1
|
Mannucci E, Targher G, Nreu B, Pintaudi B, Candido R, Giaccari A, Gallo M, Monami M. Effects of insulin on cardiovascular events and all-cause mortality in patients with type 2 diabetes: A meta-analysis of randomized controlled trials. Nutr Metab Cardiovasc Dis 2022; 32:1353-1360. [PMID: 35422359 DOI: 10.1016/j.numecd.2022.03.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Revised: 01/31/2022] [Accepted: 03/04/2022] [Indexed: 10/18/2022]
Abstract
AIM In 2019, the Italian Society of Diabetology and the Italian Association of Clinical Diabetologists nominated an expert panel to develop guidelines for drug treatment of type 2 diabetes. This expert panel, after identifying the effects of glucose-lowering agents on major adverse cardiovascular events (MACEs), all-cause mortality, and hospitalization for heart failure (HHF) as critical outcomes, decided to perform a systematic review and meta-analysis on the effect of insulin with this respect. DATA SYNTHESIS A MEDLINE database search was performed to identify all RCTs, up to June 1st, 2021, with duration≥52 weeks, in which insulin was compared with either placebo or active comparators. The principal endpoints were MACE and HHF (restricted for RCT reporting MACEs within their outcomes), all-cause mortality (irrespective of the inclusion of MACEs among the pre-specified outcomes). Mantel-Haenszel odds ratio (MH-OR) with 95% Confidence Interval (95% CI) was calculated for all the endpoints considered. Six RCTs (enrolling 8091 patients and 10,139 in the insulin and control group, respectively) were included in the analysis for MACEs and HF, and 18 in that for all-cause mortality (9760 and 11,694 patients in the insulin and control group, respectively). Treatment with insulin neither significantly increased nor reduced the risk of MACE, all-cause mortality, and HHF in comparison with placebo/active comparators (MH-OR: 1.09, 95% CI 0.97-1.23; 0.99, 95% CI 0.91, 1.08; and 0.90, 95% CI 0.78, 1.04, respectively). CONCLUSIONS This meta-analysis showed no significant effects of insulin on incident MACE, all-cause mortality, and HHF.
Collapse
Affiliation(s)
| | - Giovanni Targher
- Endocrinology, Diabetes and Metabolism, University of Verona, Italy
| | - Besmir Nreu
- Diabetology, Careggi Hospital and University of Florence, Italy
| | | | - Riccardo Candido
- Diabetes Centre District 3, Azienda Sanitaria Universitaria Integrata di Trieste, Via Puccini 48/50, 34100, Trieste, Italy
| | - Andrea Giaccari
- Centro per le Malattie Endocrine e Metaboliche, Fondazione Policlinico Universitario A. Gemelli IRCCS and Università Cattolica Del Sacro Cuore, Rome, Italy
| | - Marco Gallo
- Endocrinology and Metabolic Diseases Unit, Azienda Ospedaliera SS. Antonio e Biagio e Cesare Arrigo, Alessandria, Italy
| | - Matteo Monami
- Diabetology, Careggi Hospital and University of Florence, Italy.
