SGLT-2 inhibitors or GLP-1 receptor agonists for adults with type 2 diabetes: a clinical practice guideline

Core GRADE 7: principles for moving from evidence to recommendations and decisions

This seventh article in a seven part series presents the Core GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach for moving from evidence to recommendations or policy decisions. Core GRADE users make strong recommendations for an intervention versus a comparator when the desirable consequences clearly outweigh the undesirable consequences, and a conditional (weak) recommendation when the balance is less clear. Primary considerations in deciding on recommendations considering an individual patient perspective include balance of benefits, harms, and burdens; the certainty of evidence; and values and preferences. Secondary considerations, most important from a population perspective, include costs, feasibility, acceptability, and equity. Moving from evidence to recommendations begins with considering evidence regarding patients’ values and preferences and choosing the smallest difference in each outcome that patients perceive as important (the minimal important difference). Core GRADE users construct statements that make clear the values and preferences underlying their recommendations. In general, Core GRADE users make strong recommendations only when certainty of evidence is high or moderate. When evidence certainty is low, recommendations will be conditional under all but special circumstances.

Efficacy and hypoglycaemia outcomes with once-weekly insulin icodec versus once-daily basal insulin in type 2 diabetes according to baseline glucagon-like peptide-1 receptor agonist and sodium-glucose co-transporter-2 inhibitor use: A post hoc analysis of ONWARDS 1-5

AIMS

To assess the treatment effects of once-weekly insulin icodec (icodec) versus once-daily basal insulin comparators in individuals with type 2 diabetes (T2D) according to baseline glucagon-like peptide-1 receptor agonist (GLP-1RA) and sodium-glucose co-transporter-2 inhibitor (SGLT2i) use.

MATERIALS AND METHODS

This post hoc analysis of the randomized ONWARDS 1-5 trials of individuals with T2D assessed treatment outcomes by trial according to baseline GLP-1RA and/or SGLT2i use.

RESULTS

At screening, 21.3% (801/3765) and 36.9% (1388/3765) of participants in ONWARDS 1-5 were treated with a GLP-1RA or an SGLT2i, respectively. Baseline characteristics were broadly similar across treatment arms irrespective of GLP-1RA/SGLT2i use; GLP-1RA users had numerically higher body mass indices than non-users. Across trials, there were no statistically significant treatment interactions by GLP-1RA or SGLT2i subgroups with respect to: change in glycated haemoglobin (HbA1c) and body weight from baseline to end of treatment (except for body weight change by SGLT2i use in ONWARDS 5); weekly basal insulin dose during the last 2 weeks of treatment (except SGLT2i use in ONWARDS 5); and achievement of HbA1c less than 7% without clinically significant or severe hypoglycaemia. Irrespective of GLP-1RA/SGLT2i use, the rates of clinically significant or severe hypoglycaemia were less than one episode per patient-year of exposure across all trials except ONWARDS 4 (basal-bolus trial).

CONCLUSIONS

The efficacy and hypoglycaemia profile of icodec versus once-daily comparators was generally consistent across ONWARDS trials irrespective of background GLP-1RA and/or SGLT2i use.

Cardiovascular outcomes of SGLT-2 inhibitors' subtypes in type 2 diabetes; an updated systematic review and meta-analysis of randomized controlled trials

Introduction

The effects of Sodium-glucose cotransporter-2 (SGLT-2) inhibitors on cardiac outcomes, cardiovascular mortality (CVM), and all-cause mortality (ACM) in type 2 diabetes mellitus (T2DM) patients have been reported heterogeneously in different studies.

Methods

PubMed, Scopus, Embase, Cochrane Library, and Scholar databases were searched with relevant MeSH terms from January 1, 2010, to November 14, 2023. The study used Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The primary outcomes in all trials included the risk of ACM, CVM, hospitalization for heart failure (HHF), myocardial infarction (MI), and cerebrovascular accidents (CVA) in T2DM patients who were treated with one of the SGLT-2 inhibitors. Heterogeneity between studies was evaluated using Cochran's Q and I2 tests. The Egger's test was used to check for publication bias.

Results

Eighteen studies, including 70,830 participants, were included. A pooled estimate showed that SGLT-2 inhibitor treatment was significantly associated with reduced ACM (OR: 0.82, 95% CI: 0.75-0.90, p-value: 0.001, I2: 35.1%), CVM (OR: 0.88, 95% CI: 0.80-0.96, p-value: 0.001, I2: 0%), MI (OR: 0.88, 95% CI: 0.79-0.98, p-value: 0.001, I2: 0%), and HHF (OR: 0.67, 95% CI: 0.58-0.77, p-value: 0.001). SGL-2 inhibitor treatment had no significant relationship with CVA (stroke) (OR: 0.95, 95% CI: 0.8-1.10, p-value: 0.896). Subgroup analysis showed that the effect of SGLT-2 inhibitor treatment on outcomes varied based on the type of SGLT-2 inhibitor.

Conclusion

SGLT-2 inhibitor treatment significantly reduced CVM, ACM, MI, and HHF. Empagliflozin, Canagliflozin, and Dapagliflozin significantly reduced ACM. Canagliflozin was significantly associated with a reduction in CVM. All SGLT-2 inhibitor treatments were associated with a reduction in HHF.

Core GRADE 6: presenting the evidence in summary of findings tables

This sixth article in a seven part series presents the Core GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach to summary of findings tables. These tables provide essential information about the effects of interventions on patient important outcomes, including relative and absolute effects, certainty of evidence, and a plain language summary. For binary outcomes calculating absolute effects requires applying relative risk estimates to baseline risks from studies representative of the target population. For groups of patients with very different baseline risks, summary of findings tables include separate rows with different estimates of absolute effects. For continuous outcomes, challenges arise when individual studies use different instruments to measure patient reported outcomes. Facilitating interpretation then requires providing details about units of measurement and minimally important differences.

Glabridin Alleviates Metabolic Disorders in Diet-Induced Diabetic Mice

Glabridin (GLD) is a flavonoid derived from licorice. This study aims to evaluate GLD's therapeutic potential in ameliorating type 2 diabetes mellitus (T2DM) and elucidate its underlying mechanisms of action. A T2DM model was established using male C57BL/6J mice fed a high-fat, high-glucose diet. GLD was administered via intraperitoneal injection at doses of 10, 20, and 30 mg/kg BW, with MET (200 mg/kg BW) as a positive control. Fasting blood glucose levels, glucose tolerance, insulin tolerance, pyruvate tolerance, and serum parameters were analyzed, along with key markers of glycogen synthesis, gluconeogenesis, lipid metabolism, mitochondrial function, and endoplasmic reticulum (ER) stress. GLD significantly lowered blood glucose levels in the diabetic mice. It suppressed gluconeogenesis by inhibiting PEPCK and G6P, while promoting glycogen synthesis by activating GCK and inhibiting GSK-3β. Additionally, GLD enhanced insulin signaling by increasing IRS1 and IRS2 levels and promoting AKT phosphorylation, thereby improving insulin sensitivity. In lipid metabolism, GLD reduced hepatic steatosis and lipid accumulation by downregulating lipogenesis-related genes (SREBP1c, FAS, ACC1, and SCD1) and upregulating lipolysis-related genes (PPARα and LCAD). In energy metabolism, GLD increased mitochondrial membrane potential, reduced reactive oxygen species levels, and enhanced the expression of genes associated with mitophagy (PINK1 and Parkin) and mitochondrial biogenesis (PGC-1α, SIRT1, and TFAM). Moreover, GLD mitigated ER stress by decreasing GRP78 and CHOP levels, suppressing PERK phosphorylation, and inhibiting key stress response genes. GLD improves insulin sensitivity and exerts antidiabetic effects by ameliorating metabolic disorders, supporting its potential as a therapeutic agent for T2DM.

