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Iida O, Takahara M, Mano T. Evidence-Experience Gap and Future Perspective on the Treatment of Peripheral Artery Disease. J Atheroscler Thromb 2021; 28:1251-1259. [PMID: 34078765 PMCID: PMC8629708 DOI: 10.5551/jat.rv17058] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Peripheral artery disease (PAD) is a systemic disease associated with impaired limb function, poor quality of life, and increased cardiovascular morbidity. Its incidence has been dramatically increasing over years because of the emergence of an aging society and the increase in the number of patients with atherosclerotic risk factors. The clustering of these risk factors promotes disease development, reportedly leading to the differential location of atherosclerotic lesions in lower extremity arteries. The clinical presentations of PAD include intermittent claudication and chronic limb-threatening ischemia (CLTI). PAD is associated with a high risk of mortality and morbidity from both cardiovascular and limb events. The therapeutic goals for patients with PAD include 1) relief from PAD-related limb symptoms, 2) the prevention of new-onset and the development and recurrence of PAD, and 3) the prevention of concomitant adverse events due to coronary artery disease (CAD) and cerebrovascular disease (CVD). There are several types of antithrombotic agents, and their main role in patients with PAD is to reduce systemic events mainly including cardiovascular and lower extremity-related events. Currently, the efficacy of direct oral anticoagulant (DOAC) is also suggested by recent clinical trials. Although endovascular therapy (EVT) has been a first-line revascularization strategy for symptomatic PAD, whether clinical outcomes after EVT are comparable to those after surgical bypass therapy remains inconclusive.
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Affiliation(s)
- Osamu Iida
- Cardiovascular Center, Kansai Rosai Hospital
| | - Mitsuyoshi Takahara
- Department of Diabetes Care Medicine, Osaka University Graduate School of Medicine
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2
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CANALE MP, FEDERICI M, DI COLA G. Maximizing the medical support, the first essential complementary treatment - controlling the infection, protecting the heart and the brain. ITALIAN JOURNAL OF VASCULAR AND ENDOVASCULAR SURGERY 2021. [DOI: 10.23736/s1824-4777.21.01492-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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3
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Bajaj HS, Brown RE, Jiandani D, Venn K, Al-Asaad H, Khandwala H, Steen O, Abdel-Salam S, Aronson R. Goal achievement of HbA1c and LDL-cholesterol in a randomized trial comparing colesevelam with ezetimibe: GOAL-RCT. Diabetes Obes Metab 2020; 22:1722-1728. [PMID: 32406601 DOI: 10.1111/dom.14084] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Revised: 05/05/2020] [Accepted: 05/09/2020] [Indexed: 01/10/2023]
Abstract
AIM To compare the efficacy and safety of colesevelam and ezetimibe as second-line low density lipoprotein-cholesterol (LDL-c)-lowering options in type 2 diabetes (T2D). MATERIALS AND METHODS GOAL-RCT is a 24-week, open-label, randomized, pragmatic clinical trial. Subjects with T2D with uncontrolled HbA1c (7.1%-10%) and LDL-c (>2.0 mmol/L) were randomized 1:1 to colesevelam 3.75 g or ezetimibe 10 mg daily. The primary composite outcome was the proportion of participants achieving an LDL-c target of ≤2.0 mmol/L and HbA1c target of ≤7.0%. Intention to treat analysis was performed. RESULTS Two hundred subjects were enrolled: mean age 59 ± 10 years; mean HbA1c 8.0%; mean LDL-c 2.5 mmol/L; 97% on statin therapy. The primary composite outcome was achieved by similar proportions of participants with colesevelam (14.6%) and ezetimibe (10.5%) (Pnon-inferiority < .001, Psuperiority = .41). LDL-c reduction from baseline was less with colesevelam compared with ezetimibe (14.0% vs. 23.2%, P < .01), as was the proportion of subjects achieving an LDL-c target of ≤2.0 mmol/L (47.6% and 67.0%, respectively; P = .007). Mean HbA1c was reduced with colesevelam (-0.26 ± 0.10%), while no change was observed with ezetimibe (difference P = .06). Adverse events and discontinuation rates were higher for colesevelam (20.2% and 31.1%) compared with ezetimibe (7.2% and 6.2%), respectively. CONCLUSIONS Among subjects with T2D, the initiation of colesevelam or ezetimibe led to similar achievement of primary composite outcome (LDL-c and HbA1c within target), with ezetimibe recording a greater LDL-c reduction and better tolerability than colesevelam.
