Risk factor control in patients with Type 2 diabetes and coronary heart disease: findings from the Swedish National Diabetes Register (NDR)

Exploring Clinical Care Among Adults With Diabetes Mellitus: Alignment With Recommended Statin and Sulfonylureas Treatment

OBJECTIVES

The care of patients with diabetes mellitus (DM), compiled in the 2008 Canadian Diabetes Association clinical practice guidelines and in recommendations from the Choosing Wisely Canada program, is informed by a large body of evidence. This study sought to assess to what extent primary care providers (PCPs) incorporate recommended statin and sulfonylureas treatment in their care of patients with DM, and to identify the association between use of recommended care and PCP characteristics.

METHODS

This retrospective cohort study (2007-2017) used electronic medical records of 21,149 patients with DM receiving care from 240 PCPs participating in the Manitoba Primary Care Research Network.

RESULTS

PCPs prescribed statins to patients newly diagnosed with DM who were ≥40 years of age 41% of the time, with 45% of the prescriptions occurring ≤180 days after a new diagnosis (early treatment). PCPs least likely to prescribe recommended statin treatment had higher odds of being older (adjusted odds ratio [aOR], 1.05; 95% confidence interval [CI], 1.01 to 1.09) and fee-for-service funded (aOR, 4.36; 95% CI, 1.47 to 12.91). In addition, older PCPs (aOR, 1.06; 95% CI, 1.02 to 1.10) and women (aOR, 2.42; 95% CI, 1.11 to 5.28) were less likely to prescribe statin treatment early. Seventy-four percent of PCPs prescribed sulfonylureas to adults ≥65 years of age. No PCP characteristics were associated with prescription of sulfonylureas in the lower implementation quartile in the fully adjusted model.

CONCLUSIONS

Results suggest that PCPs' practice does not always align with current evidence-based clinical guidelines or Choosing Wisely Canada recommendations for patients with DM. Some PCP's characteristics were associated with lower implementation of recommended evidence-based care. This information can help guide future targeted medical education.

The changing face of diabetes complications

The global increase in type 2 diabetes prevalence is well documented, but international trends in complications of type 2 diabetes are less clear. The available data suggest large reductions in classic complications of type 2 diabetes in high-income countries over the past 20 years, predominantly reductions in myocardial infarction, stroke, amputations, and mortality. These trends might be accompanied by less obvious, but still important, changes in the character of morbidity in people with diabetes. In the USA, for example, substantial reductions in macrovascular complications in adults aged 65 years or older mean that a large proportion of total complications now occur among adults aged 45-64 years instead, rates of renal disease could persist more than other complications, and obesity-related type 2 diabetes could have increasing effect in youth and adults under 45 years of age. Additionally, the combination of decreasing mortality and increasing diabetes prevalence has increased the overall mean years lived with diabetes and could lead to a diversification of diabetes morbidity, including continued high rates of renal disease, ageing-related disability, and cancers. Unfortunately, data on trends in diabetes-related complications are limited to only about a dozen countries, most of which are high income, leaving the changing character for countries of low and middle income ambiguous.

Evaluation of statin prescriptions in type 2 diabetes: India Heart Watch-2

BACKGROUND

Contemporary treatment guidelines advise statin use in all patients with diabetes for reducing coronary risk. Use of statins in patients with type 2 diabetes has not been reported from India.

METHODS

We performed a multisite (n=9) registry-based study among internists (n=3), diabetologists (n=3), and endocrinologists (n=3) across India to determine prescriptions of statins in patients with type 2 diabetes. Demographic and clinical details were obtained and prescriptions were audited for various medications with a focus on statins. Details of type of statin and dosage form (low, moderate, and high) were obtained. Patients were divided into categories based on presence of cardiovascular risk into low (no risk factors, n=1506), medium (≥1 risk factor, n=5425), and high (with vascular disease, n=1769). Descriptive statistics are presented.