Effects of GLP-1 Analogues and Agonists on the Gut Microbiota: A Systematic Review

BACKGROUND

GLP-1 analogues are a relatively new class of medications that form the cornerstone of diabetes treatment. They possess invaluable glucose-lowering properties without hypoglycemic effects as well as strong cardioprotective effects. The gut microbiome has become the focus of numerous studies, demonstrating its influence not only on the gut but also on the overall well-being of the entire body. However, the effects of GLP-1 analogs on gut microbiota remain uncertain.

SCOPE OF REVIEW

Our systematic review (based on PRISMA guidelines) aimed to gather knowledge on the effects of GLP-1 analogue medications on the composition, richness, and abundance of gut microbiota in both animal and human models.

CONCLUSIONS

Thirty-eight studies were included in this systematic review. GLP-1 analogues have demonstrated a notable impact on the composition, richness, and diversity of gut microbiota. We can conclude, following the obtained research results of our study, that liraglutide promotes the growth of beneficial genera relevant for beneficial metabolic functions. Exenatide and exendin-4 administration showed various effects on the microbiome composition in animal and human studies. In animal models, it increased genera associated with improved metabolism; however, in human models, genera linked to better metabolic functions and escalated inflammation increased. Following dulaglutide administration, increases in Bacteroides, Akkermansia, and Ruminococcus, genera connected to an improved metabolic model, were significant. Finally, varied results were obtained after semaglutide treatment, in which A. muciniphila, known for its positive metabolic functions, increased; however, microbial diversity decreased. Semaglutide treatment provided various results indicating many confounding factors in semaglutide's impact on the gut microbiota. Results varied due to dissimilarities in the studied populations and the duration of the studies. Further research is essential to confirm these findings and to better recognize their implications for the clinical outcomes of patients.

Glucagon-like Peptide-1 receptor agonists for obstructive sleep apnea in patients with obesity and type 2 diabetes mellitus: a systematic review and meta-analysis

The systematic review was registered on the PROSPERO website (CRD42024558287). Our objective is to systematically summarise the clinical evidence of glucagon-like peptide-1 receptor agonists (GLP-1 RA) for obstructive sleep apnea (OSA) in patients with Obesity or/and type 2 Diabetes Mellitus (T2DM). This analysis was performed following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. 10 databases and registers Web of Science, Scopus, PubMed, APA PsycInfo, Embase, Ovid, Cochrane Library, CINAHL, Clinicaltrials.gov, and International Clinical Trials Registry Platform (ICTRP) were retrieved from the establishment to July 14, 2024 for related randomized controlled trials (RCT) and non-RCTs. Data were extracted by two investigators separately, and only the RCTs were included in the quantitative synthesis. The outcome was operated by Review Manager 5.4 and Stata 15.0. Ten studies containing eight RCTs and two non-RCTs were included. The efficacy of the GLP-1 RA group in reducing apnea-hypopnea index (AHI) was superior to that of the control group in patients with T2DM (MD = -5.68, 95%CI [-7.97, -3.38], P < 0.00001, I2 = 0%). GLP-1 RAs also possessed a tendency to reduce AHI in patients with obesity but more evidence is needed to support the findings due to the inconsistency. In consideration of the enhanced metabolic parameters observed with GLP-1 RAs, they may be recommended as useful hypoglycaemic medication for the management of T2DM with OSA. Patients with obesity and OSA may consider GLP-1 RA as a potential treatment option if the adverse events are deemed tolerable.

A meta-analysis on the risk of esophageal cancer in type 2 diabetes patients treated with GLP-1 receptor agonists

Objective

To evaluate the association between glucagon-like peptide-1 receptor agonists (GLP-1 RAs) treatment and the risk of esophageal cancer in adults with type 2 diabetes mellitus (T2DM) or obesity through a comprehensive meta-analysis.

Methods

A systematic computerized searches and collection of eligible randomized controlled trials (RCTs) was performed to compare the risk of esophageal cancer between GLP-1 RA and control agents. The bias risks and quality of the studies were evaluated, and a meta-analysis was conducted using Stata 18.0 and R 4.0.2 statistical software.

Results

The meta-analysis included data from six studies involving 13,391 participants. The pooled relative risk (RR) of esophageal cancer in patients using GLP-1 RAs compared to control agents was 0.46 (95% CI 0.13-1.59; p=0.725; I²=0%). Subgroup analyses stratified by age groups, intervention durations, BMI categories, and indications for T2DM or obesity treatment more often indicated no association between GLP-1 RAs use and increased risk of esophageal cancer.

Conclusions

GLP-1 RAs did not increase the incidence of esophageal neoplasms, and there were not probably significant within-class differences in T2DM or obesity treatment. This finding supports the safety of GLP-1 RAs as a therapeutic option for the clinical management of T2DM.

Systematic review registration

https://www.crd.york.ac.uk/PROSPERO/, identifier CRD42024543945.

Assessing the benefit-risk profile of newer glucose-lowering drugs: A systematic review and network meta-analysis of randomized outcome trials

AIM

To comprehensively evaluate the benefits and risks of glucagon-like peptide-1 receptor agonists (GLP-1RA), dipeptidyl peptidase 4 inhibitors (DPP4i), and sodium-glucose cotransporter 2 inhibitors (SGLT2i).

MATERIALS AND METHODS

A systematic search of PubMed, EMBASE, and Cochrane Central Register of Controlled Trials (CENTRAL) from inception to November 2023 to identify randomized cardiovascular and kidney outcome trials that enrolled adults with type 2 diabetes, heart failure, or chronic kidney disease and compared DPP4i, GLP-1RAs, or SGLT2i to placebo. Twenty-one outcomes (e.g., major adverse cardiovascular events [MACE], stroke, and hospitalization for heart failure [HHF]) were assessed. Data were pooled using population-averaged odds ratios (ORs) with 95% CIs.

RESULTS

Twenty-six trials enrolling 198 177 participants were included. GLP-1RAs were most effective in lowering the risks of MACE (OR, 0.85, [95% CI, 0.79 to 0.92]) and stroke (0.84 [0.77, 0.91]), but increased the risk of thyroid cancer (1.58 [1.36, 2.50]). SGLT2i showed the greatest benefits in reducing the risk of HHF (0.68 [0.64, 0.73]) and improving composite renal outcomes (0.67 [0.58, 0.77]), but increased the risk of genital infections (3.11 [2.15, 4.50]). DPP4i were associated with a lower risk of certain psychiatric disorders, Parkinson's disease (0.54 [0.32, 0.92]), and amputation (0.70 [0.86, 0.93]), but an increased risk of neuropathy (1.10 [1.02, 1.18]) and pancreatitis (1.63 [1.40, 1.91]). The weighted origami plot suggested that GLP-1RAs were more suitable for reducing macrovascular and microvascular outcomes, while DPP4i might be better for neurodegenerative diseases and cancer concerns.

CONCLUSIONS

Given the distinct benefit-risk profiles, the selection of glucose-lowering drugs should be individualized based on patient characteristics and risk factors.

Risk of depression and dementia among individuals treated with sodium-glucose cotransporter 2 inhibitors and glucagon-like peptide-1 receptor agonists

PURPOSE OF THE REVIEW

To review whether sodium-glucose cotransporter 2 (SGLT2) inhibitors and glucagon-like peptide-1 (GLP-1) receptor agonists decrease the risk of depression, suicidal ideation and cognitive impairment in later life.