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Affiliation(s)
- Harpreet S Bajaj
- LMC Diabetes & Endocrinology, Toronto, Ontario, Canada
- Leadership Sinai Center for Diabetes, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Ruth E Brown
- LMC Diabetes & Endocrinology, Toronto, Ontario, Canada
| | | | - Karri Venn
- LMC Diabetes & Endocrinology, Toronto, Ontario, Canada
| | - Hani Al-Asaad
- LMC Diabetes & Endocrinology, Toronto, Ontario, Canada
| | | | - Oren Steen
- LMC Diabetes & Endocrinology, Toronto, Ontario, Canada
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4
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Zoungas S. ADVANCE in context: The benefits, risks and feasibility of providing intensive glycaemic control based on gliclazide modified release. Diabetes Obes Metab 2020; 22 Suppl 2:5-11. [PMID: 32250522 DOI: 10.1111/dom.13968] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Revised: 01/08/2020] [Accepted: 01/13/2020] [Indexed: 01/10/2023]
Abstract
In the last 3 decades, four large multicentre, randomized clinical trials of patients with type 2 diabetes (UKPDS, ADVANCE, ACCORD and VADT) have studied different approaches to achieving near normal glycaemic targets. Each was designed against a background of international and national guidelines recommending glycaemic targets of 6.5% or less to prevent diabetic complications. Collectively, these clinical trials provide the most robust evidence of the potential vascular benefits and risks of more versus less glucose control and provide critical insights into how therapies are used. In this review, the glucose-lowering approach used by the ADVANCE trial is considered and compared with those used by the other trials.
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Affiliation(s)
- Sophia Zoungas
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- The George Institute for Global Health, Sydney, New South Wales, Australia
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5
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Tan F, Chen Q, Zhuang X, Wu C, Qian Y, Wang Y, Wang J, Lu F, Shen M, Li Y. Associated risk factors in the early stage of diabetic retinopathy. EYE AND VISION 2019; 6:23. [PMID: 31388513 PMCID: PMC6670123 DOI: 10.1186/s40662-019-0148-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/23/2019] [Accepted: 07/09/2019] [Indexed: 02/05/2023]
Abstract
Background To investigate the retinal capillary density (RCD) of the macula using optical coherence tomography angiography (OCT-A) in type 2 diabetic patients and to further determine the association with risk factors. Methods A total of 212 eyes from 212 subjects were recruited; subjects included diabetics with no retinopathy (NDR, n = 90 eyes), diabetics with mild retinopathy DR (MDR, n = 36 eyes), and healthy participants (Control, n = 86 eyes). All participants underwent OCT-A scanning. RCD was quantified by superficial and deep retinal capillary layers (SRCL and DRCL) from OCT-A images. Results RCD in SRCL and DRCL was lower in NDR (P < 0.001) as well as in MDR (P < 0.001) when compared with control eyes. Diabetic patients were subdivided according to individual risk factors, complications related to diabetes, and hyperglycemia. Diabetic patients showed lower RCD in both the SRCL and DRCL when compared with healthy controls. Diabetics with age > 55y, HbA1c > 7% had significantly reduced DRCL (P < 0.05) when compared with the other group of diabetics (age < 55y, HbA1c < 7%). Diabetics with a blood urea nitrogen (BUN) > 8.2 mmol/L had significantly reduced SRCL and DRCL when compared to the other group of diabetics. Conclusions Risk factors including older age, higher level of HbA1c, LDL-C and BUN, were associated with lower RCDs found in type 2 diabetic patients with and without mild DR by OCT-A. The impairment of retinal capillary by OCT-A may play a key role in the early monitoring of management in diabetes.