RESULTS

Prescription details were available in 8699 (men 5292, women 3407). Statins were prescribed in 55.2% and fibrates in 9.2%. Statin prescription was significantly greater among diabetologists (64.4%) compared with internists (n=53.3%) and endocrinologists (46.8%; p<0.001). Atorvastatin was prescribed in 74.1%, rosuvastatin in 29.2%, and others in 3.0%. Statin prescriptions were lower in women (52.1%) versus men (57.2%; p<0.001) and in patients aged <40 years (34.3%), versus those aged 40-49 (49.7%), 50-59 (60.1%), and ≥60 years (62.2%; p<0.001). Low-dose statins were prescribed in 1.9%, moderate dose in 85.4%, and high dose in 12.7%. Statin prescriptions were greater in the high-risk group (58.0%) compared with those in the medium-risk (53.8%) and low-risk (56.8%) groups (p <0.001). High-dose statin prescriptions were similar in the high-risk (14.5%), medium-risk (11.8%), and low-risk (13.5%) groups (p=0.31).

CONCLUSIONS

Statins are prescribed in only half of the clinic-based patients in India with type 2 diabetes. Prescription of high-dose statins is very low.

Factors influencing self-management in patients with type 2 diabetes: a quantitative systematic review protocol

AIM

To describe a protocol for a quantitative systematic review, to identify critique and summarize factors that influence self-management education.

BACKGROUND

Self-management education enables patients to manage their condition successfully and it is associated with better self-care, good control over lifestyle and leading the best possible quality of life, notwithstanding the presence of a chronic disease. Type II Diabetes is a chronic disease that requires lifestyle adjustments and disease management to keep glycaemia and long-term complications under control. Education has to be customized and based on an assessment that includes factors influencing self-management, such as personal characteristics that can optimize the educational intervention.

DESIGN

The protocol for the systematic review was conducted according to the guidelines of the Centre for Reviews and Dissemination, York (UK).

METHOD

The review question was defined in terms of population, interventions, comparators, outcomes and study designs. The protocol included decisions about the review question, inclusion criteria, search strategy, study selection, data extraction, quality assessment, data synthesis and plans for dissemination. Funding for the review was confirmed on January 2011 by the Centre of Excellence for Nursing Scholarship in Rome.

DISCUSSION

An initial summary will be made by tabulating the data; the review will be reported in a narrative style and be developed according to the PRISMA guidelines. The protocol for the systematic review will allow us to identify, among the factors influencing self-management in people with Type II diabetes, the personal characteristics most relevant to the factors of motivation and empowerment. In addition, the systematic review will also identify an appropriate self-management model.

Towards renewed health economic simulation of type 2 diabetes: risk equations for first and second cardiovascular events from Swedish register data

OBJECTIVE

Predicting the risk of future events is an essential part of health economic simulation models. In pursuit of this goal, the current study aims to predict the risk of developing first and second acute myocardial infarction, heart failure, non-acute ischaemic heart disease, and stroke after diagnosis in patients with type 2 diabetes, using data from the Swedish National Diabetes Register.

MATERIAL AND METHODS

Register data on 29,034 patients with type 2 diabetes were analysed over five years of follow up (baseline 2003). To develop and validate the risk equations, the sample was randomly divided into training (75%) and test (25%) subsamples. The Weibull proportional hazard model was used to estimate the coefficients of the risk equations, and these were validated in both the training and the test samples.

RESULTS

In total, 4,547 first and 2,418 second events were observed during the five years of follow up. Experiencing a first event substantially elevated the risk of subsequent events. There were heterogeneities in the effects of covariates within as well as between events; for example, while for females the hazard ratio of having a first acute myocardial infarction was 0.79 (0.70-0.90), the hazard ratio of a second was 1.21 (0.98-1.48). The hazards of second events decreased as the time since first events elapsed. The equations showed adequate calibration and discrimination (C statistics range: 0.70-0.84 in test samples).

