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Kosjerina V, Carstensen B, Jørgensen ME, Brock B, Christensen HR, Rungby J, Andersen GS. Discontinuation of diabetes medication in the 10 years before death in Denmark: a register-based study. THE LANCET HEALTHY LONGEVITY 2021; 2:e561-e570. [DOI: 10.1016/s2666-7568(21)00170-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Revised: 06/21/2021] [Accepted: 06/29/2021] [Indexed: 02/07/2023]
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Seidu S, Seewoodharry M, Khunti K. De-intensification in older people with type 2 diabetes: why, when and for whom? THE LANCET HEALTHY LONGEVITY 2021; 2:e531-e532. [DOI: 10.1016/s2666-7568(21)00204-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Accepted: 07/30/2021] [Indexed: 02/05/2023]
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Sinclair AJ, Heller SR, Pratley RE, Duan R, Heine RJ, Festa A, Kiljański J. Evaluating glucose-lowering treatment in older people with diabetes: Lessons from the IMPERIUM trial. Diabetes Obes Metab 2020; 22:1231-1242. [PMID: 32100382 PMCID: PMC7383926 DOI: 10.1111/dom.14013] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Revised: 02/11/2020] [Accepted: 02/20/2020] [Indexed: 01/24/2023]
Abstract
Understanding the benefits and risks of treatments to be used by older individuals (≥65 years old) is critical for informed therapeutic decisions. Glucose-lowering therapy for older patients with diabetes should be tailored to suit their clinical condition, comorbidities and impaired functional status, including varying degrees of frailty. However, despite the rapidly growing population of older adults with diabetes, there are few dedicated clinical trials evaluating glucose-lowering treatment in older people. Conducting clinical trials in the older population poses multiple significant challenges. Despite the general agreement that individualizing treatment goals and avoiding hypoglycaemia is paramount for the therapy of older people with diabetes, there are conflicting perspectives on specific glycaemic targets that should be adopted and on use of specific drugs and treatment strategies. Assessment of functional status, frailty and comorbidities is not routinely performed in diabetes trials, contributing to insufficient characterization of older study participants. Moreover, significant operational barriers and problems make successful enrolment and completion of such studies difficult. In this review paper, we summarize the current guidelines and literature on conducting such trials, as well as the learnings from our own clinical trial (IMPERIUM) that assessed different glucose-lowering strategies in older people with type 2 diabetes. We discuss the importance of strategies to improve study design, enrolment and attrition. Apart from summarizing some practical advice to facilitate the successful conduct of studies, we highlight key gaps and needs that warrant further research.
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Affiliation(s)
- Alan J. Sinclair
- Foundation for Diabetes Research in Older PeopleDiabetes Frail LimitedWorcestershireUK
- King's CollegeLondonUK
| | - Simon R. Heller
- Department of Oncology & Metabolism, University of SheffieldSheffieldUK
| | - Richard E. Pratley
- AdventHealth Translational Research Institute for Metabolism and DiabetesOrlandoFloridaUSA
| | - Ran Duan
- Eli Lilly and CompanyIndianapolisIndianaUSA
| | | | - Andreas Festa
- 1st Medical DepartmentLK StockerauNiederösterreichAustria
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Alwafi H, Wei L, Naser AY, Mongkhon P, Tse G, Man KKC, Bell JS, Ilomaki J, Fang G, Wong ICK. Trends in oral anticoagulant prescribing in individuals with type 2 diabetes mellitus: a population-based study in the UK. BMJ Open 2020; 10:e034573. [PMID: 32414823 PMCID: PMC7232627 DOI: 10.1136/bmjopen-2019-034573] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
OBJECTIVE To evaluate oral anticoagulant (OAC) prescribing trends in type 2 diabetes mellitus (T2DM) in the UK from 2001 to 2015. DESIGN A cross-sectional drug utilisation study. SETTING Electronic health records from The Health Improvement Network primary care database in the UK. PARTICIPANTS Individuals with T2DM who received a record of OAC prescription. OUTCOME MEASURES The prescribing trends of OAC medications in individuals with T2DM were examined from 2001 to 2015, stratified by age, gender and therapeutic classifications. RESULTS A total of 361 635 individuals with T2DM were identified, of whom 36 570 were prescribed OAC from 2001 to 2015. The prevalence of OAC prescribing increased by 50.0%, from 1781 individuals receiving OAC prescriptions (IROACP) (4.4 (95% CI 4.2 to 4.6) per 100 persons) in 2001, to 17 070 IROACP (6.6 (95% CI 6.5 to 6.7) per 100 persons) in 2015. The prevalence of warfarin prescribing decreased by 14.0%, from 1761 individuals receiving warfarin prescriptions (IRWP) (98.9 (95% CI 98.4 to 99.4) per 100 persons) in 2001, to 14 533 IRWP (85.1 (95% CI 84.6 to 85.7) per 100 persons) in 2015. This corresponded with increased prescribing of direct oral anticoagulants (DOACs), from 18 individuals receiving DOAC prescriptions (IRDOACP) (0.1 (95% CI 0.08 to 0.23) per 100 persons) in 2010, to 3016 IRDOACP (17.6 (95% CI 17.1 to 18.2) per 100 persons) in 2015, during the same period. CONCLUSIONS Prescribing of OACs in individuals with T2DM increased from 2001 to 2015. Since the introduction of DOACs, there has been a clear shift in prescribing towards these agents. Future studies are needed to assess the safety of coadministration of OAC medications and antidiabetic therapy with T2DM.
