Prevalence of insulin as a first-line therapy and associated factors in people with type 2 diabetes in German primary care practices

Potential overtreatment in elderly patients with diabetes mellitus: Results from a cross-sectional study in German general practice

BACKGROUND

It is important for general practitioners (GPs) to protect elderly patients with diagnosis of diabetes type 2 (DM2) from overtreatment.

OBJECTIVE

To analyse the metabolic control and treatment of elderly patients with DM2 in general practices.

METHODS

This cross-sectional study involved 46 general practices in a federal state of Germany. Inclusion criteria for patients were diagnosis of DM2, age of 70 years or above, no palliative care and at least one practice contact within the last six months. A study nurse randomly selected 10 eligible patients and extracted data on haemoglobin A1c (HbA1c), diabetes treatment, secondary prevention and GP's characteristics. Risk of overtreatment was defined as having a HbA1c <47.5 mmol/mol (6.5%) and receiving glucose-lowering drugs, and overtreatment as being at risk of overtreatment and being aged 80 years or above or living in a nursing home.

RESULTS

Among 460 participants, 36.0% received oral-antidiabetic drugs, 16.7% insulin, 16.2% both and 31.1% received diet/exercise. Overtreatment occurred in 12% of elderly patients with DM2, risk of overtreatment in 24%. Overtreatment was significantly associated with urban residency (OR 2.17). Female elderly patients with DM2 were significantly less often at risk of overtreatment (OR 0.59). Cluster effects were evident between general practices' treatment and monitoring of elderly patients with DM2 in quantitative data.

CONCLUSION

Overtreatment is a relevant problem in elderly patients with DM2 for which GPs should regularly check and start deprescribing. Cluster effects suggest heterogeneity between general practices in diabetes management and monitoring.

Meta-analysis of factors associated with antidiabetic drug prescribing for type 2 diabetes mellitus

BACKGROUND

There is a lack of consensus on prescribing alternatives to initial metformin therapy and intensification therapy for type 2 diabetes mellitus (T2DM) management. This review aimed to identify/quantify factors associated with prescribing of specific antidiabetic drug classes for T2DM.

METHODS

Five databases (Medline/PubMed, Embase, Scopus, Web of Science) were searched using the synonyms of each concept (patients with T2DM, antidiabetic drugs and factors influencing prescribing) in both free text and Medical Subject Heading (MeSH) forms. Quantitative observational studies evaluating factors associated with antidiabetic prescribing of metformin, sulfonylurea, thiazolidinedione, Dipeptidyl-peptidase 4 inhibitors (DPP4-I), sodium glucose transporter 2 inhibitors (SGLT2-I), Glucagon-Like peptide receptor agonist (GLP1-RA) and insulin in outpatient settings and published from January 2009 to January 2021 were included. Quality assessment was performed using a Newcastle-Ottawa scale. The validation was done for 20% of identified studies. The pooled estimate was measured using a three-level random-effect meta-analysis model based on odds ratio [95% confidence interval]. Age, sex, body mass index (BMI), glycaemic control (HbA1c) and kidney-related problems were quantified.

RESULTS

Of 2331 identified studies, 40 met the selection criteria. Of which, 36 and 31 studies included sex and age, respectively, while 20 studies examined baseline BMI, HbA1c and kidney-related problems. The majority of studies (77.5%, 31/40) were rated as good and despite that the overall heterogeneity for each studied factor was more than 75%, it is mostly related to within-study variance. Older age was significantly associated with higher sulfonylurea prescription (1.51 [1.29-1.76]), yet lower prescribing of metformin (0.70 [0.60-0.82]), SGLT2-I (0.57 [0.42-0.79]) and GLP1-RA (0.52 [0.40-0.69]); while higher baseline BMI showed opposite significant results (sulfonylurea: 0.76 [0.62-0.93], metformin: 1.22 [1.08-1.37], SGLT2-I: 1.88 [1.33-2.68], and GLP1-RA: 2.35 [1.54-3.59]). Both higher baseline HbA1c and having kidney-related problems were significantly associated with lower metformin prescription (0.74 [0.57-0.97], 0.39 [0.25-0.61]), but more insulin prescriptions (2.41 [1.87-3.10], 1.52 [1.10-2.10]). Also, DPP4-I prescriptions were higher for patients with kidney-related problems (1.37 [1.06-1.79]) yet lower among patients with higher HbA1c (0.82 [0.68-0.99]). Sex was significantly associated with GLP1-RA and thiazolidinedione prescribing (F:M; 1.38 [1.19-1.60] and 0.91 [0.84-0.98]).