CONCLUSION

The accuracy of health economic simulation models of type 2 diabetes can be improved by ensuring that they account for the heterogeneous effects of covariates on the risk of first and second cardiovascular events. Thus it is important to extend such models by including risk equations for second cardiovascular events.

Determinants of uncontrolled hypertension in adult type 2 diabetes mellitus: an analysis of the Malaysian diabetes registry 2009

BACKGROUND

Uncontrolled blood pressure (BP) is a significant contributor of morbidity and even mortality in type 2 diabetes (T2D) patients. This study was done to determine the significant determinants of uncontrolled blood pressure in T2D patients in Malaysia.

METHODS

Between 1st January 2009 to 31st December 2009, data from 70 889 patients with Type 2 diabetes was obtained from the Adult Diabetes Control and Management Registry for analysis; 303 centers participated in the study. Their demographic characteristics, the nature of their diabetes, their state of hypertension, treatment modalities, risk factors, and complications are described. Based on their most recent BP values, subjects were divided into controlled BP and uncontrolled BP and their clinical determinants compared. Independent determinants were identified using multivariate logistic regression.

RESULTS

The mean age of patients at diagnosis of diabetes was 52.3 ± 11.1 years old. Most were women (59.0 %) and of Malay ethnicity (61.9 %). The mean duration of diabetes was 5.9 ± 5.6 years. A total of 57.4 % were hypertensive. Of the 56 503 blood pressure (BP) measured, 13 280 (23.5 %) patients had BP <130/80 mmHg. Eighteen percent was on > two anti-hypertensive agents. Health clinics without doctor, older age (≥ 50 years old), shorter duration of diabetes (< 5 years), Malay, overweight were determinants for uncontrolled blood pressure (BP ≥130/80 mmHg). Patients who were on anti-hypertensive agent/s were 2.7 times more likely to have BP ≥130/80 mmHg. Type 2 diabetes patients who had ischaemic heart disease or nephropathy were about 20 % and 15 % more likely to have their blood pressure treated to target respectively.

CONCLUSIONS

Major independent determinants of uncontrolled BP in our group of T2D patients were Malay ethnicity, older age, recent diagnosis of diabetes, overweight and follow-up at health clinics without a doctor and possibly the improper use of anti hypertensive agent. More effort, education and resources, especially in the primary health care centres are needed to improve hypertensive care among our patients with diabetes.

Time trends in absolute and modifiable coronary heart disease risk in patients with Type 2 diabetes in the Swedish National Diabetes Register (NDR) 2003-2008

AIMS

The aim was to evaluate treatment goal achievements early in the course of Type 2 diabetes, and their effect on 10-year risk of coronary heart disease in patients receiving usual care.

METHODS

Assessment of risk factor control 3 years after diagnosis in patients with Type 2 diabetes with no previous coronary heart disease included from the Swedish National Diabetes Register; a total of 19,382 patients (mean age 58 years) in cross-sectional surveys from 2003 to 2008, and a subgroup of 4293 patients followed individually from year of diagnosis to follow-up after a mean 2.6 years. Estimation of absolute 10-year risk of coronary heart disease using the U.K. Prospective Diabetes Study risk engine, and modifiable 10-year risk defined as percentage excess risk above patients with 'normal' risk factor values.

RESULTS

Treatment goals for HbA1c , blood pressure, total and LDL cholesterol were achieved in 78.4, 65.5, 55.6% and 61.0%, respectively, in the cross-sectional survey in 2008, following a trend of generally improved control. In the individually followed patients in the subgroup, mean absolute 10-year coronary heart disease risk increased from 13.7% (men/women 16.9/9.5%) to 14.2 (men/women 17.6/9.6%) (P < 0.001) from year of diagnosis to follow-up after 2.6 years, while mean modifiable risk decreased from 37.7% (men/women 28.6/49.9%) to 19.1% (13.2/26.9%) (P < 0.001 in all).