| |
Collapse
|
2
|
Williams DM, Jones H, Stephens JW. Personalized Type 2 Diabetes Management: An Update on Recent Advances and Recommendations. Diabetes Metab Syndr Obes 2022; 15:281-295. [PMID: 35153495 PMCID: PMC8824792 DOI: 10.2147/dmso.s331654] [Citation(s) in RCA: 40] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Accepted: 01/18/2022] [Indexed: 12/19/2022] Open
Abstract
Previous guidelines for the treatment of people with type 2 diabetes mellitus (T2D) have relied heavily upon rigid algorithms for the sequential addition of pharmacotherapies to achieve target glycemic control. More recent guidelines advocate a personalized approach for diabetes treatment, to improve patient satisfaction, quality of life, medication adherence and overall health outcomes. Clinicians should work with patients to develop personalized goals for their treatment, including targeted glycemic control, weight management, prevention and treatment of associated comorbidities and avoidance of complications such as hypoglycemia. Factors that affect the intensity of treatment and choice of pharmacotherapy should include medical and patient influences. Medical considerations include the diabetes phenotype, biomarkers including genetic tests, and the presence of comorbidities such as cardiovascular, renal, or hepatic disease. Patient factors include their treatment preference, age and life expectancy, diabetes duration, hypoglycemia fear and unawareness, psychological and social circumstances. The use of a personalized approach in the management of people with T2D can reduce the cost and failure associated with the algorithmic "one-size-fits-all" approach, to anticipate disease progression, improve the response to diabetes pharmacotherapy and reduce the incidence of diabetes-associated complications. Ultimately, the use of personalized medicine in people with T2D should improve medication adherence, patient satisfaction and quality of life to reduce diabetes distress and improve physical health outcomes.
Collapse
Affiliation(s)
- David M Williams
- Department of Diabetes and Endocrinology, Morriston Hospital, Swansea Bay University Health Board, Swansea, SA6 8NL, UK
- Correspondence: David M Williams, Diabetes Centre, Morriston Hospital, Swansea, SA6 6NL., UK, Tel +441792704078, Email
| | - Hannah Jones
- Department of Diabetes and Endocrinology, Morriston Hospital, Swansea Bay University Health Board, Swansea, SA6 8NL, UK
| | - Jeffrey W Stephens
- Department of Diabetes and Endocrinology, Morriston Hospital, Swansea Bay University Health Board, Swansea, SA6 8NL, UK
- Diabetes Research Group, Swansea University Medical School, Swansea University, Swansea, SA2 8PP, UK
| |
Collapse
|
3
|
Mannucci E, Monami M, Candido R, Pintaudi B, Targher G. Effect of insulin secretagogues on major cardiovascular events and all-cause mortality: A meta-analysis of randomized controlled trials. Nutr Metab Cardiovasc Dis 2020; 30:1601-1608. [PMID: 32811736 DOI: 10.1016/j.numecd.2020.05.032] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Revised: 05/19/2020] [Accepted: 05/27/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND AND AIM In 2019, the Italian Society of Diabetology and the Italian Association of Clinical Diabetologists nominated an expert panel to develop guidelines for drug treatment of type 2 diabetes. This expert panel, after identifying the effects of glucose-lowering agents on major adverse cardiovascular events (MACEs) and all-cause mortality as critical outcomes, decided to perform a systematic review and meta-analysis on the effect of insulin secretagogues (sulfonylureas and glinides) with this respect. METHODS AND RESULTS A MEDLINE database search was performed to identify all RCTs, up to January 1st, 2020, with duration≥52 weeks, in which insulin secretagogues (glibenclamide, gliclazide, glimepiride, glipizide, chlorpropamide, repaglinide, nateglinide) were compared with either placebo or active comparators. The principal endpoints were MACE (restricted for RCT reporting MACEs within their outcomes) and all-cause mortality (irrespective of the inclusion of MACEs among the pre-specified outcomes). Mantel-Haenszel odds ratio (MH-OR) with 95% Confidence Interval (95% CI) was calculated for all the endpoints considered. Fourteen RCTs were included in the analysis for MACEs (919 in insulin secretagogues and 1,087 in control group). Insulin secretagogues were not significantly associated with an increased risk of MACEs in comparison with controls (MH-OR 1.08 [95% CI 0.96, 1.22], p = 0.20). When considering the 48 RCTs fulfilling criteria for inclusion in the analysis on all-cause mortality, insulin secretagogues were associated with a significantly increased risk of all-cause mortality (MH-OR 1.11 [1.00, 1.23], p = 0.04). CONCLUSIONS This meta-analysis suggests that insulin secretagogues are associated with an increased risk of all-cause mortality when compared with placebo or other anti-hyperglycaemic drugs.