RECENT FINDINGS

The results of studies using information derived from large registries and administrative health datasets suggest that GLP-1 receptor agonists (RAs) increase the risk of suicidality, although findings have been inconsistent. One nested-case control study reported that SGLT2i decreases the risk of depression among adults with diabetes, and findings from a small trial of the SGLT2i empagliflozin provided supportive evidence. Several observational studies reported that SGLT2i and GLP-1 RAs decrease dementia risk, with a target trial finding greater cognitive benefit associated with the use of GLP-1 RAs compared with other medicines commonly used to manage diabetes.

SUMMARY

Recent results from large observational studies suggest that SGLT2i and GLP-1 RA may decrease the risk of cognitive impairment in later life. The effects of these medicines on mood have not been as well explored, but there are concerns about the potential increased risk of suicidality among GLP-1 RA users. Prescription bias could explain some of these associations, so that robust trial evidence is now needed to confirm or dismiss the reported findings.

Peptide with Dual Roles in Immune and Metabolic Regulation: Liver-Expressed Antimicrobial Peptide-2 (LEAP-2)

Liver-expressed antimicrobial peptide 2 (LEAP-2) was originally discovered as an antimicrobial peptide that plays a vital role in the host innate immune system of various vertebrates. Recent research discovered LEAP-2 as an endogenous antagonist and inverse agonist of the GHSR1a receptor. By acting as a competitive antagonist to ghrelin, LEAP-2 influences energy balance and metabolic processes via the ghrelin-GHSR1a signaling pathway. LEAP-2 alone or the LEAP-2/ghrelin molar ratio showed potential as therapeutic targets for obesity, diabetes, and metabolic disorders. This review explores the recent advances of LEAP-2 in immune modulation and energy regulation, highlighting its potential in treating the above diseases.

Is early use of sodium-glucose cotransporter type 2 inhibitor (SGLT2i) necessary even in diabetic patients without cardiovascular disease: a prospective study regarding the effect of SGLT2i on left ventricular diastolic function

BACKGROUND

There are insufficient studies to determine whether sodium-glucose cotransporter type 2 inhibitors (SGLT2i) will help reduce early diabetic cardiomyopathy, especially in patients without documented cardiovascular disease.

METHODS

We performed a single center, prospective observation study. A total of 90 patients with type 2 diabetes patients without established heart failure or atherosclerotic cardiovascular disease were enrolled. Echocardiography, cardiac enzyme, and glucose-control data were examined before and 3 months after the administration of SGLT2i (dapagliflozin 10 mg per day). Cardiovascular risk factors included hypertension, smoking, obesity, dyslipidemia, and old age. The primary end point was the change of E/e' before and after administration of SGLT2i.

RESULTS

Most patients (86.7%) had three or more cardiovascular risk factors, and about 32% had all five risk factors. Although the decrease in E/e' after the administration of SGLT2i was observed in 20% of enrolled patients, there was no significant difference in average E/e' value or left atrial volume index before and after the SGLT2i medication. Even in patients with all known risk factors including old age, E/e' value did not decrease after adding SGLT2i (8.9 ± 2.4 vs. 8.7 ± 3.2). There was a statistically significant difference in E/e' change after the SGLT2i administration between patients younger than 60 years and those older than 60 years (-0.7 ± 2.2 vs. 1.1 ± 2.8, P = 0.002).

CONCLUSIONS

In type 2 diabetes patients without documented cardiovascular disease including heart failure, administration of SGLT2i showed no improvement in diastolic function profile. Further large-scale randomized studies are needed to determine who will benefit from potential cardiovascular events with early addition of SGLT2i.

Glycaemic control is still central in the hierarchy of priorities in type 2 diabetes management

A panel of primary care and diabetes specialists conducted focused literature searches on the current role of glycaemic control in the management of type 2 diabetes and revisited the evolution of evidence supporting the importance of early and intensive blood glucose control as a central strategy to reduce the risk of adverse long-term outcomes. The optimal approach to type 2 diabetes management has evolved over time as the evidence base has expanded from data from trials that established the role of optimising glycaemic control to recent data from cardiovascular outcomes trials (CVOTs) demonstrating organ-protective effects of newer glucose-lowering drugs (GLDs). The results from these CVOTs were derived mainly from people with type 2 diabetes and prior cardiovascular and kidney disease or multiple risk factors. In more recent years, earlier diagnosis in high-risk individuals has contributed to the large proportion of people with type 2 diabetes who do not have complications. In these individuals, a legacy effect of early and optimal control of blood glucose and cardiometabolic risk factors has been proven to reduce cardiovascular and kidney disease events and all-cause mortality. As there is a lack of RCTs investigating the potential synergistic effects of intensive glucose control and organ-protective effects of newer GLDs, this article re-evaluates the evolution of the scientific evidence and highlights the importance of integrating glycaemic control as a pivotal early therapeutic goal in most people with type 2 diabetes, while targeting existing cardiovascular and kidney disease. We also emphasise the importance of implementing multifactorial management using a multidisciplinary approach to facilitate regular review, patient empowerment and the possibility of tailoring interventions to account for the heterogeneity of type 2 diabetes.

A review of the last decade: pancreatic cancer and type 2 diabetes

Pancreatic cancer (PC) is a prevalent gastrointestinal tumour known for its high degree of malignancy, resulting in a mere 10% five-year survival rate for most patients. Over the past decade, a growing body of research has shed light on the intricate bidirectional association between PC and Type 2 diabetes (T2DM). The collection of PC- and T2DM-related articles is derived from two comprehensive databases, namely WOS (Web of Science Core Collection) and CNKI (China National Knowledge Infrastructure). This article discusses the last 10 years of research trends in PC and T2DM and explores their potential regulatory relationship as well as related medications.

Chinese expert consensus on the management of hypertension in adults with type 2 diabetes

Both hypertension and type 2 diabetes are attributable to premature death, cardiovascular and kidney diseases with largely overlapping population. Followed the GRADE approach, this expert consensus aimed to reduce the cardiovascular and kidney death and disability due to hypertension and minimize the treatment burden in adults with type 2 diabetes. Through online survey and discussion, a multidisciplinary team comprehensively prioritized seven key guideline questions. Informed by the evidence synthesis and online discussion, the team developed 12 recommendations under the GRADE Evidence-to-decision (EtD) framework. The recommendations covered the screening of hypertension in adults diagnosed with type 2 diabetes but not hypertension and the monitoring, lifestyle interventions, and medications in those diagnosed with type 2 diabetes and hypertension.

Efficacy and Safety of Pioglitazone/Metformin Fixed-Dose Combination Versus Uptitrated Metformin in Patients with Type 2 Diabetes without Adequate Glycemic Control: A Randomized Clinical Trial

INTRODUCTION

We aim to evaluate the efficacy and safety of pioglitazone/metformin fixed-dose combination (FDC) versus uptitrated metformin in patients with type 2 diabetes mellitus (T2DM) without adequate glycemic control.

METHODS

A total of 304 patients were recruited from 15 hospitals in China and randomly assigned (1:1) to the test group (pioglitazone/metformin FDC, 15/500 mg) or the control group (uptitrated metformin, 2000-2500 mg/day). The primary endpoint was the proportion of patients with glycated hemoglobin A1c (HbA1c) ≤ 6.5% and ≤ 7.0% at week 16. The secondary outcomes included the change from baseline in glucose, serum lipids, and liver function. Full analysis set (FAS) and per-protocol set (PPS) were used for analyses.