CONCLUSION

Several factors were identified as potential determinants of antidiabetic drug prescribing. The magnitude and significance of each factor differed by antidiabetic class. Patient's age and baseline BMI had the most significant association with the choice of four out of the seven studied antidiabetic drugs followed by the baseline HbA1c and kidney-related problems which had an impact on three studied antidiabetic drugs, whereas sex had the least impact on prescribing decision as it was associated with GLP1-RA and thiazolidinedione only.

The association between body height and cancer: a retrospective analysis of 784,192 outpatients in Germany

PURPOSE

Cancer risk is determined by numerous factors. Recently, body height has been linked to different cancer sites in different populations.

METHODS

This retrospective cohort study included 784,192 adult outpatients with available body height values from 2010 to 2020 using the Disease Analyzer database (IQVIA). The outcome was the incidence of cancer diagnoses within the study period according to body height, stratified by age, sex, and cancer sites.

RESULTS

Overall cancer incidence rose with increasing body height in both sexes. In women, there was a rise from 10.9 (≤ 160 cm) to 13.6 (> 180 cm) and from 16.6 (≤ 160 cm) to 26.8 (> 180 cm) cases per 1000 patient years in the 51-60 and > 70 years age group, respectively. Among men, cancer incidene increased from 23.9 (≤ 165 cm) to 26.3 (176-185 cm) and from 38.9 (≤ 165 cm) to 43.4 (176-185 cm) cases per 1000 patient years in 61-70 and > 70 years age group, respectively. The hazard ratio (HR) for developing cancer was 1.11 (95% CI 1.09-1.13) for every 10 cm increase in body height among women and 1.06 (95% CI 1.04-1.08) among men. A significant association between body height and cancer incidence was found for certain cancer sites, such as malignant melanoma, in both women (HR 1.21, 95% CI 1.11-1.33) and men (HR 1.29, 95% CI 1.18-1.42).

CONCLUSION

In this study, we present the first data from a large cohort from Germany that provide strong evidence for a positive association between body height and the overall risk of developing various cancers.

Clinical and Pharmacotherapeutic Profile of Patients with Type 2 Diabetes Mellitus Admitted to a Hospital Emergency Department

Type 2 diabetes mellitus (T2DM) is closely associated with other pathologies, which may require complex therapeutic approaches. We aim to characterize the clinical and pharmacological profile of T2DM patients admitted to an emergency department. Patients aged ≥65 years and who were already using at least one antidiabetic drug were included in this analysis. Blood glycemia, creatinine, aspartate aminotransferase (AST), alanine aminotransferase (ALT), and hemoglobin were analyzed for each patient, as well as personal pathological history, diagnosis(s) at admission, and antidiabetic drugs used before. Outcome variables were analyzed using Pearson's Chi-Square, Fisher's exact test, and linear regression test. In total, 420 patients were randomly selected (48.6% male and 51.4% female). Patients with family support showed a lower incidence of high glycemia at admission (p = 0.016). Higher blood creatinine levels were associated with higher blood glycemia (p = 0.005), and hyperuricemia (HU) (p = 0.001), as well as HU, was associated with a higher incidence of acute cardiovascular diseases (ACD) (p = 0.007). Hemoglobin levels are lower with age (p = 0.0001), creatinine (p = 0.009), and female gender (p = 0.03). The lower the AST/ALT ratio, the higher the glycemia at admission (p < 0.0001). Obese patients with (p = 0.021) or without (p = 0.027) concomitant dyslipidemia had a higher incidence of ACD. Insulin (p = 0.003) and glucagon-like peptide-1 agonists (GLP1 RA) (p = 0.023) were associated with a higher incidence of decompensated heart failure, while sulfonylureas (p = 0.009), metformin-associated with dipeptidyl peptidase-4 inhibitors (DPP4i) (p = 0.029) or to a sulfonylurea (p = 0.003) with a lower incidence. Metformin, in monotherapy or associated with DPP4i, was associated with a lower incidence of acute kidney injury (p = 0.017) or acute chronic kidney injury (p = 0.014). SGLT2i monotherapy (p = 0.0003), associated with metformin (p = 0.026) or with DPP4i (p = 0.007), as well as insulin and sulfonylurea association (p = 0.026), were associated with hydroelectrolytic disorders, unlike GLP1 RA (p = 0.017), DPP4i associated with insulin (p = 0.034) or with a GLP1 RA (p = 0.003). Insulin was mainly used by autonomous and institutionalized patients (p = 0.0008), while metformin (p = 0.003) and GLP1 RA (p < 0.0001) were used by autonomous patients. Sulfonylureas were mostly used by male patients (p = 0.027), while SGLT2 (p = 0.0004) and GLP1 RA (p < 0.0001) were mostly used by patients within the age group 65-85 years. Sulfonylureas (p = 0.008), insulin associated with metformin (p = 0.040) or with a sulfonylurea (p = 0.048), as well as DPP4i and sulfonylurea association (p = 0.031), were associated with higher blood glycemia. T2DM patients are characterized by great heterogeneity from a clinical point of view presenting with several associated comorbidities, so the pharmacotherapeutic approach must consider all aspects that may affect disease progression.