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Affiliation(s)
- Fan Tan
- 1School of Ophthalmology and Optometry, Wenzhou Medical University, 270 Xueyuan Road, Wenzhou, Zhejiang China 325027.,2Department of Ophthalmology, West China-Guang'an Hospital, Sichuan University, Guang'an, Sichuan China.,3Department of Ophthalmology, Sichuan University West China Hospital, Chengdu, Sichuan China
| | - Qi Chen
- 1School of Ophthalmology and Optometry, Wenzhou Medical University, 270 Xueyuan Road, Wenzhou, Zhejiang China 325027
| | - Xiran Zhuang
- 1School of Ophthalmology and Optometry, Wenzhou Medical University, 270 Xueyuan Road, Wenzhou, Zhejiang China 325027
| | - Chaoming Wu
- 4The Second Affiliated Hospital & Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, Zhejiang China
| | - Yanying Qian
- 4The Second Affiliated Hospital & Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, Zhejiang China
| | - Yuanyuan Wang
- 1School of Ophthalmology and Optometry, Wenzhou Medical University, 270 Xueyuan Road, Wenzhou, Zhejiang China 325027
| | - Jianhua Wang
- 5Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, FL USA.,6Electrical and Computer Engineering, University of Miami, Miami, FL USA
| | - Fan Lu
- 1School of Ophthalmology and Optometry, Wenzhou Medical University, 270 Xueyuan Road, Wenzhou, Zhejiang China 325027
| | - Meixiao Shen
- 1School of Ophthalmology and Optometry, Wenzhou Medical University, 270 Xueyuan Road, Wenzhou, Zhejiang China 325027
| | - Yingzi Li
- 1School of Ophthalmology and Optometry, Wenzhou Medical University, 270 Xueyuan Road, Wenzhou, Zhejiang China 325027
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Conte MS, Bradbury AW, Kolh P, White JV, Dick F, Fitridge R, Mills JL, Ricco JB, Suresh KR, Murad MH, Aboyans V, Aksoy M, Alexandrescu VA, Armstrong D, Azuma N, Belch J, Bergoeing M, Bjorck M, Chakfé N, Cheng S, Dawson J, Debus ES, Dueck A, Duval S, Eckstein HH, Ferraresi R, Gambhir R, Gargiulo M, Geraghty P, Goode S, Gray B, Guo W, Gupta PC, Hinchliffe R, Jetty P, Komori K, Lavery L, Liang W, Lookstein R, Menard M, Misra S, Miyata T, Moneta G, Munoa Prado JA, Munoz A, Paolini JE, Patel M, Pomposelli F, Powell R, Robless P, Rogers L, Schanzer A, Schneider P, Taylor S, De Ceniga MV, Veller M, Vermassen F, Wang J, Wang S. Global Vascular Guidelines on the Management of Chronic Limb-Threatening Ischemia. Eur J Vasc Endovasc Surg 2019; 58:S1-S109.e33. [PMID: 31182334 PMCID: PMC8369495 DOI: 10.1016/j.ejvs.2019.05.006] [Citation(s) in RCA: 718] [Impact Index Per Article: 143.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
GUIDELINE SUMMARY Chronic limb-threatening ischemia (CLTI) is associated with mortality, amputation, and impaired quality of life. These Global Vascular Guidelines (GVG) are focused on definition, evaluation, and management of CLTI with the goals of improving evidence-based care and highlighting critical research needs. The term CLTI is preferred over critical limb ischemia, as the latter implies threshold values of impaired perfusion rather than a continuum. CLTI is a clinical syndrome defined by the presence of peripheral artery disease (PAD) in combination with rest pain, gangrene, or a lower limb ulceration >2 weeks duration. Venous, traumatic, embolic, and nonatherosclerotic etiologies are excluded. All patients with suspected CLTI should be referred urgently to a vascular specialist. Accurately staging the severity of limb threat is fundamental, and the Society for Vascular Surgery Threatened Limb Classification system, based on grading of Wounds, Ischemia, and foot Infection (WIfI) is endorsed. Objective hemodynamic testing, including toe pressures as the preferred measure, is required to assess CLTI. Evidence-based revascularization (EBR) hinges on three independent axes: Patient risk, Limb severity, and ANatomic complexity (PLAN). Average-risk and high-risk patients are defined by estimated procedural and 2-year all-cause mortality. The GVG proposes a new Global Anatomic Staging System (GLASS), which involves defining a preferred target artery path (TAP) and then estimating limb-based patency (LBP), resulting in three stages of complexity for intervention. The optimal revascularization strategy is also influenced by the availability of autogenous vein for open bypass surgery. Recommendations for EBR are based on best available data, pending level 1 evidence from ongoing trials. Vein bypass may be preferred for average-risk patients with advanced limb threat and high complexity disease, while those with less complex anatomy, intermediate severity limb threat, or high patient risk may be favored for endovascular intervention. All patients with CLTI should be afforded best medical therapy including the use of antithrombotic, lipid-lowering, antihypertensive, and glycemic control agents, as well as counseling on smoking cessation, diet, exercise, and preventive foot care. Following EBR, long-term limb surveillance is advised. The effectiveness of nonrevascularization therapies (eg, spinal stimulation, pneumatic compression, prostanoids, and hyperbaric oxygen) has not been established. Regenerative medicine approaches (eg, cell, gene therapies) for CLTI should be restricted to rigorously conducted randomizsed clinical trials. The GVG promotes standardization of study designs and end points for clinical trials in CLTI. The importance of multidisciplinary teams and centers of excellence for amputation prevention is stressed as a key health system initiative.