RESULTS

In the test group, 103 (69.59%) patients reached HbA1c ≤ 7.0% (FAS, P = 0.009), with 68 (45.95%) patients achieved HbA1c ≤ 6.5 (FAS, P = 0.043). More reduction in HbA1c, homeostatic model assessment for insulin resistance, and diastolic pressure was found. Bodyweight, body mass index, and high-density lipoprotein cholesterol increased markedly. The changes of triglycerides, alanine transaminase, aspartate aminotransferase, and high-sensitivity C-reactive protein decreased noticeably. There were no significant differences in rates of adverse events between the two groups.

CONCLUSIONS

Pioglitazone/metformin FDC was superior to uptitrated metformin among patients with T2DM without adequate glycemic control.

TRIAL REGISTRATION NUMBER

This trial is registered with the Chinese Clinical Trial Registry (ChiCTR1900028606).

A discrete choice experiment to understand preferences of patients with type 2 diabetes about the attributes of GLP1 receptor agonists in Spain

OBJECTIVE

To determine the preferences regarding injection, medication frequency and complexity of GLP1 receptor agonists among patients with type 2 diabetes, treatment-naïve for such drugs in Spain. Additionally, patients' willingness to pay according to these attributes was evaluated.

METHODS

A discrete-choice experiment survey designed to evaluate patients' preferences over three attributes discriminating by age, sex and patients experience with previous injectable treatment was fulfilled by patients. The resulting model was analyzed using a conditional (fixed-effects) logistic regression.

RESULTS

A total of 180 patients (63.35 ± 11.49 years, 63.28% men, 48.41% with previous cardiovascular disease, 54.69% with a time of evolution of diabetes >10 years) recruited from 5 health care centers in Spain completed the survey. Patients viewed positively weekly injections (vs daily injections), but rated negatively a complex preparation of the dose (vs simple preparation). Whereas naïve patients for injectable medications did not consider administration timing of importance, no naïve patients considered it relevant. No relevant differences were observed according to age or gender. Patients were willing to pay 83.25€for a "no preparation required" dose. No naïve and naïve patients were willing to pay 34.61€ and 14.35€; p = 0.000, to change daily injection for a weekly injection.

CONCLUSIONS

Patients highly valued the avoidance of injections, with weekly dosing clearly preferred over daily dosing, as well as reducing the treatment complexity. These findings may provide a better understanding of what patients prefer and value in their treatment and provide guidance for clinicians making therapeutic decisions regarding treatments of patients with type 2 diabetes.

Sema4D deficiency enhances glucose tolerance through GLUT2 retention in hepatocytes

BACKGROUND

The glucose transporter 2 (GLUT2) is constitutively expressed in pancreatic beta cells and hepatocytes of mice. It is the most important receptor in glucose-stimulated insulin release and hepatic glucose transport. The Sema4D is a signalin receptor on cell membranes. The correlation between Sema4D and GLUT2 has not been reported previously. We investigated whether knockdown of Sema4D could exert a hypoglycemic effect based on the increased GLUT2 expression in Sema4D -/- mice hepatocytes.

METHODS

The glucose tolerance test and insulin tolerance test in sema4D -/- and sema4D +/+ mice were compared before and after streptozotocin (STZ) injection; the expression of GLUT2 content on the membrane surface of both groups was verified by Western blot. Then, the levels of insulin and C-peptide in the serum of the two groups of mice after STZ injection were measured by ELISA; the differentially expressed mRNAs in the liver of the two groups of mice were analyzed by transcriptomic analysis; then the differences in the expression of GLUT2, glycogen, insulin and glucagon in the two groups of mice were compared by tissue section staining. Finally, metabolomics analysis was performed to analyze the metabolites differentially expressed in the two groups of mice.

KEY FINDINGS

First, Sema4D -/- male mice exhibited significantly greater glucose tolerance than wild-type mice in a hyperglycemic environment. Secondly, Sema4D -/- mice had more retained GLUT2 in liver membranes after STZ injection according to an immunofluorescence assay. After STZ injection, Sema4D -/- male mice did not exhibit fasting hyperinsulinemia like wild-type mice. Finally, analysis of metabolomic and immunohistochemical data also revealed that Sema4D -/- mice produce hypoglycemic effects by enhancing the pentose phosphate pathway, but not glycogen synthesis.

CONCLUSIONS

Thus, Sema4D may play an important role in the regulation of glucose homeostasis by affecting GLUT2 synthesis.

Radix Astragali and Its Representative Extracts for Diabetic Nephropathy: Efficacy and Molecular Mechanism

Diabetic nephropathy (DN) is a common microvascular complication of diabetes mellitus (DM). Radix Astragali (RA), a frequently used Chinese herbal medicine in the Leguminosae family, Astragalus genus, with its extracts, has been proven to be effective in DN treatment both in clinical practice and experimental studies. RA and its extracts can reduce proteinuria and improve renal function. They can improve histopathology changes including thickening of the glomerular basement membrane, mesangial cell proliferation, and injury of endothelial cells, podocytes, and renal tubule cells. The mechanisms mainly benefited from antioxidative stress which involves Nrf2/ARE signaling and the PPARγ-Klotho-FoxO1 axis; antiendoplasmic reticulum stress which involves PERK-ATF4-CHOP, PERK/eIF2α, and IRE1/XBP1 pathways; regulating autophagy which involves SIRT1/NF-κB signaling and AMPK signaling; anti-inflammation which involves IL33/ST2 and NF-κB signaling; and antifibrosis which involves TGF-β1/Smads, MAPK (ERK), p38/MAPK, JNK/MAPK, Wnt/β-catenin, and PI3K/AKT/mTOR signaling pathways. This review focuses on the clinical efficacy and the pharmacological mechanism of RA and its representative extracts on DN, and we further document the traditional uses of RA and probe into the TCM theoretical basis for its application in DN.

Comparative risk of infection of medications used for type 2 diabetes

INTRODUCTION

Glucose-lowering drugs pose a potential infection risk among individuals with type 2 diabetes. The U.S. Food and Drug Administration has issued safety warnings regarding increased risks of urinary tract infections (UTIs) and genital infections with sodium-glucose cotransporter 2 (SGLT2) inhibitors. However, the infection risk associated with other glucose-lowering drugs remains unclear. We conducted a PubMed database search to review the infection risk of glucose-lowering drugs, focusing on meta-analysis of randomized controlled trials.

AREAS COVERED

We described the infection risks associated with SGLT2 inhibitors, dipeptidyl peptidase-4 (DPP-4) inhibitors, glucose-like peptide-1 receptor agonists, metformin, and thiazolidinediones, covering infections of the genitourinary, respiratory, and gastrointestinal systems, including skin and soft tissue infections (SSTIs).

EXPERT OPINION

SGLT2 inhibitors are associated with a higher genital infection risk, while their UTI risk remains inconclusive. DPP-4 inhibitors could be a treatment option for those intolerant to SGLT2 inhibitors, given their lower genital infection risk compared to placebo. Uncertainty persists regarding the risks of respiratory infections, gastroenteritis, and SSTIs with SGLT2 inhibitors. Limited evidence is available regarding the impact of DPP-4 inhibitors on respiratory infections. Additional research is needed to determine the comparative infection risk of other glucose-lowering drugs.

Metformin monotherapy versus predominantly older non-metformin antidiabetic medications for cerebrovascular risk in early type 2 diabetes management

AIM

Choosing the initial treatment for type 2 diabetes (T2D) is pivotal, requiring consideration of solid clinical evidence and patient characteristics. Despite metformin's historical preference, its efficacy in preventing cerebrovascular events lacked empirical validation. This study aimed to evaluate the associations between first-line monotherapy (metformin or non-metformin antidiabetic medications) and cerebrovascular complications in patients with T2D without diabetic complications.