CONCLUSIONS

A high achievement of treatment goals and a low mean modifiable 10-year coronary heart disease risk was found at the 3-year follow-up, both in the cross-sectional survey in 2008 and in patients individually followed since diagnosis. This indicates the feasibility and significance of early multifactorial risk factor treatment.

Long-term cost-effectiveness of insulin detemir versus NPH insulin in type 2 diabetes in Sweden

AIM

To evaluate the cost-effectiveness of insulin detemir vs. NPH insulin once daily, in patients with type 2 diabetes in the Swedish setting based on clinical data from a published randomized controlled trial.

METHODS

Projections of long-term outcomes were made using the IMS CORE Diabetes Model (CDM), based on clinical data from a 26-week randomized controlled trial that compared once daily insulin detemir and NPH insulin, when used to intensify insulin treatment in 271 patients with type 2 diabetes and body mass index (BMI) 25-40 kg/m(2). Trial results showed that insulin detemir was associated with a significantly lower incidence of hypoglycemic events and significantly less weight gain in comparison with NPH insulin. The analysis was conducted from a third party payer perspective and the base case analysis was performed over a time horizon of 40 years and future costs and clinical outcomes were discounted at a rate of 3% per year.

RESULTS

Insulin detemir was associated with higher mean (SD) quality-adjusted life expectancy (5.42 [0.10] vs. 5.31 [0.10] quality-adjusted life years [QALYs]) and lower overall costs (SEK 378,539 [10,372] vs. SEK 384,216 [11,230]; EUR 33,794 and EUR 34,300, respectively, where 1 EUR=11.2015 SEK) compared with NPH insulin. Sensitivity analysis showed that the principal driver of the benefits associated with insulin detemir was the lower rate of hypoglycemic events (major and minor events) vs. NPH insulin, suggesting that detemir might also be cost-saving over a shorter time horizon. Limitations of the analysis include the use of data from a trial outside Sweden in the Swedish setting.

CONCLUSIONS

Based on clinical input data derived from a previously published randomized controlled trial, it is likely that in the Swedish setting insulin detemir would be cost-saving in comparison with NPH insulin for the treatment of patients with type 2 diabetes.

Evaluation of the effectiveness of sarpogrelate on the surrogate markers for macrovascular complications in patients with type 2 diabetes

Sarpogrelate, a selective 5-HT(2) receptor antagonist, is known to have a significant effect on antiplatelet action. This study was a double-blinded, randomized, paralleled multicenter trial to compare the effects of sarpogrelate and aspirin on preventing macrovascular complications in patients with type 2 diabetes. The subjects were randomly assigned to either the sarpogrelateor the aspirin group. The baseline parameters for macrovascular complications, such as intima media thickness (IMT), ankle-brachial index (ABI), IL-6, serotonin, adiponectin, and hsCRP, were measured before drug administration. Changes were compared at 6 and 12 months after the administration of each drug. A total of 127 subjects (63 in the sarpogrelate group and 64 in the aspirin group) were pooled during the study period. No significant differences were found in baseline IMT or in other predictors of macrovascular complications. The mean IMT increased in both groups after 12 months, but there was no significant difference between the two groups. No significant change was found in the other predictors of macrovascular complications nor in the incidence of drug-related adverse events between the two groups. During the study period, no significant differences were found between the sarpogrelate group and aspirin group in the clinical indices or in the safety of the subjects related to macrovascular complications. This suggests that sarpogrelate may be clinically useful for the primary prevention of macrovascular complications in patients with type 2 diabetes.

Patient-level evaluation of community-based, multifactorial intervention to prevent diabetic nephropathy in northern alberta, Canada

OBJECTIVE

To examine whether patients with type 2 diabetes enrolled in community-based clinics uniformly benefit from interventions designed to achieve multiple risk factor targets.