Trends in Antidiabetic Drug Discovery: FDA Approved Drugs, New Drugs in Clinical Trials and Global Sales

Type 2 diabetes mellitus (T2DM) continues to be a substantial medical problem due to its increasing global prevalence and because chronic hyperglycemic states are closely linked with obesity, liver disease and several cardiovascular diseases. Since the early discovery of insulin, numerous antihyperglycemic drug therapies to treat diabetes have been approved, and also discontinued, by the United States Food and Drug Administration (FDA). To provide an up-to-date account of the current trends of antidiabetic pharmaceuticals, this review offers a comprehensive analysis of the main classes of antihyperglycemic compounds and their mechanisms: insulin types, biguanides, sulfonylureas, meglitinides (glinides), alpha-glucosidase inhibitors (AGIs), thiazolidinediones (TZD), incretin-dependent therapies, sodium-glucose cotransporter type 2 (SGLT2) inhibitors and combinations thereof. The number of therapeutic alternatives to treat T2DM are increasing and now there are nearly 60 drugs approved by the FDA. Beyond this there are nearly 100 additional antidiabetic agents being evaluated in clinical trials. In addition to the standard treatments of insulin therapy and metformin, there are new drug combinations, e.g., containing metformin, SGLT2 inhibitors and dipeptidyl peptidase-4 (DPP4) inhibitors, that have gained substantial use during the last decade. Furthermore, there are several interesting alternatives, such as lobeglitazone, efpeglenatide and tirzepatide, in ongoing clinical trials. Modern drugs, such as glucagon-like peptide-1 (GLP-1) receptor agonists, DPP4 inhibitors and SGLT2 inhibitors have gained popularity on the pharmaceutical market, while less expensive over the counter alternatives are increasing in developing economies. The large heterogeneity of T2DM is also creating a push towards more personalized and accessible treatments. We describe several interesting alternatives in ongoing clinical trials, which may help to achieve this in the near future.

Diabetes mellitus is associated with an increased incidence of aortic valve stenosis

BACKGROUND

The prognosis of patients with diabetes mellitus (DM) is particularly determined by vascular comorbidities. A recent theory implies that DM could also promote aortic valve stenosis (AS). The present study investigates this association in a large collective of outpatients.

METHODS

This retrospective cohort study compared the incidence of AS in patients with an initial diagnosis of type 2 DM and a matched non-DM cohort in 809 general and diabetologist practices in Germany between January 2005 and December 2018. Cox regression models were performed to study the association between type 2 DM and AS incidence.

RESULTS

A total of 78,805 patients with type 2 DM and 78,805 patients without diabetes were analysed. Diabetes patients were more frequently diagnosed with obesity (52% vs 21%). Four percent of patients with and three percent of without diabetes were diagnosed with AS (p < 0.001). Diabetes was significantly associated with an increased incidence of AS (HR: 1.36, p < 0.001). This association was higher in men (HR: 1.41) versus women (HR: 1.30). The strongest association was observed in young patients (18-50 years, HR: 2.35, p < 0.001).

CONCLUSION

In our study, diabetes patients had a higher incidence of aortic stenosis during their disease course.