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Affiliation(s)
- Michael S Conte
- Division of Vascular and Endovascular Surgery, University of California, San Francisco, CA, USA.
| | - Andrew W Bradbury
- Department of Vascular Surgery, University of Birmingham, Birmingham, United Kingdom
| | - Philippe Kolh
- Department of Biomedical and Preclinical Sciences, University Hospital of Liège, Wallonia, Belgium
| | - John V White
- Department of Surgery, Advocate Lutheran General Hospital, Niles, IL, USA
| | - Florian Dick
- Department of Vascular Surgery, Kantonsspital St. Gallen, St. Gallen, and University of Berne, Berne, Switzerland
| | - Robert Fitridge
- Department of Vascular and Endovascular Surgery, The University of Adelaide Medical School, Adelaide, South Australia, Australia
| | - Joseph L Mills
- Division of Vascular Surgery and Endovascular Therapy, Baylor College of Medicine, Houston, TX, USA
| | - Jean-Baptiste Ricco
- Department of Clinical Research, University Hospitalof Poitiers, Poitiers, France
| | | | - M Hassan Murad
- Mayo Clinic Evidence-Based Practice Center, Rochester, MN, USA
| | - Victor Aboyans
- Department of Cardiology, Dupuytren, University Hospital, France
| | - Murat Aksoy
- Department of Vascular Surgery American, Hospital, Turkey
| | | | | | | | - Jill Belch
- Ninewells Hospital University of Dundee, UK
| | - Michel Bergoeing
- Escuela de Medicina Pontificia Universidad, Catolica de Chile, Chile
| | - Martin Bjorck
- Department of Surgical Sciences, Vascular Surgery, Uppsala University, Sweden
| | | | | | - Joseph Dawson
- Royal Adelaide Hospital & University of Adelaide, Australia
| | - Eike S Debus
- University Heart Center Hamburg, University Hospital Hamburg-Eppendorf, Germany
| | - Andrew Dueck
- Schulich Heart Centre, Sunnybrook Health, Sciences Centre, University of Toronto, Canada
| | - Susan Duval
- Cardiovascular Division, University of, Minnesota Medical School, USA
| | | | - Roberto Ferraresi
- Interventional Cardiovascular Unit, Cardiology Department, Istituto Clinico, Città Studi, Milan, Italy
| | | | - Mauro Gargiulo
- Diagnostica e Sperimentale, University of Bologna, Italy
| | | | | | | | - Wei Guo
- 301 General Hospital of PLA, Beijing, China
| | | | | | - Prasad Jetty
- Division of Vascular and Endovascular Surgery, The Ottawa Hospital and the University of Ottawa, Ottawa, Canada
| | | | | | - Wei Liang
- Renji Hospital, School of Medicine, Shanghai Jiaotong University, China
| | - Robert Lookstein
- Division of Vascular and Interventional Radiology, Icahn School of Medicine at Mount Sinai
| | | | | | | | | | | | | | - Juan E Paolini
- Sanatorio Dr Julio Mendez, University of Buenos Aires, Argentina
| | - Manesh Patel
- Division of Cardiology, Duke University Health System, USA
| | | | | | | | - Lee Rogers
- Amputation Prevention Centers of America, USA
| | | | - Peter Schneider
- Kaiser Foundation Hospital Honolulu and Hawaii Permanente Medical Group, USA
| | - Spence Taylor
- Greenville Health Center/USC School of Medicine Greenville, USA
| | | | - Martin Veller
- University of the Witwatersrand, Johannesburg, South Africa
| | | | - Jinsong Wang
- The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Shenming Wang
- The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
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7
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Conte MS, Bradbury AW, Kolh P, White JV, Dick F, Fitridge R, Mills JL, Ricco JB, Suresh KR, Murad MH. Global vascular guidelines on the management of chronic limb-threatening ischemia. J Vasc Surg 2019; 69:3S-125S.e40. [PMID: 31159978 PMCID: PMC8365864 DOI: 10.1016/j.jvs.2019.02.016] [Citation(s) in RCA: 693] [Impact Index Per Article: 138.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Chronic limb-threatening ischemia (CLTI) is associated with mortality, amputation, and impaired quality of life. These Global Vascular Guidelines (GVG) are focused on definition, evaluation, and management of CLTI with the goals of improving evidence-based care and highlighting critical research needs. The term CLTI is preferred over critical limb ischemia, as the latter implies threshold values of impaired perfusion rather than a continuum. CLTI is a clinical syndrome defined by the presence of peripheral artery disease (PAD) in combination with rest pain, gangrene, or a lower limb ulceration >2 weeks duration. Venous, traumatic, embolic, and nonatherosclerotic etiologies are excluded. All patients with suspected CLTI should be referred urgently to a vascular specialist. Accurately staging the severity of limb threat is fundamental, and the Society for Vascular Surgery Threatened Limb Classification system, based on grading of Wounds, Ischemia, and foot Infection (WIfI) is endorsed. Objective hemodynamic testing, including toe pressures as the preferred measure, is required to assess CLTI. Evidence-based