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Affiliation(s)
- Hassan Alwafi
- Research Department of Practice and Policy, School of Pharmacy, University College London, London, London, UK
| | - Li Wei
- Research Department of Practice and Policy, School of Pharmacy, University College London, London, London, UK
| | | | - Pajaree Mongkhon
- Division of Pharmacy Practice, Department of Pharmaceutical Care, School of Pharmaceutical Sciences, University of Phayao, Phayao, Thailand
- Pharmacoepidemiology and Statistics Research Center (PESRC), Faculty of Pharmacy, Chiang Mai University, Chiang Mai, Thailand
| | - Gary Tse
- Department of Medicine and Therapeutics, Faculty of Medicine, Chinese University of Hong Kong, New Territories, Hong Kong
- Li Ka Shing Institute of Health Sciences, Faculty of Medicine, Chinese University of Hong Kong, New Territories, Hong Kong
| | - Kenneth K C Man
- Research Department of Practice and Policy, School of Pharmacy, University College London, London, London, UK
- Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, The University of Hong Kong, Hong Kong, Hong Kong
| | - J Simon Bell
- Centre for Medicine Use and Safety, Monash University, Melbourne, Victoria, Australia
| | - Jenni Ilomaki
- Centre for Medicine Use and Safety, Monash University, Melbourne, Victoria, Australia
| | - Gang Fang
- Division of Pharmaceutical Outcomes and Policy, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Ian C K Wong
- Research Department of Practice and Policy, School of Pharmacy, University College London, London, London, UK
- Pharmacology and Pharmacy, University of Hong Kong, Hong Kong, Hong Kong
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Sharma M, Nazareth I, Petersen I. Comparative effectiveness of sitagliptin vs sulphonylureas in older people. Age Ageing 2019; 48:725-732. [PMID: 31250890 DOI: 10.1093/ageing/afz078] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Revised: 04/24/2019] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND two common anti-diabetic treatments used are sitagliptin and sulphonylureas however evidence examining their comparative effectiveness in older people is limited. OBJECTIVE to evaluate effectiveness of sitagliptin vs sulphonylureas when added to metformin in older (aged ≥75) vs younger people (18-75). DESIGN retrospective cohort study. SETTING UK Primary Care. SUBJECTS 2,904 individuals prescribed sitagliptin (223 aged≥75) and 13,683 prescribed sulphonylureas (1,725 aged ≥75). METHODS multivariable regression to analyse difference in HbA1c and weight, 12 months after add-on initiation and proportion achieving different glycaemic targets. RESULTS after multivariate adjustment to remove baseline differences, the HbA1c after 12 months of treatment was on average 1 mmol/mol (95%CI -0.7 to 2.8) higher with sitagliptin vs sulphonylureas in older people though this was not statistically significant. The weight however, was significantly lower -1.4 kg (95%CI -2.1 to -0.7) with sitagliptin vs sulphonylureas. A lower proportion prescribed sitagliptin vs sulphonylureas recorded HbA1c < 48 mmol/mol by study end: Odds Ratio 0.63 (95%CI 0.42-0.95). In younger people, similar HbA1c reductions were also observed with both treatments, however weight after 12 months was even lower with sitagliptin vs sulphonylureas: -2.3 kg (95%CI -2.5 to -2.0). CONCLUSIONS similar HbA1c reduction was observed when sitagliptin or sulphonylureas were added to metformin in older and younger age-groups. Sitagliptin use led to modest comparative weight loss. There may be greater risk of over-treatment with sulphonylureas evidenced by greater proportion recording HbA1c < 48 mmol/mol by study end. This evidence supporting use of sitagliptin when add-on therapy is selected in older adults should be considered alongside the wider evidence-base and patient-preference.