METHODS

We analysed 9090 patients with T2D without complications who were prescribed either metformin or non-metformin medications as initial therapy. Propensity score matching ensured group comparability. Cox regression analyses, stratified by initial metformin use, assessed cerebrovascular disease risk, adjusting for multiple covariates and using competing risk analysis. Metformin exposure was measured using cumulative defined daily doses.

RESULTS

Metformin users had a significantly lower crude incidence of cerebrovascular diseases compared with non-users (p < .0001). Adjusted hazard ratios (aHRs) consistently showed an association between metformin use and a lower risk of overall cerebrovascular diseases (aHRs: 0.67-0.69) and severe events (aHRs: 0.67-0.69). The association with reduced risk of mild cerebrovascular diseases was significant across all models (aHRs: 0.73-0.74). Higher cumulative defined daily doses of metformin correlated with reduced cerebrovascular risk (incidence rate ratio: 0.62-0.94, p < .0001), indicating a dose-dependent effect.

CONCLUSION

Metformin monotherapy is associated with a reduced risk of cerebrovascular diseases in early-stage T2D, highlighting its dose-dependent efficacy. However, the observed benefits might also be influenced by baseline differences and the increased risks associated with other medications, such as sulphonylureas. These findings emphasize the need for personalized diabetes management, particularly in mitigating cerebrovascular risk in early T2D stages.

Physicians found an interactive tool displaying structured evidence summaries for multiple comparisons understandable and useful: a qualitative user testing study

OBJECTIVES

To evaluate and improve "Making Alternative Treatment Choices Intuitive and Trustworthy" (MATCH-IT)-a digital, interactive decision support tool displaying structured evidence summaries for multiple comparisons-to help physicians interpret and apply evidence from network meta-analysis (NMA) for their clinical decision-making.

STUDY DESIGN AND SETTING

We conducted a qualitative user testing study, applying principles from user-centered design in an iterative development process. We recruited a convenience sample of practicing physicians in Norway, Belgium, and Canada, and asked them to interpret structured evidence summaries for multiple comparisons-linked to clinical guideline recommendations-displayed in MATCH-IT. User testing included (a) introduction of a clinical scenario, (b) a think-aloud session with participant-tool interaction, and (c) a semistructured interview. We video recorded, transcribed, and analyzed user tests using directed content analysis. The results informed new updates in MATCH-IT.

RESULTS

Distributed across 5 development cycles we tested MATCH-IT with 26 physicians. Of these, 24 (94%) reported either no or sparse prior experience with interpretation of NMA. Physicians perceived MATCH-IT as easy to interpret and navigate, and appreciated its ability to provide an overview of the evidence. Visualization of effects in pictograms and inclusion of information on burden of treatment ("practical issues") were highlighted as potentially useful features in interacting with patients. We also identified problems, including undiscovered functionalities (drag and drop), suboptimal tutorial, and cumbersome navigation of the tool. In addition, physicians wanted definition/explanation of key terms (eg, outcomes and "certainty"), and there were concerns that overwhelming evidence from a large NMA would complicate applicability to clinical practice. This led to several updates with development of a new start page, tutorial, updated user interface for more efficient maneuvering, solutions to display definition of key terms and a "frequently asked questions" section. To facilitate interpretation of large networks, we improved categorization of results using color coding and added filtering functionality. These modifications allowed physicians to focus on interventions of interest and reduce information overload.

CONCLUSION

This study provides proof of concept that physicians can use MATCH-IT to understand NMA evidence. Key features of MATCH-IT in a clinical context include providing an overview of the evidence, visualization of effects, and the display of information on burden of treatments. However, unfamiliarity with the Grading of Recommendations Assessment, Development and Evaluation concepts, time constraints, and accessibility at the point of care may be challenges for use. To what extent our results are transferable to real-world clinical contexts remains to be explored.

Patient-important outcomes in type 2 diabetes: The paradigm of the sodium-glucose cotransporter-2 inhibitors and glucagon-like peptide-1 receptor agonists

The newfound knowledge in type 2 diabetes (T2D) during the past decade for the sodium-glucose cotransporter-2 inhibitors (SGLT-2i) and glucagon-like peptide-1 receptor agonists (GLP-1RA) is wealthy in favorable results for key patient-important outcomes including morbidity, mortality and health-related quality of life (HRQoL). The SGLT-2i and GLP-1RA offer cardiovascular and renal protection beyond their glucose lowering effect, reduce body weight and hypoglycemia and improve diabetes-related distress, physical function and HRQoL. Along with the fixed-ratio combinations of basal insulin/GLP-1RA, they make feasible a regimen simplification and de-escalation from high dose and multiple injections of insulin reducing treatment burden. Besides cardiorenal risk reduction, the SGLT-2i and GLP-1RA reduce the incidence of depression, cognitive decline, respiratory disease, gout, arrhythmias and other co-occurring conditions of T2D, namely multimorbidity, which frequently complicates T2D and adversely affects HRQoL. The alleviation of multimorbidity by the pleiotropic effects of the SGLT-2i and GLP-1RA, could improve patients' HRQoL. The use of the SGLT-2i and GLP-1RA should be increased within a shared decision-making in which they are reframed as cardiorenal risk-reducing medications with the potential to lower blood glucose. By improving outcomes that patients may highly perceive and value, the SGLT-2i and GLP-1RA may facilitate the contemporary person-centered management of T2D.

Sodium-glucose cotransporter-2 inhibitors and cardiovascular safety profile: a pharmacovigilance analysis of the US food and drug administration adverse event reporting system

BACKGROUND

Sodium-glucose cotransporter-2 inhibitors (SGLT2i) are effective in reducing the risk of heart failure (HF) in type 2 diabetic patients. We systematically examined the association between cardiac adverse events (CAEs) and SGLT2i.

RESEARCH DESIGN AND METHODS

We analyzed CAEs in the FDA Adverse Event Reporting System between January 2013 and March 2021. The CAEs were classified into four major groups according to their preferred terms. Disproportionality and Bayesian analyses were performed to detect signals using reporting odds ratio (ROR), proportional reporting ratio (PRR), information component (IC), and empirical Bayesian geometric mean (EBGM). Case seriousness was also described.

RESULTS

There were 2,330 CAEs associated with SGLT2i, and 81 were used for HFs. The SGLT2i were not associated with over-reporting frequencies of CAE based on ROR (ROR = 0.97, 95% confidence interval [CI]: 0.93, 1.01), PRR (PRR = 0.97, 95% CI: 0.94, 1.01), Bayesian confidence propagation neural network (IC = -0.04, IC025: N.A.), and multi-item gamma Poisson shrinker (EBGM = 0.97, EBGM05:0.94), unless further restricted to myocardial infarction (ROR = 2.03, 95% CI = 1.89, 2.17). Additionally, SGLT2i-associated CAEs are associated with 11.33% fatality and 51.25% hospitalization.

CONCLUSIONS

SGLT2i present a favorable cardiac safety profile; however, concerns should be raised regarding their potential association with specific events.