revascularization (EBR) hinges on three independent axes: Patient risk, Limb severity, and ANatomic complexity (PLAN). Average-risk and high-risk patients are defined by estimated procedural and 2-year all-cause mortality. The GVG proposes a new Global Anatomic Staging System (GLASS), which involves defining a preferred target artery path (TAP) and then estimating limb-based patency (LBP), resulting in three stages of complexity for intervention. The optimal revascularization strategy is also influenced by the availability of autogenous vein for open bypass surgery. Recommendations for EBR are based on best available data, pending level 1 evidence from ongoing trials. Vein bypass may be preferred for average-risk patients with advanced limb threat and high complexity disease, while those with less complex anatomy, intermediate severity limb threat, or high patient risk may be favored for endovascular intervention. All patients with CLTI should be afforded best medical therapy including the use of antithrombotic, lipid-lowering, antihypertensive, and glycemic control agents, as well as counseling on smoking cessation, diet, exercise, and preventive foot care. Following EBR, long-term limb surveillance is advised. The effectiveness of nonrevascularization therapies (eg, spinal stimulation, pneumatic compression, prostanoids, and hyperbaric oxygen) has not been established. Regenerative medicine approaches (eg, cell, gene therapies) for CLTI should be restricted to rigorously conducted randomizsed clinical trials. The GVG promotes standardization of study designs and end points for clinical trials in CLTI. The importance of multidisciplinary teams and centers of excellence for amputation prevention is stressed as a key health system initiative.
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Affiliation(s)
- Michael S Conte
- Division of Vascular and Endovascular Surgery, University of California, San Francisco, Calif.
| | - Andrew W Bradbury
- Department of Vascular Surgery, University of Birmingham, Birmingham, United Kingdom
| | - Philippe Kolh
- Department of Biomedical and Preclinical Sciences, University Hospital of Liège, Wallonia, Belgium
| | - John V White
- Department of Surgery, Advocate Lutheran General Hospital, Niles, Ill
| | - Florian Dick
- Department of Vascular Surgery, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Robert Fitridge
- Department of Vascular and Endovascular Surgery, The University of Adelaide Medical School, Adelaide, South Australia
| | - Joseph L Mills
- Division of Vascular Surgery and Endovascular Therapy, Baylor College of Medicine, Houston, Tex
| | - Jean-Baptiste Ricco
- Department of Clinical Research, University Hospitalof Poitiers, Poitiers, France
| | | | - M Hassan Murad
- Mayo Clinic Evidence-Based Practice Center, Rochester, Minn
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8
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Ruiz-Negrón N, Wander C, McAdam-Marx C, Pesa J, Bailey RA, Bellows BK. Factors Associated with Diabetes-Related Clinical Inertia in a Managed Care Population and Its Effect on Hemoglobin A1c Goal Attainment: A Claims-Based Analysis. J Manag Care Spec Pharm 2019; 25:304-313. [PMID: 30816810 PMCID: PMC10397755 DOI: 10.18553/jmcp.2019.25.3.304] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Despite evidence showing the benefits of treatment intensification following an elevated hemoglobin A1c (A1c), clinical inertia, or failure to establish and/or escalate treatment to achieve treatment goals, is a concern among patients diagnosed with type 2 diabetes (T2DM). Clinical inertia may contribute to increased health care utilization and costs due to poor clinical outcomes in MCOs. OBJECTIVES To (a) identify factors associated with clinical inertia in T2DM and (b) determine differences in A1c goal attainment between patients who experience clinical inertia versus treatment intensification in a commercially insured population. METHODS Medical and pharmacy claims data were used to identify commercially insured patients in a regional MCO with a recorded A1c ≥ 8.0% between January 1, 2013, and December 31, 2015. In the 4 months following the first elevated A1c value (index date), patients were classified into 2 groups: treatment intensification or clinical inertia. Treatment intensification was defined as the addition of ≥ 1 new noninsulin antihyperglycemic medication, the addition of insulin, or a dose increase of any current noninsulin antihyperglycemic medication. Patients were required to have ≥ 1 follow-up A1c value 6-12 months after the index date and continuous enrollment in the health plan for 12 months before and after the index date. Patients were excluded if they had a diagnosis for gestational diabetes or type 1 diabetes or if they were on insulin in the pre-index period. The primary outcome of attaining A1c < 7.0% was compared between groups after