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Affiliation(s)
- Manuj Sharma
- Department of Primary Care and Population Health, University College London, London, UK
| | - Irwin Nazareth
- Department of Primary Care and Population Health, University College London, London, UK
| | - Irene Petersen
- Department of Primary Care and Population Health, University College London, London, UK
- Department of Clinical Epidemiology, Aarhus University, Denmark
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Arnaud M, Pariente A, Bezin J, Bégaud B, Salvo F. Risk of Serious Trauma with Glucose-Lowering Drugs in Older Persons: A Nested Case-Control Study. J Am Geriatr Soc 2018; 66:2086-2091. [DOI: 10.1111/jgs.15515] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Revised: 06/07/2018] [Accepted: 06/07/2018] [Indexed: 11/29/2022]
Affiliation(s)
- Mickael Arnaud
- Pharmacoepidemiology Team, Bordeaux Population Health Research Center, Inserm; University of Bordeaux; Bordeaux France
| | - Antoine Pariente
- Pharmacoepidemiology Team, Bordeaux Population Health Research Center, Inserm; University of Bordeaux; Bordeaux France
- Service de Pharmacologie Médicale; Centre Hospitalier Universitaire de Bordeaux; Bordeaux France
| | - Julien Bezin
- Pharmacoepidemiology Team, Bordeaux Population Health Research Center, Inserm; University of Bordeaux; Bordeaux France
- Service de Pharmacologie Médicale; Centre Hospitalier Universitaire de Bordeaux; Bordeaux France
| | - Bernard Bégaud
- Pharmacoepidemiology Team, Bordeaux Population Health Research Center, Inserm; University of Bordeaux; Bordeaux France
- Service de Pharmacologie Médicale; Centre Hospitalier Universitaire de Bordeaux; Bordeaux France
| | - Francesco Salvo
- Pharmacoepidemiology Team, Bordeaux Population Health Research Center, Inserm; University of Bordeaux; Bordeaux France
- Service de Pharmacologie Médicale; Centre Hospitalier Universitaire de Bordeaux; Bordeaux France
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Chatterjee S, Davies MJ, Khunti K. What have we learnt from "real world" data, observational studies and meta-analyses. Diabetes Obes Metab 2018; 20 Suppl 1:47-58. [PMID: 29364585 DOI: 10.1111/dom.13178] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2017] [Revised: 11/28/2017] [Accepted: 11/28/2017] [Indexed: 12/18/2022]
Abstract
The incretin therapies glucagon-like peptide-1 receptor agonists (GLP-1 RA) and dipeptidyl peptidase-IV (DPP-IV) inhibitors are now well-established as second and third-line therapies and in combination with insulin for the treatment of type 2 diabetes. Over the last decade, there is accumulating evidence of their efficacy and safety from both large multicentre randomized clinical trials (RCT) and observational studies. Cardiovascular outcome trials have confirmed that several of these agents are also non-inferior to placebo with the GLP-1 RA liraglutide and semaglutide recently found to be superior in terms of major adverse cardiovascular events. Observational studies and post-marketing surveillance provide real world evidence of safety and effectiveness of these agents and have provided reassurance that signals for pancreatitis and pancreatic cancer seen in clinical trials are not of major concern in large patient populations. Well-designed real world studies complement RCTs and systematic reviews but appropriate data and methodologies, which are constantly improving, are necessary to answer appropriate clinical questions relating to the use of incretin therapies.
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Affiliation(s)
- Sudesna Chatterjee
- Diabetes Research Centre, University of Leicester, Leicester General Hospital, Leicester, UK
| | - Melanie J Davies
- Diabetes Research Centre, University of Leicester, Leicester General Hospital, Leicester, UK
| | - Kamlesh Khunti
- Diabetes Research Centre, University of Leicester, Leicester General Hospital, Leicester, UK
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Farrell B, Black C, Thompson W, McCarthy L, Rojas-Fernandez C, Lochnan H, Shamji S, Upshur R, Bouchard M, Welch V. Deprescribing antihyperglycemic agents in older persons: Evidence-based clinical practice guideline. CANADIAN FAMILY PHYSICIAN MEDECIN DE FAMILLE CANADIEN 2017; 63:832-843. [PMID: 29138153 PMCID: PMC5685444] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
OBJECTIVE To develop an evidence-based guideline to help clinicians make decisions about when and how to safely taper, stop, or switch antihyperglycemic agents in older adults. METHODS We focused on the highest level of evidence available and sought input from primary care professionals in guideline development, review, and endorsement processes. Seven clinicians (2 family physicians, 3 pharmacists, 1 nurse practitioner, and 1 endocrinologist) and a methodologist comprised the overall team; members disclosed conflicts of interest. We used a rigorous process, including the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach, for guideline development. We conducted a systematic review to assess evidence for the benefits and harms of deprescribing antihyperglycemic agents. We performed a review of reviews of the harms of continued antihyperglycemic medication use, and narrative syntheses of patient preferences and resource implications. We used these syntheses and GRADE quality-of-evidence ratings to generate recommendations. The team refined guideline content and recommendation wording through consensus and synthesized clinical considerations to address common front-line clinician questions. The draft guideline was distributed to clinicians and stakeholders for review and revisions were made at each stage. A decision-support algorithm was developed to accompany the guideline. RECOMMENDATIONS We recommend deprescribing antihyperglycemic medications known to contribute to hypoglycemia in older adults at risk or in situations where antihyperglycemic medications might be causing other adverse effects, and individualizing targets and deprescribing accordingly for those who are frail, have dementia, or have a limited life expectancy. CONCLUSION This guideline provides practical recommendations for making decisions about deprescribing antihyperglycemic agents. Recommendations are meant to assist with, not dictate, decision making in conjunction with patients.
