 11:e050027. [PMID: 34446495 PMCID: PMC8395264 DOI: 10.1136/bmjopen-2021-050027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION Studies demonstrate that optimal glycaemic control reduces morbidity from diabetes mellitus but remains elusive in a significant portion of patients. Although research shows that continuous glucose monitoring (CGM) and flash glucose monitoring (FGM) improves glycaemic control in selected subsets of patients with diabetes in specialty practices, we found no systematic reviews evaluating the use of CGM/FGM in primary care, where the majority of patients with diabetes are cared for.This systematic review aims to answer the questions: 'compared with usual care of self-monitoring blood glucose and haemoglobin A1c (HbA1c), does the addition of CGM/FGM use in the primary care of patients with diabetes improve glycaemic control, decrease rates of hypoglycaemia, and improve patient and physician satisfaction?' and if so, 'what subgroups of primary care patients with diabetes are most likely to benefit?'. METHODS AND ANALYSIS Aligning with the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols guidelines, a search will be conducted in PubMed, EMBASE, Scopus, CINAHL, Cochrane Central Register of Controlled Trials and Web of Science. We will include studies investigating CGM/FGM use and reporting the primary outcome measure of HbA1c and secondary outcome measures of hypoglycaemia, time in range, time below range, time above range and patient/staff satisfaction. We will examine which patient populations appear to benefit from CGM/FGM. Three independent researchers will use the Covidence systematic review software for blinded screening and study selection. The National Heart, Lung, and Blood Institute quality assessment tool and Grading of Recommendations Assessment, Development and Evaluation will be used to assess the risk of bias and quality of evidence. ETHICS AND DISSEMINATION The systematic review methodology does not require ethics approval due to the nature of the study design. Study findings will be publicly available to a wide readership across disciplines and will be published in a peer-reviewed journal. PROSPERO REGISTRATION NUMBER CRD42021229416.
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Affiliation(s)
- Alexander Kieu
- Department of Family Medicine, United Arab Emirates University, Al Ain, UAE
- Department of Family Medicine, Kanad Hospital, Al Ain, UAE
| | | | - Linda Östlundh
- National Medical Library, United Arab Emirates University, Al Ain, UAE
| | - Jeffrey King
- Department of Family Medicine, United Arab Emirates University, Al Ain, UAE
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12
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Sugimoto T, Araki A, Fujita H, Honda K, Inagaki N, Ishida T, Kato J, Kishi M, Kobayashi K, Kouyama K, Noma H, Ohishi M, Satoh-Asahara N, Shimada H, Sugimoto K, Suzuki S, Takeya Y, Tamura Y, Tokuda H, Umegaki H, Watada H, Yamada Y, Sakurai T. The Multi-Domain Intervention Trial in Older Adults With Diabetes Mellitus for Prevention of Dementia in Japan: Study Protocol for a Multi-Center, Randomized, 18-Month Controlled Trial. Front Aging Neurosci 2021; 13:680341. [PMID: 34322009 PMCID: PMC8312849 DOI: 10.3389/fnagi.2021.680341] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2021] [Accepted: 05/31/2021] [Indexed: 11/13/2022] Open
Abstract
Background: The Japan-Multi-domain Intervention Trial for Prevention of Dementia in Older Adults with Diabetes (J-MIND-Diabetes) is an 18-month, multi-centered, open-labeled, randomized controlled trial designed to identify whether multi-domain intervention targeting modifiable risk factors for dementia could prevent the progression of cognitive decline among older adults with type 2 diabetes mellitus (T2DM). This manuscript describes the study protocol for the J-MIND-Diabetes trial. Materials and Methods: Subjects of this trial will comprise a total of 300 T2DM outpatients aged 70-85 years with mild cognitive impairment. Subjects will be centrally randomized into intervention and control groups at a 1:1 allocation ratio using the stratified permuted-block randomization methods. The intervention group will participate in multi-domain intervention programs aimed at: (1) management of metabolic and vascular risk factors; (2) physical exercise and self-monitoring of physical activity; (3) nutritional guidance; and (4) social participation. The control group will receive usual T2DM care and general instructions on dementia prevention. The primary and secondary outcomes will be assessed at baseline, at 6- and 18-month follow-up. The primary outcome is change from baseline at 18 months in a global composite score combining several neuropsychological domains, including global cognitive function, memory, attention, executive function, processing speed and language. Secondary outcomes include: (1) cognitive changes in neuropsychological tests; (2) changes in geriatrics assessments; (3) metabolic control and diabetic complications; (4) changes in blood and urinary markers. Discussion: This trial will be the first trial to demonstrate the effectiveness of multi-domain intervention in preventing cognitive decline in older adults with T2DM at increased risk of dementia in Japan. Trial Registration: UMIN000035911; Registered on the University Hospital Medical Information Network Clinical Trials Registry (UMIN-CTR) 18 February 2019. (https://upload.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R000040908).