propensity score matching (PSM). Factors associated with clinical inertia were identified using logistic regression. RESULTS 3,078 patients, with a mean (SD) age of 54.4 (10.6) years and a mean (SD) baseline A1c of 9.6% (1.7), were included in the study. Of these, 1,093 patients (36%) experienced clinical inertia. After PSM, 1,760 patients remained; 880 in each group. In the clinical inertia group, 23% of patients achieved an A1c < 7.0% in the post-index period, compared with 35% in the treatment intensification group (P < 0.001). A greater likelihood of experiencing clinical inertia was associated with baseline treatment with 2 (OR = 1.51, 95% CI = 1.22-2.86; P < 0.001) or ≥ 3 (OR = 1.78, 95% CI = 1.30-2.42; P < 0.001) antihyperglycemic medications (vs. none), baseline age ≥ 65 years (OR = 2.11, 95% CI = 1.63-2.74; P < 0.001), and diagnosis of coronary heart disease (OR = 1.44, 95% CI = 1.10-1.88; P = 0.007). A baseline A1c ≥ 9.0% (vs. 8.0%-8.9%) was associated with a lower likelihood of experiencing clinical inertia (OR = 0.56, 95% CI = 0.48-0.66; P < 0.001). CONCLUSIONS More than a third of patients in a commercially insured population with T2DM and a baseline A1c ≥ 8% experienced clinical inertia. Clinical inertia resulted in worse A1c outcomes over the 12-month follow-up period. Results of this study suggest that treatment intensification should be monitored, with efforts made to educate health care providers on strategies aimed at improving glycemic control for high-risk patients. DISCLOSURES This study was funded by a grant from Janssen Scientific Affairs, which was involved in study design, interpretation of results, and manuscript review. Wander reports consulting fees from Sanofi Aventis outside the submitted work. McAdam-Marx reports grants from Sanofi Aventis and AstraZeneca outside the submitted work. Pesa and Bailey were employees of Janssen Scientific Affairs during the conduct of the study. Bailey also reports stock ownership in Johnson and Johnson. This study was presented as a poster at the Academy of Managed Care Pharmacy Nexus 2017; October 16-19, 2017; Grapevine, TX.
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Affiliation(s)
- Natalia Ruiz-Negrón
- Department of Pharmacotherapy, University of Utah, Salt Lake City, and Select Health, Murray, Utah
| | | | - Carrie McAdam-Marx
- Pharmaceutical Evaluation and Policy Division, University of Arkansas for Medical Sciences, Little Rock
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9
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Rosenstock J, Handelsman Y, Vidal J, Ampudia Blasco FJ, Giorgino F, Liu M, Perfetti R, Meier JJ. Propensity-score-matched comparative analyses of simultaneously administered fixed-ratio insulin glargine 100 U and lixisenatide (iGlarLixi) vs sequential administration of insulin glargine and lixisenatide in uncontrolled type 2 diabetes. Diabetes Obes Metab 2018; 20:2821-2829. [PMID: 29974618 PMCID: PMC6282993 DOI: 10.1111/dom.13462] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2018] [Revised: 06/29/2018] [Accepted: 06/29/2018] [Indexed: 01/02/2023]
Abstract
AIM To conduct two exploratory analyses to compare indirectly the efficacy and safety of simultaneous administration of insulin glargine 100 U (iGlar) and the glucagon-like peptide-1 receptor agonist (GLP-1RA) lixisenatide (Lixi) as a single-pen, titratable, fixed-ratio combination (iGlarLixi [LixiLan trials]) vs sequential administration of iGlar + Lixi (GetGoal Duo trials) in people with type 2 diabetes (T2D). MATERIALS AND METHODS Propensity-score matching based on baseline covariates was used to compare simultaneous iGlarLixi vs sequential combination of iGlar + Lixi with the addition of Lixi in patients who did not reach the glycated haemoglobin (HbA1c) goal of <53 mmol/mol (<7%) after short-term use of iGlar alone (LixiLan-O vs GetGoal Duo-1 comparison) and vs sequential addition of Lixi in uncontrolled patients after long-term use of iGlar alone (LixiLan-L vs GetGoal Duo-2 comparison). RESULTS In both analyses, compared with sequential iGlar + Lixi, iGlarLixi led to significantly greater HbA1c reductions with associated weight loss and significantly more patients reaching target HbA1c <53 mmol/mol despite lower insulin doses. Symptomatic hypoglycaemia rates were similar, despite greater HbA1c reductions with iGlarLixi. Lower rates of gastrointestinal adverse events were observed with iGlarLixi, probably as a result of the more gradual titration of Lixi with iGlarLixi. CONCLUSIONS Indirect propensity-score-matched exploratory comparisons suggest that early treatment with a simultaneous, titratable, fixed-ratio combination of basal insulin and a GLP-1RA (iGlarLixi) may be more effective and possess better gastrointestinal tolerability than a sequential approach of adding a GLP-1RA in patients with uncontrolled T2D initiating or intensifying basal insulin therapy.