Cardio-renal-metabolic disease in primary care setting

In the primary care setting providers have more tools available than ever before to impact positively obesity, diabetes, and their complications, such as renal and cardiac diseases. It is important to recognise what is available for treatment taking into account diabetes heterogeneity. For those who develop type 2 diabetes (T2DM), effective treatments are available that for the first time have shown a benefit in reducing mortality and macrovascular complications, in addition to the well-established benefits of glucose control in reducing microvascular complications. Some of the newer medications for treating hyperglycaemia have also a positive impact in reducing heart failure (HF). Technological advances have also contributed to improving the quality of care in patients with diabetes. The use of technology, such as continuous glucose monitoring systems (CGM), has improved significantly glucose and glycated haemoglobin A1c (HbA1c) values, while limiting the frequency of hypoglycaemia. Other technological support derives from the use of predictive algorithms that need to be refined to help predict those subjects who are at great risk of developing the disease and/or its complications, or who may require care by other specialists. In this review we also provide recommendations for the optimal use of the new medications; sodium-glucose co-transporter-2 inhibitors (SGLT2i) and Glucagon-like peptide-receptor agonists 1 (GLP1RA) in the primary care setting considering the relevance of these drugs for the management of T2DM also in its early stage.

Time-dependent risk of fracture in adults with type 2 diabetes receiving anti-diabetic drug: A one-stage network meta-analysis

AIMS

To assess the time-dependent risk of fracture in adults with type 2 diabetes receiving anti-diabetic drugs.

MATERIALS AND METHODS

We searched MEDLINE, EMBASE, and Cochrane Library up to 18 November 2021, for randomized controlled trials (RCTs) and propensity-score-matched non-randomized studies (NRSs) comparing all anti-diabetic drugs with standard treatment or with each other on fracture in adults with type 2 diabetes. The study performed a one-stage network meta-analysis using discrete-time hazard regression with reconstructed individual time-to-event data.

RESULTS

This network meta-analysis involved seven RCTs (65,051 adults with type 2 diabetes) with a median follow-up of 36 months and three propensity-score-based NRSs (17,954 participants) with a median follow-up of 27.3 months. Among anti-diabetic drugs, thiazolidinediones increased the overall hazard of fracture by 42% (95% credible interval [CrI], 3%-97%) and almost tripled the risk after 4 years (hazard ratio [HR], 2.74; 95% CrI, 1.53-4.80). Credible subgroup analysis suggested that thiazolidinediones increased the hazard of fracture only in females (HR, 2.19; 95% CrI, 1.26-3.74) but not among males (HR, 0.81; 95% CrI, 0.45-1.40). Moderate certainty evidence established that thiazolidinediones increase 92 fractures in five years per 1000 female patients. We did not find the risk of fractures with other anti-diabetic drugs including metformin, sulfonylureas, sodium-glucose cotransporter-2 (SGLT2) inhibitors, and dipeptidyl peptidase-4 (DPP-4) inhibitors.

CONCLUSIONS

Long-term use of thiazolidinediones elevates the risk of fracture among females with type 2 diabetes. There is no evidence eliciting fracture risk associated with other anti-diabetic drugs.

Effect and pharmacological mechanism of Salvia miltiorrhiza and its characteristic extracts on diabetic nephropathy

ETHNOPHARMACOLOGICAL RELEVANCE

Diabetic nephropathy (DN) is a severe diabetic microvascular complication with an increasing prevalence rate and lack of effective treatment. Traditional Chinese medicine has been proven to have favorable efficacy on DN, especially Salvia miltiorrhiza Bunge (SM), one of the most critical and conventional herbs in the treatment. Over the past decades, studies have demonstrated that SM is a potential treatment for DN, and the exploration of the underlying mechanism has also received much attention.

AIM OF THIS REVIEW

This review aims to systematically study the efficacy and pharmacological mechanism of SM in the treatment of DN to understand its therapeutic potential more comprehensively.

MATERIALS AND METHODS

Relevant information was sourced from Google Scholar, PubMed, Web of Science, and CNKI databases.

RESULTS

Several clinical trials and systematic reviews have indicated that SM has definite benefits on the kidneys of diabetic patients. And many laboratory studies have further revealed that SM and its characteristic extracts, mainly including salvianolic acids and tanshinones, can exhibit pharmacological activity against DN by the regulation of metabolism, renal hemodynamic, oxidative stress, inflammation, fibrosis, autophagy, et cetera, and several involved signaling pathways, thereby preventing various renal cells from abnormal changes in DN, including endothelial cells, podocytes, epithelial cells, and mesangial cells.

CONCLUSION

As a potential drug for the treatment of DN, SM has multi-component, multi-target, and multi-pathway pharmacological effects. This work will not only verify the satisfactory curative effect of SM in the treatment of DN but also provide helpful insights for the development of new anti-DN drugs and the application of traditional Chinese medicine.

Glucagon-like peptide-1 receptor agonists for the management of diabetic peripheral neuropathy

Diabetes mellitus is a prevalent chronic disease characterized by hyperglycemia. Diabetic peripheral neuropathy (DPN) is one of the complications of diabetes mellitus and is caused by neuron injury induced by hyperglycemic circumstances. The incidence of DPN varies among different countries and regions, ranging from nearly 20% to over 70%. Patients with DPN may encounter symmetric pain or discomfort of the extremes, leading to reduced quality of life and even amputation. The pharmacological management for painful DPN mainly includes antidepressants due to their analgesic effects. Nevertheless, effective therapies to impact the pathogenesis and progression of DPN are lacking. Glucagon-like peptide-1 receptor (GLP-1R) agonists show efficacy in controlling blood glucose and serve as a treatment modality for diabetes mellitus. In recent years, evidence has been proposed that GLP-1R agonists exert neuroprotective effects through modulating inflammation, oxidative stress, and mitochondrial dysfunction. On the other hand, clinical evidence on the potential of GLP-1R agonists for treating DPN is still controversial and limited. This narrative review summarizes the preclinical and clinical studies investigating the capacity of GLP-1R agonists as therapeutic agents for DPN.

Interpretation and use of a decision support tool for multiple treatment options: a combined randomised controlled trial and survey of medical students

OBJECTIVES

To investigate medical students' ability to interpret evidence, as well as their self-assessed understandability, perceived usefulness and preferences for design alternatives in an interactive decision support tool, displaying GRADE evidence summaries for multiple treatment options (Making Alternative Treatment CHoices Intuitive and Trustworthy, MATCH-IT).

DESIGN

A combined randomised controlled trial and survey. Participants were presented with a clinical scenario and randomised to one of two versions of the MATCH-IT tool (A/B), instructed to explore the evidence and decide on a recommendation. Participants answered a questionnaire assessing interpretation, treatment recommendation self-assessed understandability and perceived usefulness before exposure to the other MATCH-IT version and asked questions on design preferences.

SETTING

Online lecture in an evidence-based medicine (EBM) introductory course.

PARTICIPANTS

149 third-year medical students. 52% (n=77) had 6 months of clinical training and 48% (n=72) had preclinical training only.

INTERVENTIONS

The MATCH-IT tool version A uses colour coding to categorise interventions by magnitude and direction of effects and displays all outcomes in a table on entry. Version B has no colour coding, and the user must decide which outcomes to display in the table.

MAIN OUTCOME MEASURES

Interpretation of evidence, treatment recommendation, perceived usefulness and understandability, preference for format and design alternatives.

RESULTS

82.5% (n=123) of medical students correctly answered ≥4 out of 5 multiple choice questions assessing interpretation of data. 75.8% (n=114) of students made a treatment recommendation in accordance with an expert panel for the same clinical scenario. 87.2% (n=130) found the tool understandable while 91.9% perceived the tool as useful in addressing the clinical scenario.

CONCLUSION

Medical students with no prior training in EBM can interpret and use the MATCH-IT tool. Certain design alternatives were preferred but had no bearing on interpretation of evidence or understandability of the tool.