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Affiliation(s)
- Taiki Sugimoto
- Center for Comprehensive Care and Research on Memory Disorders, National Center for Geriatrics and Gerontology, Obu, Japan.,Medical Genome Center, National Center for Geriatrics and Gerontology, Obu, Japan
| | - Atsushi Araki
- Department of Diabetes, Metabolism, and Endocrinology, Tokyo Metropolitan Geriatric Hospital, Tokyo, Japan
| | - Hiroki Fujita
- Department of Endocrinology, Diabetes and Geriatric Medicine, Akita University Graduate School of Medicine, Akita, Japan
| | - Keiko Honda
- Department of Medical Nutrition, Kagawa Nutrition University, Saitama, Japan
| | - Nobuya Inagaki
- Department of Diabetes, Endocrinology and Nutrition, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Takeshi Ishida
- Department of Internal Medicine, Saitama Citizens Medical Center, Saitama, Japan
| | - Junichi Kato
- Department of Internal Medicine, Hyogo Prefectural Rehabilitation Center at Nishi-Harima, Tatsuno, Japan
| | - Minoru Kishi
- Department of Internal Medicine, Nishiwaki Municipal Hospital, Nishiwaki, Japan
| | - Kazuki Kobayashi
- Department of Diabetes and Metabolic Disease, Asahi General Hospital, Chiba, Japan
| | - Kunichi Kouyama
- Department of Diabetes Medicine, Hyogo-Chuo National Hospital, Sanda, Japan
| | - Hisashi Noma
- Department of Data Science, Institute of Statistical Mathematics, Tokyo, Japan
| | - Mitsuru Ohishi
- Department of Cardiovascular Medicine and Hypertension, Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima, Japan
| | - Noriko Satoh-Asahara
- Department of Endocrinology, Metabolism, and Hypertension Research, Clinical Research Institute National Hospital Organization, Kyoto Medical Center, Kyoto, Japan
| | - Hiroyuki Shimada
- Center for Gerontology and Social Science, National Center for Geriatrics and Gerontology, Obu, Japan
| | | | - Susumu Suzuki
- Diabetes Center, Ohta Nishinouchi Hospital, Koriyama, Japan
| | - Yasushi Takeya
- Department of Geriatric and General Medicine, Osaka University Graduate School of Medicine, Suita, Japan
| | - Yoshiaki Tamura
- Department of Diabetes, Metabolism, and Endocrinology, Tokyo Metropolitan Geriatric Hospital, Tokyo, Japan
| | - Haruhiko Tokuda
- Medical Genome Center, National Center for Geriatrics and Gerontology, Obu, Japan.,Department of Clinical Laboratory, National Center for Geriatrics and Gerontology, Obu, Japan
| | - Hiroyuki Umegaki
- Department of Community Healthcare and Geriatrics, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Hirotaka Watada
- Department of Metabolism and Endocrinology, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Yuichiro Yamada
- Department of Endocrinology, Diabetes and Geriatric Medicine, Akita University Graduate School of Medicine, Akita, Japan
| | - Takashi Sakurai
- Center for Comprehensive Care and Research on Memory Disorders, National Center for Geriatrics and Gerontology, Obu, Japan.,Department of Cognition and Behavior Science, Nagoya University Graduate School of Medicine, Nagoya, Japan
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13
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Gadsby R. Operationalising individualised glycaemic targets in older people with diabetes. J Diabetes Complications 2021; 35:107872. [PMID: 33558150 DOI: 10.1016/j.jdiacomp.2021.107872] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2021] [Revised: 01/20/2021] [Accepted: 01/20/2021] [Indexed: 10/22/2022]
Affiliation(s)
- Roger Gadsby
- Warwick Medical School, University of Warwick Coventry, UK.
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14
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Echouffo-Tcheugui JB, Daya N, Lee AK, Tang O, Ndumele CE, Windham BG, Shah AM, Selvin E. Severe Hypoglycemia, Cardiac Structure and Function, and Risk of Cardiovascular Events Among Older Adults With Diabetes. Diabetes Care 2021; 44:248-254. [PMID: 33199469 PMCID: PMC7783928 DOI: 10.2337/dc20-0552] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Accepted: 10/14/2020] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To assess the association of severe hypoglycemia measured at baseline with cardiovascular disease (CVD) among community-dwelling older individuals with diabetes, a group particularly susceptible to hypoglycemia. RESEARCH DESIGN AND METHODS We included older adults with diabetes from the Atherosclerosis Risk in Communities (ARIC) study who attended visit 5 (2011-2013, baseline). Severe hypoglycemia at baseline was defined with use of first position ICD-9 codes from hospitalizations, emergency department visits, and ambulance calls. We examined cross-sectional associations of severe hypoglycemia with echocardiographic indices of cardiac structure-function. We prospectively evaluated the risks of incident or recurrent CVD (coronary heart disease, stroke, or heart failure) and all-cause mortality, from baseline to 31 December 2018, using negative binomial and Cox regression models. RESULTS Among 2,193 participants (mean [SD] age 76 [5] years, 57% female, 32% Blacks), 79 had a history of severe hypoglycemia at baseline. Severe hypoglycemia was associated with a lower left ventricular (LV) ejection fraction (adjusted β-coefficient -3.66% [95% CI -5.54, -1.78]), higher LV end diastolic volume (14.80 mL [95% CI 8.77, 20.84]), higher E-to-A ratio (0.11 [95% CI 0.03, 0.18]), and higher septal E/e' (2.48 [95% CI 1.13, 3.82]). In adjusted models, severe hypoglycemia was associated with incident or recurrent CVD (incidence rate ratio 2.19 (95% CI 1.24, 3.88]) and all-cause mortality (hazard ratio 1.71 [95% CI 1.10, 2.67]) among those without prevalent CVD. CONCLUSIONS Our findings suggest that a history of severe hypoglycemia is associated with alterations in cardiac function and is an important marker of future cardiovascular risk in older adults.
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Affiliation(s)
- Justin B Echouffo-Tcheugui
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, Johns Hopkins University, Baltimore, MD
| | - Natalie Daya
- Department of Epidemiology and Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Alexandra K Lee
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco, CA
| | - Olive Tang
- Department of Epidemiology and Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Chiadi E Ndumele
- Division of Cardiology, Department of Medicine, Johns Hopkins University, Baltimore, MD
| | - B Gwen Windham
- Division of Geriatrics, Department of Medicine, University of Mississippi Medical Center, Jackson, MS
| | - Amil M Shah
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, MA
| | - Elizabeth Selvin
- Department of Epidemiology and Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
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15
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Mattishent K, Loke YK. Meta-Analysis: Association Between Hypoglycemia and Serious Adverse Events in Older Patients Treated With Glucose-Lowering Agents. Front Endocrinol (Lausanne) 2021; 12:571568. [PMID: 33763024 PMCID: PMC7982741 DOI: 10.3389/fendo.2021.571568] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Accepted: 01/11/2021] [Indexed: 12/17/2022] Open
Abstract
AIMS We conducted a meta-analysis of serious adverse events (dementia, macro- and micro-vascular events, falls and fractures, and death) associated with hypoglycemia in older patients treated with glucose lowering drugs. MATERIALS AND METHODS Meta-analysis of studies reporting on hypoglycemia and adverse events. The search included studies from two previously published systematic reviews, and an updated search of MEDLINE and EMBASE from April 2014 to November 2019. We assessed study validity based on ascertainment of hypoglycemia, adverse events and adjustment for confounders, and conducted a random effects meta-analyses, assessing heterogeneity using the I2 statistic. RESULTS We included 44 studies involving 2,507,434 participants. Most of the studies used adjusted analysis for confounders and hypoglycaemic events were typically identified based on healthcare databases (severe events). Hypoglycemia was associated with increased likelihood of death in a meta-analysis of eighteen studies, pooled OR 2.02 (95% Confidence Interval 1.75-2.32). Studies assessing mortality signal a time-response relationship with a higher risk of adverse events occurring within the first 90 days after hypoglycemia. Our meta-analysis of nine studies demonstrated that hypoglycaemic episodes were associated with dementia - pooled OR 1.50 (95% CI 1.29-1.74). Our meta-analysis of nineteen studies demonstrated associations between hypoglycaemia and macrovascular complications, pooled OR 1.81 (95% CI 1.70-1.94), and microvascular complications (two studies) pooled OR 1.77 (95% CI 1.49-2.10). There is also an association between hypoglycemia and cardiovascular death (six studies) - pooled OR 2.11 (95% CI 1.55 to 2.87). Similarly, our meta-analysis of six studies demonstrated an association between hypoglycemia and falls and fractures, pooled OR 1.78 (95% CI 1.44-2.21) and 1.68 (95% CI 1.37-2.07) respectively. CONCLUSION This meta-analysis confirms previously reported concerns of serious harm following hypoglycemia, especially in the immediate time period after a hypoglycaemic event. Avoidance of hypoglycaemic episodes should be a priority in this vulnerable population.