METHODS

Using data from community-based clinics in Alberta, Canada, we examined whether patients achieved targets for blood pressure (<130/80 mm Hg), A1c (≤7%), low-density lipoprotein (LDL) cholesterol (<2.5 mmol/L), weight reduction, exercising, smoking cessation, and meal plan management among 235 patients between 2004 to 2007 with a 1-year follow-up. The effectiveness of the clinics was assessed by the number of targets achieved by individual patients. Patients achieving different degrees of success (0-2, 3-4, and ≥5 targets) were compared.

RESULTS

Mean age of patients at baseline was 62 years (standard deviation [SD], 12 years), 43% were female, 77% had a history of cardiovascular disease, and mean diabetes duration was 9 years (SD, 9 years). Overall, 47 patients achieved 0 to 2 targets (group 1), 132 achieved 3 to 4 targets (group 2), and 56 achieved ≥5 targets (group 3) out of 7 targets. More patients in group 1 were male and had longer diabetes duration and were more likely to smoke or use insulin. Despite reductions in A1c in all groups and similar use of antihypertensives, there was no improvement in weight or systolic blood pressure (which actually increased) in group 1. Successful patients (group 3) were more likely to report adherence with exercise and a meal plan.

CONCLUSIONS

Despite equally intensive, target-driven pharmacotherapy, this community-based multifactorial intervention was less effective among a subset of patients who did not adhere to lifestyle changes. Strategies to effectively address lifestyle factors will be important as this intervention is refined.

Progression of glycaemia and cardiovascular risk factors in patients of different age groups with new type 2 diabetes over 5 years of follow-up in a diabetes quality improvement initiative

AIMS

To examine progression of glycaemia and cardiovascular risk factors in type 2 diabetes cases participating in a quality improvement initiative.

METHODS

1108 new type 2 diabetes cases enrolled on the Otago Diabetes Register had clinical data recorded at baseline and 5 years. Means and standard deviations or percentages were calculated for variables of interest for <40, 40-59, 60-79 and 80-100 year age groups. p-Values for differences over time and among groups were calculated. Ordinal regression, with robust standard errors, was used to examine intensification of diabetes treatment.

RESULTS

For all age groups blood pressure and lipid levels approached recommended targets at 5 years (p<0.001). Glycated haemoglobin worsened, especially in the youngest age group (from 7.3±1.9% to 7.9±1.7%, p<0.001) who had the highest odds of more intense diabetes treatment at 5 years: 6.2 (95% CI 3.5-11.2) compared with 3.3 (95% CI 2.7-4.1) for 40-59-year olds, 2.8 (95% CI 2.3-3.3) for 60-79-year olds and 1.4 (95% CI 0.9-2.0) for ≥80-year olds.

CONCLUSIONS

Good management of type 2 diabetes patients, principally in primary care, can lead to improved blood pressure and lipid levels. Targets for glycaemic control and weight are less readily achieved especially among young age groups.

Blood lipids in 75,048 type 2 diabetic patients: a population-based survey from the Swedish National diabetes register

BACKGROUND

Type 2 diabetes and diabetic dyslipidemia are high-risk conditions for cardiovascular disease. However, the description of the distribution of blood lipids in diabetic patients has not been based on population-based surveys. The aim of this study was to describe diabetic dyslipidemia in a large unselected sample of patients from the Swedish National Diabetes Register.

METHODS

Blood lipid profiles and clinical characteristics in 75,048 type 2 diabetic patients (57% men) were studied.

RESULTS

Pronounced hypertriglyceridemia (triglycerides >4.0mmol/l) was seen in 3.4% of the patients. Total cholesterol (TC), LDL-cholesterol (LDL-C), HDL-cholesterol (HDL-C) and non-HDL-C were generally higher, and LDL-C/HDL-C and Non-HDL-C/HDL-C ratios were lower in women. Mean TC, LDL-C as well as HDL-C values were lower in patients treated with lipid-lowering agents, whereas triglycerides was higher than in the untreated patients. In patients not treated with lipid-lowering agents all blood lipids increased in women and decreased in men (except HDL-C) at higher ages. Patients with LDL-C/HDL-C ratio ≥ 3 were slightly younger, less frequently used lipid-lowering drugs and had not so often a history of coronary heart disease or stroke.