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Affiliation(s)
| | | | - Josep Vidal
- Hospital Clinic of BarcelonaBarcelonaSpain
- Centro Investigación Biomédica en Red en Diabetes y Enfermeades Metabólicas (CIBERDEM)MadridSpain
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10
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Strey CBM, de Carli LA, Fantinelli M, Gobbato SS, Bassols GF, Losekann A, Coral GP. Impact of Diabetes Mellitus and Insulin on Nonalcoholic Fatty Liver Disease in the Morbidly Obese. Ann Hepatol 2018; 17:585-591. [PMID: 29893699 DOI: 10.5604/01.3001.0012.0922] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
INTRODUCTION AND AIM The prevalence of obesity, type 2 diabetes mellitus and non-alcoholic fatty liver disease are increasing. Type 2 diabetes mellitus may aggravate non-alcoholic fatty liver disease, increasing the risk of developing cirrhosis and hepatocellular carcinoma. This study aims to determine the effect of type 2 diabetes mellitus and insulin therapy on non-alcoholic fatty liver disease in the patients with morbid obesity. MATERIAL AND METHODS Clinical, anthropometric and laboratory data were analyzed together with intraoperative liver biopsies from morbidly obese patients undergoing bariatric surgery. RESULTS 219 patients with morbid obesity were evaluated. Systemic arterial hypertension (55.9% vs. 33.8%, p = 0.004) and dyslipidemia (67.1% vs. 39.0%, p < 0.001) were more prevalent in patients with diabetes when compared to patients without diabetes. In multivariate analysis, type 2 diabetes mellitus was an independent risk factor for severe steatosis (RR = 2.04, p = 0.023) and severe fibrosis (RR = 4.57, p = 0.013). Insulin therapy was significantly associated with non-alcoholic steatohepatitis (RR = 1.89, p = 0.001) and fibrosis (RR = 1.75, p = 0.050) when all patients were analysed, but when only patients with diabetes were analysed, insulin therapy was not associated with non-alcoholic steatohepatitis or fibrosis. CONCLUSION Type 2 diabetes mellitus plays an important role in the progression of non-alcoholic fatty liver disease as an independent risk factor for severe fibrosis.
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Affiliation(s)
- Cláudia B M Strey
- Department of Hepatology, Universidade Federal de Ciências da Saúde de Porto Alegre, Porto Alegre, RS, Brazil
| | - Luiz A de Carli
- Obesity Treatment Center, Santa Casa de Misericórdia de Porto Alegre, Porto Alegre, RS, Brazil
| | - Marciane Fantinelli
- Obesity Treatment Center, Santa Casa de Misericórdia de Porto Alegre, Porto Alegre, RS, Brazil
| | - Sabrina S Gobbato
- Obesity Treatment Center, Santa Casa de Misericórdia de Porto Alegre, Porto Alegre, RS, Brazil
| | - Guilherme F Bassols
- Obesity Treatment Center, Santa Casa de Misericórdia de Porto Alegre, Porto Alegre, RS, Brazil
| | - Alexandre Losekann
- Department of Internal Medicine, Faculdade de Medicina da Pontifícia Universidade Católica do Rio Grande do Sul, Proto Alegre, RS, Brazil
| | - Gabriela P Coral
- Department of Hepatology, Universidade Federal de Ciências da Saúde de Porto Alegre, Porto Alegre, RS, Brazil
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Blonde L, Aschner P, Bailey C, Ji L, Leiter LA, Matthaei S. Gaps and barriers in the control of blood glucose in people with type 2 diabetes. Diab Vasc Dis Res 2017; 14:172-183. [PMID: 28467203 PMCID: PMC5418936 DOI: 10.1177/1479164116679775] [Citation(s) in RCA: 88] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Glycaemic control is suboptimal in a large proportion of people with type 2 diabetes who are consequently at an increased and avoidable risk of potentially severe complications. We sought to explore attitudes and practices among healthcare professionals that may contribute to suboptimal glycaemic control through a review of recent relevant publications in the scientific literature. METHODS An electronic search of the PubMed database was performed to identify relevant publications from January 2011 to July 2015. The electronic search was complemented by a manual search of abstracts from key diabetes conferences in 2014/2015 available online. RESULTS Recently published data indicate that glycaemic control is suboptimal in a substantial proportion (typically 40%-60%) of people with diabetes. This is the case across geographic regions and in both low- and higher-income countries. Therapeutic inertia appears to be an important contributor to poor glycaemic control in up to half of people with type 2 diabetes. In particular, prescribers are often willing to tolerate extended periods of 'mild' hyperglycaemia as well as having low expectations for their patients. There are often delays of 3 years or longer in initiating or intensifying glucose-lowering therapy when needed. CONCLUSION Many people with type 2 diabetes are failed by current management, with approximately half not achieving or maintaining appropriate target blood glucose levels, leaving these patients at increased and avoidable risk of serious complications. Review criteria: The methodology of this review article is detailed in the 'Methods' section.