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16
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Everett CC, Reynolds C, Fernandez C, Stocken DD, Sharples LD, Sathyapalan T, Heller S, Storey RF, Ajjan RA. Rationale and design of the LIBERATES trial: Protocol for a randomised controlled trial of flash glucose monitoring for optimisation of glycaemia in individuals with type 2 diabetes and recent myocardial infarction. Diab Vasc Dis Res 2020; 17:1479164120957934. [PMID: 33081502 PMCID: PMC7919208 DOI: 10.1177/1479164120957934] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Hyperglycaemia in individuals with type 2 diabetes (T2D) and myocardial infarction (MI) is associated with guarded clinical prognosis. Studies improving glucose levels in T2D following MI relied on HbA1c as the main glycaemic marker, failing to address potential adverse effects of hypoglycaemia and glucose variability. We describe the design of the LIBERATES trial that investigates the role of flash glucose monitoring in optimising glycaemic markers in high vascular risk individuals with T2D. This multicentre trial is designed to recruit up to 150 insulin and/or sulphonylurea-treated T2D patients, within 5 days of a proven MI. Individuals will be randomised 1:1 into intervention and control groups using flash glucose monitoring sensors and traditional self-monitoring of blood glucose, respectively. The control group will also wear a blinded continuous glucose monitoring sensor. The primary outcome is the difference in time spent in euglycaemia (defined as glucose levels between 3.9-10.0 mmol/l), comparing study groups 3 months following recruitment, assessed daily for 14 days and as an average. Secondary and exploratory end points include time spent in hypoglycaemia and hyperglycaemia, HbA1c, quality of life measures, major adverse cardiac events and cost-effectiveness of the intervention. This study will establish the role of flash glucose monitoring in glycaemic management of individuals with T2D sustaining a cardiac event.(Trial Registration: ISRCTN14974233, registered 12th June 2017).
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Affiliation(s)
- Colin C Everett
- Clinical Trials Research Unit, University of Leeds, Leeds, West Yorkshire, UK
| | - Catherine Reynolds
- Clinical Trials Research Unit, University of Leeds, Leeds, West Yorkshire, UK
| | - Catherine Fernandez
- Clinical Trials Research Unit, University of Leeds, Leeds, West Yorkshire, UK
| | - Deborah D Stocken
- Clinical Trials Research Unit, University of Leeds, Leeds, West Yorkshire, UK
| | - Linda D Sharples
- London School of Hygiene and Tropical Medicine, University of London, Bloomsbury, London, UK
| | | | - Simon Heller
- Department of Oncology and Metabolism, Sheffield Teaching Hospitals Trust, Sheffield, South Yorkshire, UK
| | - Robert F Storey
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, South Yorkshire, UK
| | - Ramzi A Ajjan
- Leeds Institute for Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, West Yorkshire, UK
- Department of Diabetes and Endocirnology, Leeds Teaching Hospitals Trust, Leeds, West Yorkshire, UK
- Ramzi A Ajjan, Leeds Institute for Cardiovascular and Metabolic Medicine, University of Leeds, The LIGHT Laboratories, Clarendon Way, Leeds, West Yorkshire LS2 9JT, UK.
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17
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Bollig C, Torbahn G, Bauer J, Brefka S, Dallmeier D, Denkinger M, Eidam A, Klöppel S, Zeyfang A, Voigt-Radloff S. Evidence gap on antihyperglycemic pharmacotherapy in frail older adults : A systematic review. Z Gerontol Geriatr 2020; 54:278-284. [PMID: 32303827 PMCID: PMC8096761 DOI: 10.1007/s00391-020-01724-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Accepted: 03/25/2020] [Indexed: 12/13/2022]
Abstract
Background Although antihyperglycemic pharmacotherapy in frail older adults with type 2 diabetes mellitus (T2DM) is challenging, recommendations from international guidelines are mainly based on indirect evidence from trials not including frail participants. Objective This systematic review investigated the effectiveness and safety of pharmacotherapy in frail older adults with T2DM. Material and methods Randomized (RCT) and non-randomized prospective clinical trials (non-RCT) were searched in three electronic databases (Medline, Embase, Central) up to October 2018. Trials in older adults with T2DM who were assessed as significantly or severely impaired by defined cut-off scores of assessment instruments on frailty, activities of daily living or physical functional impairment were included. Results Two reviewers independently screened 17,391 references for inclusion and assessed risk of bias with ROBINS‑I. Five non-RCTs and no RCT were identified. Treatment of T2DM without insulin compared to insulin could be associated with increased improvement in cardiac functions in patients with cardiac resynchronization therapy and with decreased falls in frail older women. While better glycemic control with low variability and low HbA1c (hemoglobin A1c) values (<7%) was associated with better maintenance of physical function in community-dwelling older persons, higher HbA1c values (8–8.9%) were associated with a reduction in the composite outcome of death or functional decline in community-dwelling diabetic older adults with need for skilled assistance. Due to serious risk of bias in all studies, results should be considered with caution. Conclusion Well-designed, large-scale RCTs including this important group of patients are required to assess the effectiveness and safety of pharmacotherapy and HbA1c targets. Electronic supplementary material The online version of this article (10.1007/s00391-020-01724-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Claudia Bollig
- Institute for Evidence in Medicine, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Hugstetter Str. 49, 79106, Freiburg, Germany. .,Cochrane Germany, Cochrane Germany Foundation, Freiburg, Germany.