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Affiliation(s)
- Barbara Farrell
- Scientist at the Bruyère Research Institute and C.T. Lamont Primary Health Care Research Centre, Assistant Professor in the Department of Family Medicine at the University of Ottawa in Ontario, and Adjunct Assistant Professor in the School of Pharmacy at the University of Waterloo in Ontario.
| | - Cody Black
- Research Coordinator at the Bruyère Research Institute
| | - Wade Thompson
- Research Coordinator at the Bruyère Research Institute and a master's candidate in the School of Epidemiology, Public Health and Preventive Medicine at the University of Ottawa
| | - Lisa McCarthy
- Assistant Professor in the Leslie Dan Faculty of Pharmacy at the University of Toronto in Ontario and a pharmacy scientist at Women's College Hospital Research Institute
| | - Carlos Rojas-Fernandez
- Assistant Professor in the School of Pharmacy and the School of Public Health and Health Systems at the University of Waterloo and Schlegel Research Chair in Geriatric Pharmacotherapy at the Schlegel-University of Waterloo Research Institute on Ageing
| | - Heather Lochnan
- Associate Professor of Medicine at the University of Ottawa and is an endocrinologist at the Ottawa Hospital
| | - Salima Shamji
- Assistant Professor in the Department of Family Medicine at the University of Ottawa
| | - Ross Upshur
- Professor in the Dalla Lana School of Public Health at the University of Toronto
| | - Manon Bouchard
- Nurse practitioner with the Bruyère Academic Family Health Team
| | - Vivian Welch
- Assistant Professor in the School of Epidemiology, Public Health and Preventive Medicine, Deputy Director of the Centre for Global Health at the University of Ottawa, and a clinical epidemiology methodologist at the Bruyère Research Institute
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Farrell B, Black C, Thompson W, McCarthy L, Rojas-Fernandez C, Lochnan H, Shamji S, Upshur R, Bouchard M, Welch V. [Not Available]. CANADIAN FAMILY PHYSICIAN MEDECIN DE FAMILLE CANADIEN 2017; 63:e452-e465. [PMID: 29138168 PMCID: PMC5685459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Objectif Formuler des lignes directrices fondées sur les données probantes afin d’aider les cliniciens à décider du moment et de la façon sécuritaire de réduire la dose des antihyperglycémiants, de mettre fin au traitement ou de passer à un autre agent chez les personnes âgées. Méthodes Nous nous sommes concentrés sur les données les plus probantes disponibles et avons cherché à obtenir les commentaires des professionnels de première ligne durant le processus de rédaction, de révision et d’adoption des lignes directrices. L’équipe était formée de 7 professionnels de la santé (2 médecins de famille, 3 pharmaciens, 1 infirmière praticienne et 1 endocrinologue) et d’une spécialiste de la méthodologie; les membres ont divulgué tout conflit d’intérêts. Nous avons eu recours à un processus rigoureux, y compris l’approche GRADE (Grading of Recommendations Assessment, Development and Evaluation) pour formuler les lignes directrices. Nous avons effectué une revue systématique dans le but d’évaluer les données probantes indiquant les bienfaits et les torts liés à la déprescription des antihyperglycémiants. Nous avons révisé les revues des torts liés à la poursuite du traitement antihyperglycémiant, et effectué des synthèses narratives des préférences des patients et des répercussions sur les ressources. Ces synthèses et évaluations de la qualité des données selon l’approche GRADE ont servi à formuler les recommandations. L’équipe a peaufiné le texte sur le contenu et les recommandations des lignes directrices par consensus et a synthétisé les considérations cliniques afin de répondre aux questions courantes des cliniciens de première ligne. Une version préliminaire des lignes directrices a été distribuée aux cliniciens et aux intervenants aux fins d’examen, et des révisions ont été apportées au texte à chaque étape. Un algorithme d’appui décisionnel a été conçu pour accompagner les lignes directrices. Recommandations Nous recommandons de déprescrire les antihyperglycémiants reconnus pour contribuer à l’hypoglycémie chez les personnes âgées à risque ou dans les situations où les antihyperglycémiants pourraient causer d’autres effets indésirables, et d’individualiser les cibles et de déprescrire en conséquence chez les personnes frêles, atteintes de démence ou dont l’espérance de vie est limitée. Conclusion Les présentes lignes directrices émettent des recommandations pratiques pour décider du moment et de la façon de déprescrire les antihyperglycémiants. Elles visent à contribuer au processus de décision conjointement avec le patient et non à le dicter.
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Affiliation(s)
- Barbara Farrell
- Scientifique à l'Institut de recherche Élisabeth-Bruyère et au Centre de recherche C.T. Lamont en soins de santé primaires, professeure adjointe au Département de médecine familiale de l'Université d'Ottawa et professeure adjointe auxiliaire à la Faculté de pharmacie de l'Université de Waterloo, en Ontario.