CONCLUSION

The distribution of blood lipids in this large sample of unselected type 2 diabetic patients challenges the previous conception of diabetic dyslipidemia, and calls for new studies to explain the roles of LDL-C and HDL-C as strong cardiovascular risk factors in type 2 diabetes.

Clinical use and effectiveness of lipid lowering therapies in diabetes mellitus--an observational study from the Swedish National Diabetes Register

OBJECTIVES

To describe the use and evaluate the effectiveness of different lipid lowering therapies in unselected patients with type 1 and type 2 diabetes in clinical practice.

DESIGN

Observational population-based study using the personal identification number to link information from the National Diabetes Register, the Prescribed Drug Register and the Patient register in Sweden. All patients in the NDR aged 18-75 years with diabetes more than one year were eligible, but only patients starting any lipid lowering treatment with at least three prescriptions 1 July 2006-30 June 2007 were included (n = 37,182). The mean blood lipid levels in 2008 and reductions in LDL cholesterol were examined.

RESULTS

Blood lipid levels were similar in patients treated with simvastatin, atorvastatin and rosuvastatin, showing similar lipid lowering effect as currently used. Users of pravastatin, fluvastatin, ezetimib and fibrate more seldom reach treatment goals. Moderate daily doses of the statins were used, with 76% of simvastatin users taking 20 mg or less, 48% of atorvastatin users taking 10 mg, 55% of pravastatin users taking 20 mg, and 76% of rosuvastatin users taking 5 or 10 mg.

CONCLUSIONS

This observational study shows that the LDL-C levels in patients taking simvastatin, atorvastatin or rosuvastatin are very similar as currently used, as well as their LDL-C lowering abilities. There is potential to intensify lipid lowering treatment to reduce the remaining high residual risk and achieve better fulfilment of treatment goals, since the commonly used doses are only low to moderate.

Systolic blood pressure and risk of cardiovascular diseases in type 2 diabetes: an observational study from the Swedish national diabetes register

OBJECTIVES

To estimate risks of fatal/nonfatal coronary heart disease (CHD), stroke and cardiovascular disease (CVD) with SBP in an observational study of patients with type 2 diabetes.

METHODS

Twelve thousand, six hundred and seventy-seven patients aged 30-75 years, treated with antihypertensive drugs, without previous congestive heart failure, followed for 5 years.

RESULTS

Risk curves of CHD and stroke increased progressively with higher baseline or updated mean SBP in a Cox model, in all participants, and in two subgroups without (n = 10 304) or with (n = 2373) a history of CVD, with no J-shaped risk curves at low SBP levels. Hazard ratios for CHD and stroke per 10-mmHg increase in updated mean SBP in all participants, adjusting for clinical characteristics and traditional risk factors, were 1.08 (1.04-1.13) and 1.20 (1.13-1.27), P < 0.001. With updated mean SBP of 110-129 mmHg as reference, SBP of at least 140 mmHg showed risk increases of 37% for CHD, 86% for stroke and 44% for CVD (P = 0.001 to <0.001), whereas SBP of 130-139 mmHg showed nonsignificant risk increases for these outcomes. With baseline SBP of 110-129 mmHg, CHD and CVD risks increased with further SBP reduction, hazard ratios were 1.77 and 1.73 (P = 0.002), but decreased considerably for CHD, stroke and CVD with higher baseline SBP.

CONCLUSION

Risks of CHD and stroke increased progressively with higher SBP, with no J-shaped curves, although risk increase was significant only for SBP of at least 140 mmHg, but not comparing 130-139 and 110-129 mmHg. Additionally, baseline SBP of 110-129 mmHg showed increased CHD and CVD risk with further SBP reduction during follow-up, whereas baseline SBP of at least 130 showed benefits.