| | - Gabriel Torbahn
- Institute for Evidence in Medicine, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Hugstetter Str. 49, 79106, Freiburg, Germany.,Institute for Biomedicine of Aging, Friedrich-Alexander-Universität Erlangen-Nürnberg, Nuremberg, Germany
| | - Jürgen Bauer
- Center for Geriatric Medicine, University of Heidelberg and Agaplesion Bethanien Hospital, Heidelberg, Germany
| | - Simone Brefka
- Agaplesion Bethesda Clinic, Geriatric Research Unit Ulm University, Ulm, Germany
| | - Dhayana Dallmeier
- Agaplesion Bethesda Clinic, Geriatric Research Unit Ulm University, Ulm, Germany
| | - Michael Denkinger
- Agaplesion Bethesda Clinic, Geriatric Research Unit Ulm University, Ulm, Germany
| | - Annette Eidam
- Center for Geriatric Medicine, University of Heidelberg and Agaplesion Bethanien Hospital, Heidelberg, Germany
| | - Stefan Klöppel
- University Hospital of Old Age Psychiatry and Psychotherapy, University of Bern, Bern, Switzerland
| | - Andrej Zeyfang
- Department of Epidemiology, University of Ulm, Ulm, Germany
| | - Sebastian Voigt-Radloff
- Institute for Evidence in Medicine, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Hugstetter Str. 49, 79106, Freiburg, Germany. .,Center for Geriatric Medicine and Gerontology Freiburg, Medical Center Faculty of Medicine, University of Freiburg, Freiburg, Germany.
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18
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Dimitrios P, Michael D, Vasilios K, Konstantinos S, Konstantinos I, Ioanna Z, Konstantinos P, Spyridon B, Asterios K. Liraglutide as Adjunct to Insulin Treatment in Patients with Type 1 Diabetes: A Systematic Review and Meta-analysis. Curr Diabetes Rev 2020; 16:313-326. [PMID: 31203802 DOI: 10.2174/1573399815666190614141918] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2019] [Revised: 03/24/2019] [Accepted: 05/03/2019] [Indexed: 02/08/2023]
Abstract
BACKGROUND A few Randomized Controlled Trials (RCTs) have evaluated the use of liraglutide in Type 1 Diabetes (T1D). Through the present systematic review and meta-analysis, we aim at critically appraising and summarizing those RCTs, providing precise effect estimates. METHODS We searched major databases and grey literature from their inception to October 2018, for RCTs with a duration ≥ 12 weeks, comparing liraglutide with placebo or any other comparator as adjunct to insulin in patients with T1D, investigating major efficacy and safety endpoints. This review is reported in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) statement. RESULTS We included 5 trials with 2,445 randomized participants. Liraglutide provided modest reductions in HbA1c, with liraglutide 1.8 mg producing the greatest decrease (MD = -0.24%, 95% CI -0.32 to -0.16, I2=0%). Significant weight reduction, up to 4.87 kg with liraglutide 1.8 mg was also observed (95% CI -5.31 to -4.43, I2=0%). Decrease in total daily insulin dose, primarily driven by a decrease in bolus insulin requirements, was demonstrated. Liraglutide decreased non-significantly the odds for severe hypoglycemia (OR=0.80, 95% CI 0.57-1.14, I2=0%), while it increased significantly the odds for gastrointestinal adverse events (for nausea, OR=4.70, 95% CI 3.68-6.00, I2=37%, and for vomiting, OR=2.50, 95% CI 1.54-4.72, I2=27%). A significant increase in heart rate was also demonstrated. No association with diabetic ketoacidosis or malignancies was identified. CONCLUSION In patients with T1D, liraglutide might prove be an adjunct to insulin, improving glycemic control, inducing body weight loss and decreasing exogenous insulin requirements and severe hypoglycemia.
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Affiliation(s)
- Patoulias Dimitrios
- Second Propedeutic Department of Internal Medicine, General Hospital "Hippokration", Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Doumas Michael
- Second Propedeutic Department of Internal Medicine, General Hospital "Hippokration", Aristotle University of Thessaloniki, Thessaloniki, Greece
- VAMC and George Washington University, Washington, DC, United States
| | - Kotsis Vasilios
- Third Department of Internal Medicine, General Hospital "Papageorgiou", Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Stavropoulos Konstantinos
- Second Propedeutic Department of Internal Medicine, General Hospital "Hippokration", Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Imprialos Konstantinos
- Second Propedeutic Department of Internal Medicine, General Hospital "Hippokration", Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Zografou Ioanna
- Second Propedeutic Department of Internal Medicine, General Hospital "Hippokration", Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Petidis Konstantinos
- Second Propedeutic Department of Internal Medicine, General Hospital "Hippokration", Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Bakatselos Spyridon
- First Department of Internal Medicine, General Hospital "Hippokration", Thessaloniki, Greece
| | - Karagiannis Asterios
- Second Propedeutic Department of Internal Medicine, General Hospital "Hippokration", Aristotle University of Thessaloniki, Thessaloniki, Greece
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19
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Mattishent K, Lane K, Salter C, Dhatariya K, May HM, Neupane S, Loke YK. Continuous glucose monitoring in older people with diabetes and memory problems: a mixed-methods feasibility study in the UK. BMJ Open 2019; 9:e032037. [PMID: 31740472 PMCID: PMC6937046 DOI: 10.1136/bmjopen-2019-032037] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Abstract
OBJECTIVES Older people with diabetes are at increased risk of harm from hypoglycaemia, particularly where there are coexisting memory problems. Continuous glucose monitoring (CGM) offers important benefits in terms of detecting hypoglycaemia, but the feasibility of use and extent of data capture has not been tested in this patient group. Our objective was to investigate the feasibility of trialling a CGM intervention in the community setting in older people with diabetes and memory problems. DESIGN Mixed-methods feasibility study. SETTING Community dwellings in the UK. PARTICIPANTS Patients aged ≥65 with diabetes and abbreviated mental test score ≤8 or known dementia. INTERVENTION FreeStyle Libre CGM. PRIMARY AND SECONDARY OUTCOME MEASURES Feasibility criteria were numbers of eligible patients, recruitment, attrition, extent of capture of glucose readings and adverse events. Qualitative interview. RESULTS We identified 49 eligible participants; 17 consented, but 5 withdrew before recording of data because they or their carers felt unable to manage study procedures. 12 participants (mean age 85 years) completed the study without adverse events. Data capture across 14 days ranged between 3% and 92% (mean 55%); 6 participants had <60% capture. Hypoglycaemic events were recorded in six out of nine insulin users. Qualitative interviews found: the device does not interfere with daily activities, usability and comfort was positive, and it was helpful for carers in monitoring participants' glucose concentrations. CONCLUSIONS The device was acceptable to participants, and carers reported greater ease in monitoring the participant's glucose concentrations. However, completeness of data capture varied considerably with this device due to the need for users to conduct ≥3 scans per day. Real-time devices with automated data transfer may be more suitable in older people with memory problems.