| | - Cody Black
- Coordonnateur de la recherche à l'Institut de recherche Élisabeth-Bruyère
| | - Wade Thompson
- Coordonnateur de la recherche à l'Institut de recherche Élisabeth-Bruyère et candidat à la maîtrise à la Faculté d'épidémiologie, de santé publique et de médecine préventive de l'Université d'Ottawa
| | - Lisa McCarthy
- Professeure adjointe à la Faculté de pharmacie Leslie Dan de l'Université de Toronto, en Ontario, et scientifique pharmacienne à l'Institut de recherche de l'Hôpital Women's College
| | - Carlos Rojas-Fernandez
- Professeur adjoint à la Faculté de pharmacie ainsi qu'à la Faculté de santé publique et des systèmes de santé de l'Université de Waterloo, et titulaire de la chaire de recherche Schlegel en pharmacothérapie gériatrique à l'Institut de recherche Schlegel-UW sur le vieillissement
| | - Heather Lochnan
- Professeure agrégée de médecine à l'Université d'Ottawa et endocrinologue à l'Hôpital d'Ottawa
| | - Salima Shamji
- Professeure adjointe au Département de médecine familiale de l'Université d'Ottawa
| | - Ross Upshur
- Professeur à la Dalla Lana School of Public Health de l'Université de Toronto
| | - Manon Bouchard
- Infirmière praticienne dans l'Équipe de santé familiale universitaire Bruyère
| | - Vivian Welch
- Professeure adjointe à la Faculté d'épidémiologie, de santé publique et de médecine préventive de l'Université d'Ottawa, directrice adjointe du Centre de santé mondiale de l'Université d'Ottawa et spécialiste de méthodologie épidémiologique clinique à l'Institut de recherche Élisabeth-Bruyère
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Meneilly GS, Berard LD, Cheng AYY, Lin PJ, MacCallum L, Tsuyuki RT, Yale JF, Nasseri N, Richard JF, Goldin L, Langer A, Tan MK, Leiter LA. Insights Into the Current Management of Older Adults With Type 2 Diabetes in the Ontario Primary Care Setting. Can J Diabetes 2017; 42:23-30. [PMID: 28583470 DOI: 10.1016/j.jcjd.2017.03.003] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2016] [Revised: 02/09/2017] [Accepted: 03/03/2017] [Indexed: 01/07/2023]
Abstract
OBJECTIVE The Goal Oriented controL of Diabetes in the Elderly populatioN (GOLDEN) Program assessed the management of older persons with type 2 diabetes in Canadian primary care. METHODS Data were extracted from the records of 833 consecutively identified persons 65 years of age or older who had type 2 diabetes and were taking 1 antihyperglycemic agent or more; they were managed by 64 physicians from 36 Ontario clinics. RESULTS More than half (53%) had glycated hemoglobin (A1C) levels of 7.0% or lower, 41% had blood pressure levels below 130/80 mm Hg, and 73% had low-density lipoprotein levels of 2.0 mmol/L or lower; 19% met all 3 criteria. Over the past year, 11% had been assessed for frailty, 16% for cognitive dysfunction and 19% for depression; 88% were referred for eye checkups, and 83% had undergone foot examinations. One-tenth were taking 4 or more antihyperglycemic agents, 87% statins and 52% an angiotensin-converting enzyme inhibitor. More than half of those with high clinical complexity had A1C levels of 7.0% or lower; of these, one-third were taking a sulfonylurea, and one-fifth were taking insulin. In the patients with A1C levels of 7.0% or above and low clinical complexity, there was often no up-titration or initiation of additional antihyperglycemic agents. CONCLUSIONS Older persons with type 2 diabetes often have multiple comorbidities. Unlike eye and foot examinations, there was less emphasis on evaluating for frailty, cognitive dysfunction and depression. The GOLDEN patients had generally well-controlled glycemic, blood pressure and cholesterol profiles, but whether these would be reflected in a "sicker" population is not known. Personalized strategies are necessary to avoid undertreatment of "healthy" older patients and overtreatment of the frail elderly.
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Affiliation(s)
- Graydon S Meneilly
- Department of Medicine, Vancouver Hospital and the University of British Columbia, Vancouver, British Columbia, Canada.