Collapse
Affiliation(s)
- Edoardo Mannucci
- Diabetology, Careggi Hospital and University of Florence, Italy.
| | - Matteo Monami
- Diabetology, Careggi Hospital and University of Florence, Italy
| | - Riccardo Candido
- Diabetes Centre District 3, Azienda Sanitaria Universitaria Integrata di Trieste, Via Puccini 48/50, 34100, Trieste, Italy
| | | | - Giovanni Targher
- Endocrinology, Diabetes and Metabolism, University of Verona, Italy
| |
Collapse
|
4
|
Harada M, Fujihara K, Osawa T, Yamamoto M, Kaneko M, Ishizawa M, Matsubayashi Y, Yamada T, Yamanaka N, Seida H, Kodama S, Ogawa W, Sone H. Association of treatment-achieved HbA1c with incidence of coronary artery disease and severe eye disease in diabetes patients. DIABETES & METABOLISM 2020; 46:331-334. [DOI: 10.1016/j.diabet.2018.08.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/16/2018] [Revised: 08/21/2018] [Accepted: 08/21/2018] [Indexed: 01/09/2023]
|
5
|
Presley CA, Chipman J, Min JY, Grijalva CG, Greevy RA, Griffin MR, Roumie CL. Evaluation of Frailty as an Unmeasured Confounder in Observational Studies of Antidiabetic Medications. J Gerontol A Biol Sci Med Sci 2019; 74:1282-1288. [PMID: 30256914 PMCID: PMC6625595 DOI: 10.1093/gerona/gly224] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2018] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND It is unknown whether observational studies evaluating the association between antidiabetic medications and mortality adequately account for frailty. Our objectives were to evaluate if frailty was a potential confounder in the relationship between antidiabetic medication regimen and mortality and how well administrative and clinical electronic health record (EHR) data account for frailty. METHODS We conducted a retrospective cohort study in a single Veterans Health Administration (VHA) healthcare system of 500 hospitalizations-the majority due to heart failure-of Veterans who received regular VHA care and initiated type 2 diabetes treatment from 2001 to 2008. We measured frailty using a modified frailty index (FI, >0.21 frail). We obtained antidiabetic medication regimen and time-to-death from administrative sources. We compared FI among patients on different antidiabetic regimens. Stepwise Cox proportional hazards regression estimated time-to-death by demographic, administrative, clinical EHR, and FI data. RESULTS Median FI was 0.22 (interquartile range 0.18, 0.27). Frailty differed across antidiabetic regimens (p < .001). An FI increase of 0.05 was associated with an increased risk of death (hazard ratio 1.45, 95% confidence interval 1.32, 1.60). Cox proportional hazards model for time-to-death including demographic, administrative, and clinical EHR data had a c-statistic of 0.70; adding FI showed marginal improvement (c-statistic 0.72). CONCLUSIONS Frailty was associated with antidiabetic regimen and death, and may confound that relationship. Demographic, administrative, and clinical EHR data, commonly used to balance differences among exposure groups, performed moderately well in assessing risk of death, with minimal gain from adding frailty. Study design and analytic techniques can help minimize potential confounding by frailty in observational studies.