Relation between obesity and the attainment of optimal blood pressure and lipid targets in high vascular risk outpatients

Obesity is associated with hypertension, dyslipidemia, and diabetes, but it is also an independent cardiovascular risk factor. We sought to evaluate the differences in treatment patterns and attainment of guideline-recommended targets among high-risk vascular outpatients in relation to their body mass index (BMI). The prospective Vascular Protection and Guideline Orientated Approach to Lipid Lowering Registries recruited 7,357 high-risk vascular outpatients in Canada from 2001 to 2004. We stratified the patient population into 3 groups according to their BMI: normal weight (BMI <24.9 kg/m²), overweight (BMI 25 to 29.9 kg/m²), and obese (BMI >30 kg/m²). We evaluated the rates of attainment for contemporary guideline targets of blood pressure (<140/90 or <130/80 mm Hg in the presence of diabetes) and lipids (low-density lipoprotein [LDL] <2.5 mmol/L [96.7 mg/dl] and total cholesterol [TC]/high-density lipoprotein [HDL] ratio <4.0). Of the 7,357 patients, 1,305 (17.7%) were normal weight, 2,791 (37.9%) overweight, and 3,261 (44.4%) obese, as determined by the BMI. Obese patients were younger and more likely to have hypertension and diabetes (all p <0.001 for trend). Obese patients had higher baseline blood pressure, TC, LDL cholesterol, triglyceride levels and TC/HDL ratio, and lower HDL cholesterol. Obese patients were more likely to be treated with antihypertensive agents (p = 0.002), angiotensin-converting enzyme inhibitors (p = 0.024), angiotensin receptor blockers (p <0.001), and high-dose statin therapy (p = 0.001). On multivariable analyses, obese patients were less likely to attain the blood pressure (odds ratio 0.77, 95% confidence interval 0.66 to 0.90, p = 0.001) and TC/HDL ratio (odds ratio 0.48, 95% confidence interval 0.42 to 0.55, p <0.001) targets but not the LDL targets (odds ratio 0.89, 95% confidence interval 0.78 to 1.03, p = 0.11). In conclusion, only a minority ambulatory patients at high cardiovascular risk achieved both guideline-recommended blood pressure and lipid targets, and this significant treatment gap was more pronounced among obese patients. Our findings underscore the opportunity to optimize the treatment of these high-risk patients.

Glycaemic goals in patients with type 2 diabetes: current status, challenges and recent advances

Recommendations for the management of type 2 diabetes include rigorous control of blood glucose levels and other risk factors, such as hypertension and dyslipidaemia. In clinical practice, many patients do not reach goals for glycaemic control. Causes of failure to control blood glucose include progression of underlying pancreatic beta-cell dysfunction, incomplete adherence to treatment (often because of adverse effects of weight gain and hypoglycaemia) and reluctance of clinicians to intensify therapy. There is increasing focus on strategies that offer potential to improve glycaemic control. Structured patient education has been shown to improve glycaemic control and other cardiovascular risk factors in people with type 2 diabetes. Payment of general practitioners by results has been shown to improve glycaemic control. New classes of glucose-lowering agents have expanded the treatment options available to clinicians and patients and include the dipeptidyl peptidase 4 (DPP-4) inhibitors and glucagon-like peptide-1 (GLP-1) receptor agonists. These new classes of therapy and other strategies outlined above could help clinicians to individualize treatment and help a greater proportion of patients to achieve long-term control of blood glucose.