GLP-1 Receptor Agonists and Related Mental Health Issues; Insights from a Range of Social Media Platforms Using a Mixed-Methods Approach

The emergence of glucagon-like peptide-1 receptor agonists (GLP-1 RAs; semaglutide and others) now promises effective, non-invasive treatment of obesity for individuals with and without diabetes. Social media platforms' users started promoting semaglutide/Ozempic as a weight-loss treatment, and the associated increase in demand has contributed to an ongoing worldwide shortage of the drug associated with levels of non-prescribed semaglutide intake. Furthermore, recent reports emphasized some GLP-1 RA-associated risks of triggering depression and suicidal thoughts. Consistent with the above, we aimed to assess the possible impact of GLP-1 RAs on mental health as being perceived and discussed in popular open platforms with the help of a mixed-methods approach. Reddit posts yielded 12,136 comments, YouTube videos 14,515, and TikTok videos 17,059, respectively. Out of these posts/entries, most represented matches related to sleep-related issues, including insomnia (n = 620 matches); anxiety (n = 353); depression (n = 204); and mental health issues in general (n = 165). After the initiation of GLP-1 RAs, losing weight was associated with either a marked improvement or, in some cases, a deterioration, in mood; increase/decrease in anxiety/insomnia; and better control of a range of addictive behaviors. The challenges of accessing these medications were a hot topic as well. To the best of our knowledge, this is the first study documenting if and how GLP-1 RAs are perceived as affecting mood, mental health, and behaviors. Establishing a clear cause-and-effect link between metabolic diseases, depression and medications is difficult because of their possible reciprocal relationship, shared underlying mechanisms and individual differences. Further research is needed to better understand the safety profile of these molecules and their putative impact on behavioral and non-behavioral addictions.

Qualitative study of guideline panelists: innovative surveys provided valuable insights regarding patient values and preferences

OBJECTIVES

To explore guideline panelists' understanding of panel surveys for eliciting panels' inferences regarding patient values and preferences, and the influence of the surveys on making recommendations.

STUDY DESIGN AND SETTING

We performed sampling and data collection from all four guideline panels that had conducted the surveys through October 2020. We collected the records of all panel meetings and interviewed some panelists in different roles. We applied inductive thematic analysis for analyzing and interpreting data.

RESULTS

We enrolled four guideline panels with 99 panelists in total and interviewed 25 of them. Most panelists found the survey was easy to follow and facilitated the incorporation of patient values and preferences in the tradeoffs between benefits and harms or burdens. The variation of patient preferences and uncertainty regarding patient values and preferences reflected in the surveys helped the panels ponder the strength of recommendations. In doing so, the survey results enhanced a rationale for panels' decision on the recommendations.

CONCLUSION

The panel surveys have proved to help guideline panels explicitly consider and incorporate patient values and preferences in making recommendations. Guideline panels would benefit from widespread use of the panel surveys, particularly when primary evidence regarding patient values and preferences is scarce.

Comparison of statistical methods for integrating real-world evidence in a rare events meta-analysis of randomized controlled trials

Rare events meta-analyses of randomized controlled trials (RCTs) are often underpowered because the outcomes are infrequent. Real-world evidence (RWE) from non-randomized studies may provide valuable complementary evidence about the effects of rare events, and there is growing interest in including such evidence in the decision-making process. Several methods for combining RCTs and RWE studies have been proposed, but the comparative performance of these methods is not well understood. We describe a simulation study that aims to evaluate an array of alternative Bayesian methods for including RWE in rare events meta-analysis of RCTs: the naïve data synthesis, the design-adjusted synthesis, the use of RWE as prior information, the three-level hierarchical models, and the bias-corrected meta-analysis model. The percentage bias, root-mean-square-error, mean 95% credible interval width, coverage probability, and power are used to measure performance. The various methods are illustrated using a systematic review to evaluate the risk of diabetic ketoacidosis among patients using sodium/glucose co-transporter 2 inhibitors as compared with active-comparators. Our simulations show that the bias-corrected meta-analysis model is comparable to or better than the other methods in terms of all evaluated performance measures and simulation scenarios. Our results also demonstrate that data solely from RCTs may not be sufficiently reliable for assessing the effects of rare events. In summary, the inclusion of RWE could increase the certainty and comprehensiveness of the body of evidence of rare events from RCTs, and the bias-corrected meta-analysis model may be preferable.

Clinical outcomes in heart failure patients with and without atrial fibrillation receiving sodium-glucose cotransporter-2 inhibitor

We report a retrospective analysis of a nationwide health database to study the association between sodium-glucose cotransporter-2 inhibitor (SGLT2I) use and the incidence of adverse clinical outcomes among heart failure (HF) patients with and without atrial fibrillation (AF) stratified by CHA2DS2-VASc score. The outcome of this study was on the development of adverse events, including acute myocardial infarction (AMI), hemorrhagic stroke, ischemic stroke, cardiovascular (CV) death, and all-cause mortality. By dividing the number of adverse events by the total person-years, the incidence rate was calculated. The hazard ratio (HR) was estimated by the Cox proportional hazard model. A total of 95% confidence interval (CI) was also presented to show the risk of adverse events for HF patients with and without AF taking SGLT2I. SGLT2I users had a lower risk of AMI (adjusted HR = 0.83; 95% CI = 0.74, 0.94), CV death (adjusted HR = 0.47; 95% CI = 0.42, 0.51), and all-cause death (adjusted HR = 0.39; 95% CI = 0.37, 0.41). Considering HF patients without AF and SGLT2I as the reference group, HF patients without AF but with SGLT2I had a reduced risk of adverse outcomes of 0.48 (95% CI = 0.45, 0.50), and HF patients with AF and SGLT2I had the decreased hazard ratio of 0.55 (95% CI = 0.50, 0.61). The adjusted HR of adverse outcomes for HF patients with CHA2DS2-VASc score less than 2 and SGLT2I without and with AF relative to HF patients without AF nor SGLT2I were 0.53 (95% CI = 0.41, 0.67) and 0.24 (95% CI = 0.12, 0.47), respectively. Compared to HF patients with no history of AF and SGLT2I, if patients additionally with SGLT2I and CHA2DS2-VASc score ≥ 2, the risk of the adverse outcomes was reduced with adjusted HR of 0.48 (95% CI = 0.45, 0.50); if patients additionally with AF and CHA2DS2-VASc score ≥ 2, the risk of the adverse outcomes was decreased with adjusted HR of 0.88 (95% CI = 0.80, 0.97); if patients additionally with AF, SGLT2I, and CHA2DS2-VASc score ≥ 2, the risk of the adverse outcomes was diminished with adjusted HR of 0.52 (95% CI = 0.47, 0.58). We concluded that SGLT2I has a protective effect in HF patients, and the risk reduction is greater with a score of < 2 and without AF.

Do SGLT2 inhibitors and GLP-1 receptor agonists modulate differently the risk of stroke ? Discordance between randomised controlled trials and observational studies

Stroke represents a major burden in patients with type 2 diabetes, yet this cerebrovascular complication has been less carefully investigated than the risk of cardiovascular mortality, heart failure and renal disease. Some data suggested that glucagon-like peptide-1 receptor agonists (GLP-1RAs) exert a better protection against stroke than sodium-glucose cotransporter 2 inhibitors (SGLT2is). However, this conclusion was derived from indirect comparisons in absence of any head-to-head randomised controlled trial (RCT). The present comprehensive review compares the effects of SGLT2is versus GLP-1RAs on nonfatal and fatal/nonfatal strokes in network meta-analyses of RCTs (mostly cardiovascular outcome trials) versus placebo, on the one hand, and in real-life observational cohort studies, on the other hand. Whereas network meta-analyses of placebo-controlled RCTs confirm a slight but significant (in 11 out of 13 meta-analyses) higher incidence of stroke in patients treated with SGLT2is compared with those treated with GLP-1RAs, a large majority of retrospective observational cohort studies (19 out of 21) failed to find any significant difference in the risk of stroke between the two pharmacological classes. Available, yet limited, findings suggest that SGLT2is may be more efficacious against haemorrhagic than ischaemic strokes, in patients at risk for atrial fibrillation and in patients with chronic kidney disease.