| | - Lori D Berard
- Winnipeg Regional Health Authority, Health Sciences Centre, Winnipeg Diabetes Research Group, Department of Medicine, Section of Endocrinology, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Alice Y Y Cheng
- Division of Endocrinology and Metabolism, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Peter J Lin
- Canadian Heart Research Centre, Toronto, Ontario, Canada
| | - Lori MacCallum
- Banting and Best Diabetes Centre, Faculty of Medicine and Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada
| | - Ross T Tsuyuki
- EPICORE Centre, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Jean-François Yale
- Division of Endocrinology and Metabolism, McGill University, Montréal, Québec, Canada
| | | | | | - Lianne Goldin
- Canadian Heart Research Centre, Toronto, Ontario, Canada
| | - Anatoly Langer
- Canadian Heart Research Centre, Toronto, Ontario, Canada; Terrence Donnelly Heart Centre, Division of Cardiology, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Mary K Tan
- Canadian Heart Research Centre, Toronto, Ontario, Canada
| | - Lawrence A Leiter
- Division of Endocrinology & Metabolism, Li Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto, Ontario, Canada
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Hamada S, Gulliford MC. Drug prescribing during the last year of life in very old people with diabetes. Age Ageing 2017; 46:147-151. [PMID: 28181655 PMCID: PMC5388282 DOI: 10.1093/ageing/afw174] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2016] [Accepted: 10/05/2016] [Indexed: 12/24/2022] Open
Abstract
Objective to evaluate primary care drug utilisation during the last year of life, focusing on antidiabetic and cardiovascular drugs, in patients of advanced age with diabetes. Design population-based cohort study. Setting primary care database in the UK. Subjects patients with type 2 diabetes who died at over 80 years of age between 2011 and 13. Methods main outcome measures included proportions of patients prescribed different classes of drugs, comparing the first (Q1) and the fourth quarters (Q4) of the last year of life. Results the study included 5,324 patients, with the median age 86 years and 50% female. Three-fourths of the patients received five or more drugs, and the total number of drugs prescribed was almost stable at 6.2 ± 3.1 (mean ± SD) during the last year of life. Substantial proportions of patients were treated with antidiabetic drugs (78%), antihypertensive drugs (76%), statins (62%) and low-dose aspirin (46%) in Q1. Prescribing of these drugs slightly decreased by 3–8% in Q4. There were increases in prescribing of anti-infectives (35% in Q1 to 50% in Q4), drugs for nervous system (63% to 73%), drugs for respiratory system (24% to 33%) and systemic hormonal drugs (22% to 27%). Conclusion patients of advanced age with type 2 diabetes were often treated with antidiabetic and cardiovascular drugs even when approaching death. More research is needed to generate evidence to guide optimal drug utilisation for older people with a limited life expectancy.
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Affiliation(s)
- Shota Hamada
- Department of Primary Care and Public Health Sciences, King's College London, London, UK
- Address correspondence to: S. Hamada, Department of Primary Care and Public Health Sciences, King's College London, 3rd floor, Addison House, London SE1 1UL, UK. Tel: +44 (0)20 7848 6426; Fax: +44 (0)20 7848 6620.
| | - Martin C. Gulliford
- Department of Primary Care and Public Health Sciences, King's College London, London, UK
- National Institute for Health Research (NIHR) Biomedical Research Centre at Guy's and St Thomas’ NHS Foundation Trust, London, UK
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Baviera M, Avanzini F, Marzona I, Tettamanti M, Vannini T, Cortesi L, Fortino I, Bortolotti A, Merlino L, Trevisan R, Roncaglioni MC. Cardiovascular complications and drug prescriptions in subjects with and without diabetes in a Northern region of Italy, in 2002 and 2012. Nutr Metab Cardiovasc Dis 2017; 27:54-62. [PMID: 27956023 DOI: 10.1016/j.numecd.2016.10.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2016] [Revised: 09/30/2016] [Accepted: 10/16/2016] [Indexed: 11/22/2022]
Abstract
BACKGROUND AND AIMS In contrast to the well-documented global prevalence of diabetes, much less is known about the epidemiology of cardiovascular (CV) complications in recent years. We describe the incidence of major CV events, deaths and drug prescribing patterns from 2002 to 2012 in subjects with (DM) or without diabetes mellitus (No DM). METHODS AND RESULTS Subjects and outcomes were identified using linkable health administrative databases of Lombardy, a region in Northern Italy. A logistic regression model was used to compare myocardial infarction (MI), stroke, major amputation and death between DM and No DM in 2002 and 2012 and between the two index years in each population. The interaction between years and diabetes was introduced in the model. From 2002 to 2012 the incidence of major CV complications and death fell in both groups with a larger reduction among DM only for CV events: OR (95% CI) for the interaction 0.86 (0.79-0.93) for MI, 0.89 (0.82-0.96) for stroke, 0.78 (0.57-1.06) for major amputations. CV prevention drugs rose considerably from 2002 to 2012 particularly in DM and a switch towards safer antihyperglycemic drugs was also observed. CONCLUSIONS Major CV complications and death declined from 2002 to 2012 in both DM and No DM. This might be due to a larger increase in prescriptions of CV drugs in DM and a relevant change toward recommended antihyperglycemic drugs.
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Affiliation(s)
- M Baviera
- Laboratory of Cardiovascular Prevention, IRCCS - Istituto di Ricerche Farmacologiche "Mario Negri", Milan, Italy.