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Affiliation(s)
| | - Kathleen Lane
- Norwich Medical School, University of East Anglia, Norwich, UK
| | | | - Ketan Dhatariya
- Elsie Bertram Diabetes Centre, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, Norfolk, UK
| | - Helen M May
- Older People's Medicine, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, Norfolk, UK
| | - Sankalpa Neupane
- Elsie Bertram Diabetes Centre, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, Norfolk, UK
| | - Yoon K Loke
- Norwich Medical School, University of East Anglia, Norwich, UK
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20
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Mattishent K, Richardson K, Dhatariya K, Savva GM, Fox C, Loke YK. The effects of hypoglycaemia and dementia on cardiovascular events, falls and fractures and all-cause mortality in older individuals: A retrospective cohort study. Diabetes Obes Metab 2019; 21:2076-2085. [PMID: 31069922 DOI: 10.1111/dom.13769] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Revised: 04/23/2019] [Accepted: 05/05/2019] [Indexed: 11/30/2022]
Abstract
AIMS Older individuals with diabetes are susceptible to harm as the result of hypoglycaemia; however, the consequences of hypoglycaemia in older individuals with dementia are not known. We aimed to test the association between hypoglycaemia and serious adverse events in older patients with diabetes and dementia, and whether the consequences of hypoglycaemia were affected by the presence of dementia. MATERIALS AND METHODS This was a cohort study using the Clinical Practice Research Datalink in England (1997-2016). We selected participants, intervention (exposure) and follow-up to mirror two hypothetical target randomized controlled trials. The exposure of target trial 1 was hypoglycaemia in patients with dementia. Target trial 2 examined adverse effects of hypoglycaemia according to dementia status. We used Cox proportional hazard regression to estimate adjusted hazard ratios (aHR) for falls, fractures, cardiovascular events and mortality. RESULTS In target trial 1, hypoglycaemia was associated with increased risk during a 12-month follow-up period for falls and fractures (aHR, 1.94 [95% CI, 1.67-2.24]), for cardiovascular events (aHR, 2.00 [95% CI, 1.61-2.48]) and for mortality (aHR, 2.36 [95% CI, 2.09-2.67]). In target trial 2, the presence of dementia was associated with increased risk of adverse events, following hypoglycaemia, during a 12-month follow-up period for falls and factures (aHR, 1.72 [95% CI, 1.51-1.96]) and for mortality (aHR, 1.27 [95% CI, 1.15-1.41]), but dementia had no effect on cardiovascular events (aHR, 1.14 [95% CI, 0.95 to 1.36]). CONCLUSIONS Hypoglycaemia is associated with early increased risk of serious adverse events in older individuals with diabetes and dementia.
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Affiliation(s)
| | | | - Ketan Dhatariya
- Department of Diabetes and Endocrinology, Norfolk and Norwich University Hospital NHS Foundation Trust, Norwich, UK
| | - George M Savva
- Quadram Institute Bioscience, Norwich Research Park, Norwich, UK
| | - Chris Fox
- Norwich Medical School, University of East Anglia, Norwich, UK
| | - Yoon K Loke
- Norwich Medical School, University of East Anglia, Norwich, UK
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21
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Hambling CE, Khunti K, Cos X, Wens J, Martinez L, Topsever P, Del Prato S, Sinclair A, Schernthaner G, Rutten G, Seidu S. Factors influencing safe glucose-lowering in older adults with type 2 diabetes: A PeRsOn-centred ApproaCh To IndiVidualisEd (PROACTIVE) Glycemic Goals for older people: A position statement of Primary Care Diabetes Europe. Prim Care Diabetes 2019; 13:330-352. [PMID: 30792156 DOI: 10.1016/j.pcd.2018.12.005] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2018] [Revised: 12/17/2018] [Accepted: 12/28/2018] [Indexed: 12/23/2022]
Abstract
Diabetes in later life is associated with a range of factors increasing the complexity of glycaemic management. This position statement, developed from an extensive literature review of the subject area, represents a consensus opinion of primary care clinicians and diabetes specialists. It highlights many challenges facing older people living with type 2 diabetes and aims to support primary care clinicians in advocating a comprehensive, holistic approach. It emphasises the importance of the wishes of the individual and their carers when determining glycaemic goals, as well as the need to balance intended benefits of treatment against the risk of adverse treatment effects. Its ultimate aim is to promote consistent high-quality care for older people with diabetes.