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Affiliation(s)
- Lawrence Blonde
- Department of Endocrinology, Ochsner Medical Center, New Orleans, LA, USA
- Lawrence Blonde, Department of Endocrinology, Ochsner Medical Center, 1514 Jefferson Highway, New Orleans, LA 70121, USA.
| | - Pablo Aschner
- Endocrinology Unit, Javeriana University School of Medicine, Bogotá, Colombia
| | - Clifford Bailey
- School of Life & Health Sciences, Aston University, Birmingham, UK
| | - Linong Ji
- Peking University People’s Hospital, Beijing, China
| | - Lawrence A Leiter
- Keenan Research Center in the Li Ka Shing Knowledge Institute, St. Michael’s Hospital and Division of Endocrinology & Metabolism, University of Toronto, Toronto, ON, Canada
| | - Stephan Matthaei
- Diabetes, Metabolism and Endocrinology Center, Quakenbrück Hospital, Quakenbrück, Germany
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12
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Roussel R, Martinez L, Vandebrouck T, Douik H, Emiel P, Guery M, Hunt B, Valentine WJ. Evaluation of the long-term cost-effectiveness of liraglutide therapy for patients with type 2 diabetes in France. J Med Econ 2016; 19:121-34. [PMID: 26413789 DOI: 10.3111/13696998.2015.1100998] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
OBJECTIVES The present study aimed to compare the projected long-term clinical and cost implications associated with liraglutide, sitagliptin and glimepiride in patients with type 2 diabetes mellitus failing to achieve glycemic control on metformin monotherapy in France. METHODS Clinical input data for the modeling analysis were taken from two randomized, controlled trials (LIRA-DPP4 and LEAD-2). Long-term (patient lifetime) projections of clinical outcomes and direct costs (2013 Euros; €) were made using a validated computer simulation model of type 2 diabetes. Costs were taken from published France-specific sources. Future costs and clinical benefits were discounted at 3% annually. Sensitivity analyses were performed. RESULTS Liraglutide was associated with an increase in quality-adjusted life expectancy of 0.25 quality-adjusted life years (QALYs) and an increase in mean direct healthcare costs of €2558 per patient compared with sitagliptin. In the comparison with glimepiride, liraglutide was associated with an increase in quality-adjusted life expectancy of 0.23 QALYs and an increase in direct costs of €4695. Based on these estimates, liraglutide was associated with an incremental cost-effectiveness ratio (ICER) of €10,275 per QALY gained vs sitagliptin and €20,709 per QALY gained vs glimepiride in France. CONCLUSION Calculated ICERs for both comparisons fell below the commonly quoted willingness-to-pay threshold of €30,000 per QALY gained. Therefore, liraglutide is likely to be cost-effective vs sitagliptin and glimepiride from a healthcare payer perspective in France.
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Affiliation(s)
- Ronan Roussel
- a a AP-HP, Bichat Hospital, Department of Diabetology-Endocrinology-Nutrition, Department Hospital University FIRE , Paris , France
- b b INSERM, UMRS 1138, Centre de Recherche des Cordeliers , Paris , France
- c c University Paris Diderot Sorbonne Paris Cité, UFR de Médecine , Paris , France
| | - Luc Martinez
- d d Department of General Practice , Pierre et Marie Curie University , Paris , France
| | | | - Habiba Douik
- f f Novo Nordisk Pharmaceutique SAS , Paris , France
| | - Patrick Emiel
- f f Novo Nordisk Pharmaceutique SAS , Paris , France
| | | | - Barnaby Hunt
- g g Ossian Health Economics and Communications , Basel , Switzerland
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