Collapse
Affiliation(s)
- Caroline A Presley
- Department of Medicine, University of Alabama at Birmingham, Nashville, Tennessee
| | - Jonathan Chipman
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jea Young Min
- Veterans Health Administration-Tennessee Valley Healthcare System, Geriatric Research Education and Clinical Center (GRECC), Nashville
- Department of Health Policy
| | - Carlos G Grijalva
- Veterans Health Administration-Tennessee Valley Healthcare System, Geriatric Research Education and Clinical Center (GRECC), Nashville
- Department of Health Policy
| | - Robert A Greevy
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Marie R Griffin
- Veterans Health Administration-Tennessee Valley Healthcare System, Geriatric Research Education and Clinical Center (GRECC), Nashville
- Department of Health Policy
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Christianne L Roumie
- Veterans Health Administration-Tennessee Valley Healthcare System, Geriatric Research Education and Clinical Center (GRECC), Nashville
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| |
Collapse
|
6
|
Dicembrini I, Monami M, Mannucci E. Dypeptidylpeptidase-4 inhibitors and the cardiovascular system: How to manage the fil rouge. Nutr Metab Cardiovasc Dis 2019; 29:215-219. [PMID: 30718142 DOI: 10.1016/j.numecd.2018.12.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Revised: 12/18/2018] [Accepted: 12/27/2018] [Indexed: 02/08/2023]
Abstract
Dypeptidylpeptidase-4 (DPP-4) inhibitors are a therapeutic option for improving glucose control in patients with type 2 diabetes. They can be prescribed at different stages of the natural history of the disease because of their low risk for hypoglycemia and associated weight gain. For all new drugs for diabetes, the US Food and Drug Administration requires the demonstration of the cardiovascular (CV) safety profile through pooled analyses of phase 3 studies or specifically designed trials. A significant superiority over placebo has been observed with a sodium-dependent glucose transporter-2 inhibitor, empagliflozin, and two glucagon-like peptide-1 receptor agonists, liraglutide and semaglutide, thus suggesting cardioprotective effects for some antidiabetic drugs. The neutral results of CV safety trials on DPP-4 inhibitors have been disappointing, appearing to contradict the data from pooled analyses and meta-analyses of early trials. The main aim of this review is to find a possible interpretation for the differences between the results of these early trials and the CV safety studies with DPP-4 inhibitors. We conclude that the hypothesis of additional beneficial effects by DPP-4 inhibitors (beyond the improvement of glucose control), on the CV system in low-risk patients in primary prevention, needs to be verified with specifically designed studies.
Collapse
Affiliation(s)
| | - M Monami
- Diabetology, University of Florence, Italy
| | - E Mannucci
- Diabetology, University of Florence, Italy.
| |
Collapse
|
7
|
Zinman B, Skyler JS, Riddle MC, Ferrannini E. Diabetes Research and Care Through the Ages. Diabetes Care 2017; 40:1302-1313. [PMID: 28931706 DOI: 10.2337/dci17-0042] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2017] [Accepted: 07/26/2017] [Indexed: 02/03/2023]
Abstract
As has been well established, the Diabetes Care journal's most visible signature event is the Diabetes Care Symposium held each year during the American Diabetes Association's Scientific Sessions. Held this past year on 10 June 2017 in San Diego, California, at the 77th Scientific Sessions, this event has become one of the most attended sessions during the Scientific Sessions. Each year, in order to continue to have the symposium generate interest, we revise the format and content of this event. For this past year, our 6th annual symposium, I felt it was time to provide a comprehensive overview of our efforts in diabetes care to determine, first and foremost, how we arrived at our current state of management. I also felt the narrative needed to include the current status of management, especially with a focus toward cardiovascular disease, and finally, we wanted to ask what the future holds. Toward this goal, I asked four of the most noted experts in the world to provide their opinion on this topic. The symposium started with a very thoughtful presentation by Dr. Jay Skyler entitled "A Look Back as to How We Got Here." That was followed by two lectures on current concepts by Dr. Bernard Zinman entitled "Current Treatment Paradigms Today-How Well Are We Doing?" and by Dr. Matthew Riddle entitled "Evolving Concepts and Future Directions for Cardiovascular Outcomes Trials." The final lecture for the symposium was delivered by Dr. Ele Ferrannini and was entitled "What Does the Future Hold?" As always, a well-attended and well-received symposium is now the norm for our signature event and our efforts were rewarded by the enthusiasm of the attendees. This narrative summarizes the lectures held at the symposium.-William T. CefaluChief Scientific, Medical & Mission Officer, American Diabetes Association.