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Affiliation(s)
- C E Hambling
- Department of Public Health and Primary Care, School of Clinical Medicine, Box 285, Cambridge Biomedical Campus, Cambridge, CB2 0SR, United Kingdom; Diabetes Research Centre, University of Leicester, Leicester General Hospital, Gwendolen Road, Leicester, LE5 4PW, United Kingdom.
| | - K Khunti
- Diabetes Research Centre, University of Leicester, Leicester General Hospital, Gwendolen Road, Leicester, LE5 4PW, United Kingdom
| | - X Cos
- Sant Marti de Provençals Primary Care Centres, Institut Català de la Salut, University Research Institute in Primary Care (IDIAP Jordi Gol), Barcelona, Spain
| | - J Wens
- Department of Medicine and Health Sciences, Primary and Interdisciplinary Care Antwerp, University of Antwerp, Antwerp, Belgium
| | - L Martinez
- Department of General Medicine, Pierre and Marie Curie University, Paris, France
| | - P Topsever
- Department of Family Medicine, Acibadem Mehmet Ali Aydinlar University School of Medicine, Kerem Aydinlar Campus, 34752 Atasehir, Istanbul, Turkey
| | - S Del Prato
- Department of Clinical and Experimental Medicine, Section of Diabetes, University of Pisa, Pisa, Italy
| | - A Sinclair
- Foundation for Diabetes Research in Older People (FDROP), Diabetes Frail, Luton, United Kingdom
| | - G Schernthaner
- Department of Medicine 1, Rudolfstiftung Hospital, Juchgasse 25, 1030 Vienna, Austria
| | - G Rutten
- Julius Center for Health Sciences and Primary Care, University Medical Center, Utrecht, University, Utrecht, the Netherlands
| | - S Seidu
- Diabetes Research Centre, University of Leicester, Leicester General Hospital, Gwendolen Road, Leicester, LE5 4PW, United Kingdom
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22
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Sugimoto T, Ono R, Kimura A, Saji N, Niida S, Toba K, Sakurai T. Impact of Glycemic Control on Daily Living Activities Over 1-Year Follow-up in Memory Clinic Patients With Diabetes. J Am Med Dir Assoc 2019; 20:792-794. [PMID: 31043357 DOI: 10.1016/j.jamda.2019.03.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2019] [Revised: 03/06/2019] [Accepted: 03/10/2019] [Indexed: 01/21/2023]
Affiliation(s)
- Taiki Sugimoto
- Center for Comprehensive Care and Research on Memory Disorders, National Center for Geriatrics and Gerontology, Obu, Japan; Medical Genome Center, National Center for Geriatrics and Gerontology, Obu, Japan; Department of Community Health Sciences, Kobe University, Graduate School of Health Sciences, Kobe, Japan; Japan Society for the Promotion of Science, Tokyo, Japan
| | - Rei Ono
- Department of Community Health Sciences, Kobe University, Graduate School of Health Sciences, Kobe, Japan
| | - Ai Kimura
- Center for Comprehensive Care and Research on Memory Disorders, National Center for Geriatrics and Gerontology, Obu, Japan; Medical Genome Center, National Center for Geriatrics and Gerontology, Obu, Japan; Department of Cognition and Behavior Science, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Naoki Saji
- Center for Comprehensive Care and Research on Memory Disorders, National Center for Geriatrics and Gerontology, Obu, Japan
| | - Shumpei Niida
- Medical Genome Center, National Center for Geriatrics and Gerontology, Obu, Japan
| | - Kenji Toba
- Center for Comprehensive Care and Research on Memory Disorders, National Center for Geriatrics and Gerontology, Obu, Japan
| | - Takashi Sakurai
- Center for Comprehensive Care and Research on Memory Disorders, National Center for Geriatrics and Gerontology, Obu, Japan; Department of Cognition and Behavior Science, Nagoya University Graduate School of Medicine, Nagoya, Japan
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23
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Abdelhafiz AH, Sinclair AJ. Cognitive Frailty in Older People with Type 2 Diabetes Mellitus: the Central Role of Hypoglycaemia and the Need for Prevention. Curr Diab Rep 2019; 19:15. [PMID: 30806826 DOI: 10.1007/s11892-019-1135-4] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
PURPOSE OF REVIEW To highlight the central role of hypoglycaemia in the causation of cognitive frailty and explore ways of recognition and prevention of hypoglycaemia. RECENT FINDINGS Cognitive frailty is an emerging new concept defined as the concomitant presence of physical frailty and cognitive impairment. In older people with diabetes, cognitive frailty is associated with an increased risk of mortality greater than from either physical frailty or cognitive impairment alone. Hypoglycaemia is directly associated with increased risk of cognitive impairment and physical frailty which are the two components of cognitive frailty. The incidence of hypoglycaemia in older people with diabetes is rising and hypoglycaemia-related hospitalisation has overtaken that of hyperglycaemia. Recognition of hypoglycaemic episodes in old age remains challenging which leads to misdiagnoses and under-reporting. Therefore, hypoglycaemia prevention strategies are needed. Research is still required to investigate whether prevention of hypoglycaemia would lead to a reduction in the incidence of cognitive frailty.
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Affiliation(s)
- A H Abdelhafiz
- Department of Geriatric Medicine, Rotherham General Hospital, Moorgate Road, Rotherham, S60 2UD, UK.
| | - A J Sinclair
- Foundation for Diabetes Research in Older People, Diabetes Frail Ltd, Droitwich Spa, WR9 0QH, UK
- Kings College, London, SE1 9NH, UK
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24
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Zhao Q, Zhou F, Zhang Y, Zhou X, Ying C. Fasting plasma glucose variability levels and risk of adverse outcomes among patients with type 2 diabetes: A systematic review and meta-analysis. Diabetes Res Clin Pract 2019; 148:23-31. [PMID: 30583033 DOI: 10.1016/j.diabres.2018.12.010] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2018] [Revised: 11/11/2018] [Accepted: 12/17/2018] [Indexed: 01/06/2023]
Abstract
AIM This systematic review and meta-analysis assessed the association between fasting plasma glucose (FPG) variability levels and the risk of retinopathy and all-cause mortality in patients with type 2 diabetes. METHODS PubMed and EMBASE were searched to identify studies that evaluated the association between FPG variability and retinopathy and all-cause mortality in patients with type 2 diabetes mellitus. The hazard ratios (HRs) and 95% confidence intervals (CIs) were pooled with the random-effects model. RESULTS Eight studies were included in our meta-analysis. Five studies evaluated the impact of FPG variability on all-cause mortality and showed that high FPG variability was associated with the risk of all-cause mortality (HR 1.28, 95% CI 1.12-1.46; three studies). For median or mean FPG variability levels under 20%, the relationship between all-cause mortality and FPG variability was not significant. Three studies evaluated FPG variability and the risk of diabetic retinopathy and showed that high FPG variability was strongly associated with the risk of retinopathy (odds ratio (OR) = 3.68; 95% CI 1.01-13.4). CONCLUSION High FPG variability levels were positively associated with the risk of retinopathy and all-cause mortality in patients with type 2 diabetes.