| | - F Avanzini
- Laboratory of Cardiovascular Prevention, IRCCS - Istituto di Ricerche Farmacologiche "Mario Negri", Milan, Italy
| | - I Marzona
- Laboratory of Cardiovascular Prevention, IRCCS - Istituto di Ricerche Farmacologiche "Mario Negri", Milan, Italy
| | - M Tettamanti
- Laboratory of Geriatric Epidemiology, IRCCS - Istituto di Ricerche Farmacologiche "Mario Negri", Milan, Italy
| | - T Vannini
- Laboratory of Cardiovascular Prevention, IRCCS - Istituto di Ricerche Farmacologiche "Mario Negri", Milan, Italy
| | - L Cortesi
- Laboratory of Quality Assessment of Geriatric Therapies and Services, IRCCS - Istituto di Ricerche Farmacologiche "Mario Negri", Milan, Italy
| | - I Fortino
- Regional Health Ministry, Lombardy Region, Milan, Italy
| | - A Bortolotti
- Regional Health Ministry, Lombardy Region, Milan, Italy
| | - L Merlino
- Regional Health Ministry, Lombardy Region, Milan, Italy
| | - R Trevisan
- Diabetology Unit, Department of Internal Medicine, Ospedali Riuniti di Bergamo, Italy
| | - M C Roncaglioni
- Laboratory of Cardiovascular Prevention, IRCCS - Istituto di Ricerche Farmacologiche "Mario Negri", Milan, Italy
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Mattishent K, Loke YK. Meta-analysis: Association between hypoglycaemia and serious adverse events in older patients. J Diabetes Complications 2016; 30:811-8. [PMID: 27083445 DOI: 10.1016/j.jdiacomp.2016.03.018] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2016] [Revised: 02/26/2016] [Accepted: 03/15/2016] [Indexed: 01/30/2023]
Abstract
AIMS We aimed to conduct a meta-analysis of serious adverse events (macro- and microvascular events, falls and fractures, death) associated with hypoglycaemia in older patients. METHODS We searched MEDLINE and EMBASE spanning a ten-year period up to March 2015 (with automated PubMed updates to October 2015). We selected observational studies reporting on hypoglycaemia and associated serious adverse events, and conducted a meta-analysis. We assessed study validity based on ascertainment of hypoglycaemia, adverse events and adjustment for confounders. RESULTS We included 17 studies involving 1.86 million participants. Meta-analysis of eight studies demonstrated that hypoglycemic episodes were associated with macrovascular complications, odds ratio (OR) 1.83 (95% confidence interval [CI] 1.64, 2.05), and microvascular complications in two studies OR 1.77 (95% CI 1.49, 2.10). Meta-analysis of four studies demonstrated an association between hypoglycaemia and falls or fractures, OR 1.89 (95% CI 1.54, 2.32) and 1.92 (95% CI 1.56, 2.38) respectively. Hypoglycaemia was associated with increased likelihood of death in a meta-analysis of eight studies, OR 2.04 (95% Confidence Interval 1.68, 2.47). CONCLUSION Our meta-analysis raises major concerns about a range of serious adverse events associated with hypoglycaemia. Clinicians should prioritize individualized therapy and closer monitoring strategies to avoid hypoglycaemia in susceptible older patients.
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Affiliation(s)
| | - Yoon Kong Loke
- Norwich Medical School, University of East Anglia, Norwich, NR4 7TJ, UK.
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Cai X, Yang W, Chen Y, Gao X, Zhou L, Zhang S, Han X, Ji L. Efficacy of hypoglycemic treatment in type 2 diabetes stratified by age or diagnosed age: a meta-analysis. Expert Opin Pharmacother 2016; 17:1591-8. [PMID: 27322963 DOI: 10.1080/14656566.2016.1202921] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
AIM To compare the effects of blood glucose lowering regimens in groups of patients categorized by baseline age and diagnosed age. METHODS Placebo-controlled randomized trials in type 2 diabetes patients with a study length ≥12 weeks were included. RESULTS A total of 246 trials were included. HbA1c changes from baseline corrected by placebo were comparable in sulfonylurea treatment between older and younger patients' groups (weighted mean difference (WMD), -1.28% vs -0.92%, p > 0.05). Treatment with metformin between groups resulted in a comparable change in HbA1c levels (WMD, -0.97% vs -1.23%, p > 0.05). Treatment with α-glucosidase inhibitor (WMD, -0.68% vs -0.67%, p > 0.05), treatment with thiazolidinedione (WMD, -0.74% vs -1.01%, p > 0.05), treatment with DPP-4 inhibitors (WMD, -0.67% vs -0.67%, p > 0.05), and treatment with SGLT2 inhibitors (WMD, -0.54% vs -0.67%, p > 0.05) between groups also resulted in comparable HbA1c changes. Treatment with GLP-1 analogs between groups in HbA1c changes were also comparable (p > 0.05). Regression analysis indicated that the baseline age or diagnosed age was not associated with the HbA1c changes from baseline. CONCLUSION In each hypoglycemic treatment, the baseline age or diagnosed age was not associated with the HbA1c changes from baseline.