Collapse
Affiliation(s)
- Bernard Zinman
- Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Jay S Skyler
- Diabetes Research Institute, University of Miami, Miami, FL
| | - Matthew C Riddle
- Division of Endocrinology, Diabetes & Clinical Nutrition, Oregon Health & Science University, Portland, OR
| | - Ele Ferrannini
- CNR Institute of Clinical Physiology, and the Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| |
Collapse
|
8
|
Anyanwagu U, Mamza J, Donnelly R, Idris I. Effects of background statin therapy on glycemic response and cardiovascular events following initiation of insulin therapy in type 2 diabetes: a large UK cohort study. Cardiovasc Diabetol 2017; 16:107. [PMID: 28830436 PMCID: PMC5567903 DOI: 10.1186/s12933-017-0587-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2017] [Accepted: 08/13/2017] [Indexed: 02/24/2023] Open
Abstract
Aim Statins may increase the risk of new-onset diabetes and adversely affect glycaemic control, but their effects on the glycemic response and mortality outcomes following commencement of insulin therapy in patients with Type 2 Diabetes (T2D) are unclear. Methods A retrospective cohort study was conducted in 12,725 insulin initiators with T2D using The Health Improvement Network (THIN) UK database. Changes in HbA1c at 6, 12, 24 and 36 months, and the 5-year risk of mortality and (3-point) major adverse cardiovascular events (MACE), were compared between prior users (n = 10,682) and non-users (n = 2043) of statin therapy who were newly commenced on insulin treatment. Cox proportional hazard models were used to estimate the hazard ratios of the different outcomes. Results Mean age of the cohort was 58.7 ± 14.0 years (51% male) and mean baseline HbA1c was 8.7 ± 1.8%. A greater initial reduction in HbA1c was observed following insulin initiation in the non-users of statins compared with the users, which was significant in the short term (−0.34% vs −0.26% at 6 months; mean diff = −0.09%, p = 0.004) but not in the long term: −0.31% versus −0.35% at 3 years (mean diff = 0.05%, p = 0.344). CV events (3-point MACE) were 878 versus 217 in statin users versus non-users (20.7 vs 30.9 per 1000 person-years; adjusted Hazard Ratio (aHR) 1.36 (95% CI 1.15–1.62; p < 0.0001). In a subgroup analysis of individual statins, HbA1c was higher throughout the study duration with all statins relative to non-users of statin therapy (p < 0.05). The aHRs for 3-point MACE for atorvastatin, simvastatin, rosuvastatin and pravastatin were 0.82 (95% CI 0.68–0.98), 0.67 (0.55–0.82), 0.56 (0.39–0.81) and 0.78 (0.60–1.01), respectively. Conclusions Following initiation of insulin therapy in patients with T2D in routine care, concurrent use of a statin was associated with less good glycaemic control in the short-term but a much lower risk of major adverse CV events. Electronic supplementary material The online version of this article (doi:10.1186/s12933-017-0587-6) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Uchenna Anyanwagu
- Division of Medical Sciences & Graduate Entry Medicine, School of Medicine, University of Nottingham, Royal Derby Hospital, Uttoxeter Road, Derby, DE22 3DT, UK
| | - Jil Mamza
- Division of Medical Sciences & Graduate Entry Medicine, School of Medicine, University of Nottingham, Royal Derby Hospital, Uttoxeter Road, Derby, DE22 3DT, UK
| | - Richard Donnelly
- Division of Medical Sciences & Graduate Entry Medicine, School of Medicine, University of Nottingham, Royal Derby Hospital, Uttoxeter Road, Derby, DE22 3DT, UK
| | - Iskandar Idris
- Division of Medical Sciences & Graduate Entry Medicine, School of Medicine, University of Nottingham, Royal Derby Hospital, Uttoxeter Road, Derby, DE22 3DT, UK.
| |
Collapse
|