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Affiliation(s)
- Qian Zhao
- The Graduate School, Xuzhou Medical University, Xuzhou, Jiangsu 221002, PR China
| | - Fan Zhou
- The Graduate School, Xuzhou Medical University, Xuzhou, Jiangsu 221002, PR China
| | - Yusheng Zhang
- The Graduate School, Xuzhou Medical University, Xuzhou, Jiangsu 221002, PR China
| | - Xiaoyan Zhou
- Laboratory of Morphology, Xuzhou Medical University, Xuzhou, Jiangsu 221004, PR China
| | - Changjiang Ying
- Department of Endocrinology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu 221002, PR China.
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25
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Mattishent K, Loke YK. Detection of asymptomatic drug-induced hypoglycemia using continuous glucose monitoring in older people - Systematic review. J Diabetes Complications 2018; 32:805-812. [PMID: 29887300 DOI: 10.1016/j.jdiacomp.2018.05.005] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2018] [Revised: 04/23/2018] [Accepted: 05/02/2018] [Indexed: 02/03/2023]
Abstract
AIM We conducted a systematic review of the use of continuous glucose monitoring (CGM) in older patients, in order to consolidate the growing evidence base in this area. METHODS Our protocol was registered on PROSPERO (CRD42017068523). We searched SCI Web of Science, Ovid SP MEDLINE and EMBASE from January 2010 to June 2017 for observational studies and randomized controlled trial of CGM in older patients (mean age 65 or older) with diabetes. We excluded studies that involved only hospitalized patients. Two reviewers independently extracted data blood sugar values (in particular, hypoglycemic episodes) captured with the use of CGM. We also assessed adverse events and acceptability of CGM. RESULTS After screening 901 abstracts, we included nine studies with a total of 989 older patients with diabetes. The CGM studies reveal that hypoglycemic episodes were occurring in a sizeable proportion (28-65%) of participants. Most (80-100%) of these episodes were asymptomatic, with some patients spending nearly 2 h per day in the hypoglycemic range. Older people with diabetes found CGM acceptable and experienced improved health-related well-being. CONCLUSION CGM frequently picks up asymptomatic hypoglycemic episodes in older patients with diabetes. Users of CGM report improved well-being, and reduction of diabetes-related stress.
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Affiliation(s)
- K Mattishent
- Norwich Medical School, University of East Anglia, NR4 7UY, United Kingdom.
| | - Y K Loke
- Norwich Medical School, University of East Anglia, NR4 7UY, United Kingdom
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26
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Malawana M, Kerry S, Mathur R, Robson J. HbA1c and hypoglycaemia in intensively treated type 2 diabetes: a retrospective cohort study in primary care. JRSM Open 2018; 9:2054270418773669. [PMID: 30013791 PMCID: PMC6041855 DOI: 10.1177/2054270418773669] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Objective To establish whether low HbA1c is associated with clinical hypoglycaemia among people with type 2 diabetes prescribed insulins or sulphonylureas. Design Retrospective cohort study using routine electronic GP health records collected between January 2013 and December 2015. Setting Three east London Clinical Commissioning Groups. Participants Two cohorts of adults with type 2 diabetes prescribed either (i) insulins with or without other oral antidiabetic medication (n = 6788, 36.4%) or (ii) sulphonylureas with or without other oral antidiabetic medications excluding insulins (n = 11,840, 63.6%). Main outcome measures First clinically recorded hypoglycaemia and all-cause mortality. Hazard ratios (HR) adjusting for age, ethnicity, renal function and comorbidities were calculated using Cox regression models. Results Compared with an HbA1c of 53–63 mmol/mol, the adjusted HR of hypoglycaemia in those with a low HbA1c, below 53 mmol/mol, in the insulin and sulphonylurea cohorts were 1.26 (95% CI, 0.97 to 1.62) and 1.54 (95% CI, 1.27 to 1.87), respectively. Adjusted HRs of all-cause mortality from low HbA1c in the insulin and sulphonylurea cohorts were 1.54 (95% CI, 1.15 to 2.07) and 1.42 (95% CI, 1.11 to 1.81), respectively. Increasing age and renal impairment were also associated with increased hypoglycaemic risk in both cohorts. Conclusions HbA1c below 53 mmol/mol was associated with episodes of clinical hypoglycaemia among people with type 2 diabetes prescribed sulphonylureas, and all-cause mortality in those prescribed insulins and sulphonylureas. These findings support the need for reviewing glycaemic targets and the intensities of treatment in those with low HbA1c prescribed insulins or sulphonylureas to reduce the risk of hypoglycaemia.
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Affiliation(s)
- Manil Malawana
- Centre for Primary Care and Public Health, Queen Mary University of London, London E1 2AB, UK
| | - Sally Kerry
- Centre for Primary Care and Public Health, Queen Mary University of London, London E1 2AB, UK
| | - Rohini Mathur
- Department of Non-Communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK
| | - John Robson
- Centre for Primary Care and Public Health, Queen Mary University of London, London E1 2AB, UK
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27
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Nunes AP, Iglay K, Radican L, Engel SS, Yang J, Doherty MC, Dore DD. Hypoglycaemia seriousness and weight gain as determinants of cardiovascular disease outcomes among sulfonylurea users. Diabetes Obes Metab 2017; 19:1425-1435. [PMID: 28497592 DOI: 10.1111/dom.13000] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2017] [Revised: 04/28/2017] [Accepted: 04/30/2017] [Indexed: 12/23/2022]
Abstract
AIMS Certain treatments for type 2 diabetes mellitus cause hypoglycaemia and weight gain, and thus might counteract the benefits of intensive glucose control. We quantify the association of cardiovascular disease (CVD) outcomes with hypoglycaemia and weight gain among patients with type 2 diabetes treated with sulfonylureas. MATERIALS AND METHODS This cohort study included patients from January 2009 through December 2014 who were selected from within a deidentified nationwide electronic health records repository, including multiple provider networks and electronic medical records systems. Hypoglycaemia measures from structured data fields and free text clinical notes were categorized as serious or non-serious. Covariate adjusted Poisson regression analysis was used to assess the association between frequency of hypoglycaemia (by severity), or magnitude of weight change, and incidence of acute myocardial infarction (AMI), congestive heart failure (CHF) and stroke. RESULTS Among 143 635 eligible patients, we observed 5669 cases of AMI, 14 109 incident cases of CHF and 7017 cases of stroke. Overall incidence rates were 1.53, 4.26 and 1.92 per 100 person-years for AMI, CHF and stroke, respectively. The associations between overall hypoglycaemia and each of the CVD outcomes were positive, with stronger associations observed for serious hypoglycaemia and attenuated or null associations observed for non-serious hypoglycaemia. Weight change exhibited a U-shaped association with increased risks associated with both weight loss and weight gain relative to stable weight. CONCLUSIONS This study provides evidence of increased CVD risk associated with hypoglycaemia, especially with serious hypoglycaemia events. While associations were attenuated with non-serious hypoglycaemia, the results were suggestive of a potential increased risk.