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Affiliation(s)
- Xiaoling Cai
- a Endocrine & Metabolism Department , Peking University People's Hospital , Beijing , China
| | - Wenjia Yang
- a Endocrine & Metabolism Department , Peking University People's Hospital , Beijing , China
| | - Yifei Chen
- a Endocrine & Metabolism Department , Peking University People's Hospital , Beijing , China
| | - Xueying Gao
- a Endocrine & Metabolism Department , Peking University People's Hospital , Beijing , China
| | - Lingli Zhou
- a Endocrine & Metabolism Department , Peking University People's Hospital , Beijing , China
| | - Simin Zhang
- a Endocrine & Metabolism Department , Peking University People's Hospital , Beijing , China
| | - Xueyao Han
- a Endocrine & Metabolism Department , Peking University People's Hospital , Beijing , China
| | - Linong Ji
- a Endocrine & Metabolism Department , Peking University People's Hospital , Beijing , China
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Hamada S, Gulliford MC. Mortality in Individuals Aged 80 and Older with Type 2 Diabetes Mellitus in Relation to Glycosylated Hemoglobin, Blood Pressure, and Total Cholesterol. J Am Geriatr Soc 2016; 64:1425-31. [PMID: 27295278 PMCID: PMC6680323 DOI: 10.1111/jgs.14215] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Objectives To evaluate whether low glycosylated hemoglobin (HbA1c), blood pressure (BP), and total cholesterol (TC) are associated with lower risk of all‐cause mortality in very old individuals with type 2 diabetes mellitus. Design Population‐based cohort study. Setting Primary care database in the United Kingdom. Participants Individuals aged 80 and older with type 2 diabetes mellitus (N = 25,966). Measurements Associations between baseline HbA1c, BP, and TC and all‐cause mortality were evaluated in Cox proportional hazards models. Analyses were adjusted for sex, age, duration of diabetes mellitus, lifestyle variables, HbA1c, BP, TC, comorbidities, prescribing of antidiabetic and cardiovascular drugs, and participants’ general practice. Results There were 4,490 deaths during follow‐up (median 2.0 years; mortality 104.7 per 1,000 person‐years). Mortality in participants with low (<6.0% (<42 mmol/mol)) or high (≥8.5% (≥69 mmol/mol)) HbA1c was similar to that in those with the reference HbA1c (8.0–8.4% (64–68 mmol/mol)). Mortality was lowest in individuals with HbA1c of 7.0–7.4% (53–57 mmol/mol) (80.9 per 1,000 person‐years, adjusted hazard ratio (aHR) = 0.80, 95% confidence interval (CI) = 0.70–0.91, P = .001). Mortality was higher in individuals with lower BP (e.g., <130/70 mmHg, 151.7 per 1,000 person‐years, aHR = 1.52, 95% CI = 1.34–1.72, P < .001 vs reference BP <150/90 mmHg) and in the lowest TC category (<3.0 mmol/L, 138.7 per 1,000 person‐years, aHR = 1.42, 95% CI = 1.24–1.64, P < .001 vs reference TC 4.5–4.9 mmol/L). The relationship between TC and mortality varied according to sex and prescription of lipid‐lowering drugs. Conclusion Low HbA1c, BP, and TC may be associated with higher mortality in very old adults with type 2 diabetes mellitus. Further research is required to understand these associations and to identify optimal treatment targets in this population.
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Affiliation(s)
- Shota Hamada
- Department of Primary Care and Public Health Sciences, King's College London, London, United Kingdom
| | - Martin C Gulliford
- Department of Primary Care and Public Health Sciences, King's College London, London, United Kingdom.,National Institute for Health Research, Biomedical Research Centre, Guy's and St Thomas' National Health Service Foundation Trust, London, United Kingdom
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Mattishent K, Loke YK. Bi-directional interaction between hypoglycaemia and cognitive impairment in elderly patients treated with glucose-lowering agents: a systematic review and meta-analysis. Diabetes Obes Metab 2016; 18:135-41. [PMID: 26446922 DOI: 10.1111/dom.12587] [Citation(s) in RCA: 66] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2015] [Revised: 09/12/2015] [Accepted: 10/01/2015] [Indexed: 01/17/2023]
Abstract
AIMS To examine the bi-directional relationship, whereby hypoglycaemia is a risk factor for dementia, and where dementia increases risk of hypoglycaemia in older patients with diabetes mellitus treated with glucose-lowering agents. METHODS We searched MEDLINE and EMBASE over a 10-year span from 2005 to 2015 (with automated PubMed updates to August 2015) for observational studies of the association between hypoglycaemia and cognitive impairment or dementia in participants aged >55 years. Assessment of study validity was based on ascertainment of hypoglycaemia, dementia and risk of confounding. We conducted random effects inverse variance meta-analyses, and assessed heterogeneity using the I(2) statistic. RESULTS We screened 1177 citations, and selected 12 studies, of which nine were suitable for meta-analysis. There were a total of 1,439,818 participants, with a mean age of 75 years. Meta-analysis of five studies showed a significantly increased risk of dementia in patients who had hypoglycaemic episodes: pooled odds ratio 1.68 [95% confidence interval (CI) 1.45, 1.95]. We also found a significantly increased risk of hypoglycaemia in patients with dementia: pooled odds ratio from five studies 1.61 (95% CI 1.25, 2.06). Limitations of the study were heterogeneity in the meta-analysis, and uncertain ascertainment of dementia and hypoglycaemic outcomes and temporal relationships. Publication bias may have favoured the reporting of more significant findings. CONCLUSIONS Our meta-analysis shows a bi-directional relationship between cognitive impairment and hypoglycaemia in older patients. Glucose-lowering therapy should be carefully tailored and monitored in older patients who are susceptible to cognitive decline.
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Affiliation(s)
- K Mattishent
- Norwich Medical School, University of East Anglia, Norwich, UK
| | - Y K Loke
- Norwich Medical School, University of East Anglia, Norwich, UK
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