Evidence-based approach for managing hypertension in type 2 diabetes

Blood pressure (BP) control is a critical part of managing patients with type 2 diabetes. Perhaps it is the single most important aspect of diabetes care, which unlike hyperglycemia and dyslipidemia can reduce both micro- and macrovascular complications. Hypertension is more prevalent in individuals with diabetes than general population, and in most cases its treatment requires two or more pharmacological agents (about 30% of individuals with diabetes need 3 or more medications to control BP). In this article we describe the key evidence that has contributed to our understanding that reduced BP translates into positive micro- and macrovascular outcomes. We review the data supporting current recommendation for BP target < 130/80 mmHg. Two studies suggest that a lower BP goal could be even more beneficial. We also present the comparative benefits of various antihypertensive drugs in reducing diabetes-related micro- and macrovascular complications. Finally we propose an evidence-based algorithm of how to initiate and titrate antihypertensive pharmacotherapy in affected individuals. Overall, achieving BP < 130/80 mmHg is more important than searching for the “best” antihypertensive agent in patients with diabetes.

Current pharmacotherapeutic concepts for the treatment of cardiovascular disease in diabetics

With the growing worldwide obesity epidemic, obesity, type 2 diabetes mellitus and hypertension leading to premature cardiovascular events, are increasingly prevalent. Diabetes mellitus is a significant public health concern and more aggressive management of the condition and its complications, particularly cardiovascular disease, is warranted. Endothelial cell dysfunction is now known to be present at the earliest stages of metabolic syndrome, and insulin resistance and may precede the clinical diagnosis of type 2 diabetes mellitus by several years. The current focus on endothelial cell function as a potential target of pharmacotherapy in the management of cardiovascular disease in diabetics seems warranted, though not all drugs currently prescribed target endothelial cell function equally. In this review, we consider the six classes of drugs currently prescribed for the treatment of hypertension as they impact endothelial cell function and advocate for the development of novel drugs that can repair the endothelium and enhance nitric oxide availability thus preventing future cardiovascular events.

Failure to control risk factors among patients with type 2 diabetes; experience from a Greek cohort

We reviewed the records of 313 diabetic patients attending a diabetes clinic for at least two years. Despite improvements in the control rates of cardiovascular risk factors, only 8.9% of the patients reached all the metabolic target goals simultaneously at the end, indicating a gap between guidelines and clinical practice.

Effect of tight control of HbA1c and blood pressure on cardiovascular diseases in type 2 diabetes: an observational study from the Swedish National Diabetes Register (NDR)

AIM

To estimate hazard ratio (HR) of first incident fatal/non-fatal cardiovascular diseases (CVD) in female/male type 2 diabetic patients, with tight versus adverse control of HbA1c and blood pressure (BP) at baseline, age 30-70 years, no baseline CVD, followed for mean 5.7 years.

METHODS

2593 patients with tight control of HbA1c <7.5% and BP < or = 140/90 mmHg (median 6.5%/130/80 mmHg), and 2160 patients with adverse control 7.5-9.0%/141-190/91-110 mmHg (median 8.1%/155/85 mmHg).

RESULTS

The hazard ratio (HR) for CVD with tight/adverse control was 0.67 (0.55-0.80; p<0.001), adjusting for age, sex, duration, hypoglycaemic treatment, smoking, BMI, lipid-lowering drugs, antihypertensive drugs, microalbuminuria. Adjusted HR for myocardial infarction, coronary heart disease, stroke and total mortality were 0.72 (0.56-0.92; p=0.01), 0.69 (0.55-0.86; p<0.001), 0.62 (0.45-0.84; p<0.001), 1.00 (0.72-1.39). The partial population-attributable risk percent for myocardial infarction, stroke and CVD was 23%, 33%, 29% if adverse HbA1c/BP control could be avoided, while 43%, 38%, 39% with overweight and smoking also avoided. Baseline lower BMI and absence of microalbuminuria were associated with tight control.

CONCLUSION

Median difference of HbA1c/BP 1.6%/25/5 mmHg between tight and adverse control considerably reduced the risk of cardiovascular diseases. The findings call for a multi-factorial approach to improve HbA1c, BP, obesity, smoking, and microalbuminuria.