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Affiliation(s)
- Anthony P Nunes
- Optum Epidemiology, Boston, Massachusetts
- Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Massachusetts
| | | | | | | | - Jing Yang
- Optum Epidemiology, Boston, Massachusetts
| | | | - David D Dore
- Optum Epidemiology, Boston, Massachusetts
- Department of Health Services, Policy and Practice, Brown University School of Public Health, Providence, Rhode Island
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28
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Abstract
In an increasingly obese and ageing population, type 2 diabetes (T2DM) and osteoporotic fracture are major public health concerns. Understanding how obesity and type 2 diabetes modulate fracture risk is important to identify and treat people at risk of fracture. Additionally, the study of the mechanisms of action of obesity and T2DM on bone has already offered insights that may be applicable to osteoporosis in the general population. Most available evidence indicates lower risk of proximal femur and vertebral fracture in obese adults. However the risk of some fractures (proximal humerus, femur and ankle) is higher, and a significant number fractures occur in obese people. BMI is positively associated with BMD and the mechanisms of this association in vivo may include increased loading, adipokines such as leptin, and higher aromatase activity. However, some fat depots could have negative effects on bone; cytokines from visceral fat are pro-resorptive and high intramuscular fat content is associated with poorer muscle function, attenuating loading effects and increasing falls risk. T2DM is also associated with higher bone mineral density (BMD), but increased overall and hip fracture risk. There are some similarities between bone in obesity and T2DM, but T2DM seems to have additional harmful effects and emerging evidence suggests that glycation of collagen may be an important factor. Higher BMD but higher fracture risk presents challenges in fracture prediction in obesity and T2DM. Dual energy X-ray absorptiometry underestimates risk, standard clinical risk factors may not capture all relevant information, and risk is under-recognised by clinicians. However, the limited available evidence suggests that osteoporosis treatment does reduce fracture risk in obesity and T2DM with generally similar efficacy to other patients.
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Affiliation(s)
- Jennifer S Walsh
- Academic Unit of Bone Metabolism, Mellanby Centre for Bone Research, University of Sheffield, Sheffield, UK.
| | - Tatiane Vilaca
- Academic Unit of Bone Metabolism, Mellanby Centre for Bone Research, University of Sheffield, Sheffield, UK
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29
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Wallander M, Axelsson KF, Nilsson AG, Lundh D, Lorentzon M. Type 2 Diabetes and Risk of Hip Fractures and Non-Skeletal Fall Injuries in the Elderly: A Study From the Fractures and Fall Injuries in the Elderly Cohort (FRAILCO). J Bone Miner Res 2017; 32:449-460. [PMID: 27664946 DOI: 10.1002/jbmr.3002] [Citation(s) in RCA: 63] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2016] [Revised: 09/21/2016] [Accepted: 09/22/2016] [Indexed: 01/26/2023]
Abstract
Questions remain about whether the increased risk of fractures in patients with type 2 diabetes (T2DM) is related mainly to increased risk of falling or to bone-specific properties. The primary aim of this study was to investigate the risk of hip fractures and non-skeletal fall injuries in older men and women with and without T2DM. We included 429,313 individuals (aged 80.8 ± 8.2 years [mean ± SD], 58% women) from the Swedish registry "Senior Alert" and linked the data to several nationwide registers. We identified 79,159 individuals with T2DM (45% with insulin [T2DM-I], 41% with oral antidiabetics [T2DM-O], and 14% with no antidiabetic treatment [T2DM-none]) and 343,603 individuals without diabetes. During a follow-up of approximately 670,000 person-years, we identified in total 36,132 fractures (15,572 hip fractures) and 20,019 non-skeletal fall injuries. In multivariable Cox regression models where the reference group was patients without diabetes and the outcome was hip fracture, T2DM-I was associated with increased risk (adjusted hazard ratio (HR) [95% CI] 1.24 [1.16-1.32]), T2DM-O with unaffected risk (1.03 [0.97-1.11]), and T2DM-none with reduced risk (0.88 [0.79-0.98]). Both the diagnosis of T2DM-I (1.22 [1.16-1.29]) and T2DM-O (1.12 [1.06-1.18]) but not T2DM-none (1.07 [0.98-1.16]) predicted non-skeletal fall injury. The same pattern was found regarding other fractures (any, upper arm, ankle, and major osteoporotic fracture) but not for wrist fracture. Subset analyses revealed that in men, the risk of hip fracture was only increased in those with T2DM-I, but in women, both the diagnosis of T2DM-O and T2DM-I were related to increased hip fracture risk. In conclusion, the risk of fractures differs substantially among patients with T2DM and an increased risk of hip fracture was primarily found in insulin-treated patients, whereas the risk of non-skeletal fall injury was consistently increased in T2DM with any diabetes medication. © 2016 American Society for Bone and Mineral Research.
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Affiliation(s)
- Märit Wallander
- Department of Medicine Huddinge, Karolinska Institute, Stockholm, Sweden.,Geriatric Medicine, Center for Bone Research at the Sahlgrenska Academy, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden
| | - Kristian F Axelsson
- Geriatric Medicine, Center for Bone Research at the Sahlgrenska Academy, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden.,Department of Orthopaedic Surgery, Skaraborg Hospital, Skövde, Sweden
| | - Anna G Nilsson
- Geriatric Medicine, Center for Bone Research at the Sahlgrenska Academy, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden
| | - Dan Lundh
- School of Bioscience, University of Skövde, Skövde, Sweden
| | - Mattias Lorentzon
- Geriatric Medicine, Center for Bone Research at the Sahlgrenska Academy, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden
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