Role of Intraoperative Neurophysiological Monitoring in Preventing Stroke After Cardiac Surgery

BACKGROUND

Perioperative stroke after cardiac surgical procedures carries significant morbidity. Dual intraoperative neurophysiological monitoring with electroencephalography (EEG) and somatosensory-evoked potentials detects cerebral hypoperfusion and predicts postoperative stroke in noncardiac procedures. We further evaluated preoperative risk factors and intraoperative neuromonitoring ability to predict postoperative stroke after cardiac operations.

METHODS

All patients who underwent cardiac operations with intraoperative neurophysiological monitoring from 2009 to 2020 at a single academic medical center were retrospectively analyzed. Patients with circulatory arrest were excluded. Risks factors analyzed were sex, age, tobacco use, hypertension, diabetes mellitus, dyslipidemia, atrial fibrillation, prior cerebrovascular accident, cerebrovascular disease, antiplatelet/anticoagulant use, abnormal somatosensory-evoked potentials and EEG baselines, and significant somatosensory-evoked potentials and EEG change as well as their permanence. Patients were divided into 2 groups by 30-day postoperative stroke occurrence. Univariate and multivariate logistical regressions were used for postoperative stroke significant predictors, and Kaplan-Meier curves estimated survival.

RESULTS

The study included 620 patients (67.6% men), mean age 65.1 ± 14.1 years, with stroke in 5.32%. In univariate analysis, diabetes (odds ratio [OR], 2.62) and permanence of EEG change (OR, 5.35) were each associated with increased postoperative stroke odds. In multivariate analysis, diabetes (OR, 2.64) and permanent EEG change (OR, 4.22) were independently significantly associated with postoperative stroke. Overall survival was significantly better for patients with no intraoperative neurophysiological monitoring changes (P < .005).

CONCLUSIONS

Permanent EEG change and diabetes were significant postoperative stroke predictors in cardiac operations. Furthermore, overall survival out to 10 years postoperatively was significantly higher in the group without intraoperative neurophysiological monitoring changes, emphasizing its important predictive role.

The current role of SGLT2 inhibitors in type 2 diabetes and beyond: a narrative review

INTRODUCTION

Sodium-glucose cotransporter 2 inhibitors (SGLT2is, gliflozins), the most recent oral antihyperglycaemic agents, provide a cardiorenal protection, an effect independent of their glucose-lowering potency.

AREAS COVERED

The antihyperglycaemic potency of SGLT2is was compared with that of dipeptidyl peptidase-4 inhibitors and glucagon-like peptide-1 receptor agonists, especially when added to metformin monotherapy. Main results of cardiovascular/renal outcome trials with SGLT2is were summarized in different populations: patients with type 2 diabetes mellitus (T2DM) with or without established cardiovascular disease, patients (with or without T2DM) with heart failure (with reduced or preserved left ventricular ejection fraction) and in patients (with or without T2DM) with chronic kidney disease (CKD, including stage 4). Original papers and meta-analyses of these different trials have consistently reported a reduction in hospitalization for heart failure (alone or combined with cardiovascular mortality) and a reduced progression of CKD, with an overall good safety profile.

EXPERT OPINION

Global use of SGLT2is has increased over time but remains suboptimal despite clinically relevant cardiovascular and renal protection, particularly in patients most likely to benefit. SGLT2is has proven both positive benefit-risk balance and cost-effectiveness in at risk patients. New prospects are expected in other complications, i.e. metabolic-associated fatty liver disease and neurodegenerative disorders.

[Characteristics of purchases of hypoglycemic agents in pharmacy retail sector in 2016-2020 years dynamics]

BACKGROUND

Procurement of medicines reflects the demand and frequency of prescribing certain drugs, which makes it possible to assess the quality of medical care and compliance with standards. The Russian pharmaceutical market is dynamically developing and expanding, therefore, the commercial sector of drug circulation is a significant part of it and should be studied along with public procurement. Given the significant number of patients diagnosed with diabetes mellitus (DM) in our country, we considered it appropriate and interesting to analyze the structure and volume of turnover of antidiabetic drugs in the retail trade over five years.

AIM

to assess the dynamics of the cost and sales volumes of hypoglycemic drugs in the commercial sector for 2019-2020 compared to 2016.

MATERIALS AND METHODS

The analysis was made on the basis of the data of antidiabetic drugs purchases in Russian pharmacies in 2016 and 2019-2020, according to 95257 pharmacies data.

RESULTS

In 2020, compared to 2016, we see a significant increase in the number of packages purchases (+14,952,897 rub.) and the purchases total amount (+9,377,975,722 rub.), in parallel with the increase in average price per box of the hypoglycemic drug +199, 57 rub. The average price for DPP4 decreased. The cost per pack of metformin remains one of the lowest, second only to glibenclamide and gliclazide. The most expensive drugs include GLP1 group representatives. Insulin purchases have halved, when budget for GLP1 have increased by 10 times, for SGLT2 by 9.5 times, and for DPP4 by 2.1 times. In 2020, metformin gliclazide, a combination of glibencladimide with metformin, glibenclamide and vildgaliptin remain leaders in the number of purchased packages. The purchase leaders in terms of budget share are: metformin, gliclazide, liraglutide, vildagliptin and dapagliflozinCONCLUSION: There are positive trends in the demand for more effective innovative hypoglycemic drugs, however, the affordability of drugs still dominates over the feasibility of their clinical use, and a high percentage of drug turnover in the commercial sector might indicates insufficient funding for drug provision for patients with diabetes mellitus.

Professional medical education approaches: mobilizing evidence for clinicians

Rapidly proliferating high-quality evidence supports daily decision-making in clinical practice. Continuing professional medical education links this evidence to practicing clinicians who are strongly motivated to improve the quality of their care by using the latest information. Approaches to professional education vary, and their effects depend on specific scenarios. This narrative review summarizes the main approaches for professional medical education that facilitate the mobilization of evidence for clinicians. It includes traditional learning (passive and active dissemination of educational materials, lectures, and mass media dissemination), constructivist learning (engaging in local consensus processes and education outreach visits, interfacing with local opinion leaders, conducting patient-mediated interventions, employing audit and feedback processes, and utilizing clinical decision-supporting systems), and blended learning approaches (the integration of in-person or online passive learning with active and creative learning by the learners). An optimized selection from these approaches is challenging but critical to clinicians and healthcare systems.

Risk of diabetic ketoacidosis of SGLT2 inhibitors in patients with type 2 diabetes: a systematic review and network meta-analysis of randomized controlled trials

Background: Sodium-glucose cotransporter-2 (SGLT2) inhibitors have proven to be effective in improving glycemic control in patients with type 2 diabetes mellitus (T2DM). However, the risk of diabetic ketoacidosis (DKA) in patients remains unclear. The purpose of this study is to conduct this systematic review and network meta-analysis for the risk of DKA of SGLT2 inhibitors in patients with T2DM. Methods: We searched for randomized controlled trials (RCTs) concerning SGLT2 inhibitors in patients with T2DM in PubMed, EMBASE (Ovid SP), Cochrane Central Register of Controlled Trials (Ovid SP), and ClinicalTrials.gov from inception to January 2022. The primary outcomes were the risk of DKA. We assessed the sparse network with a fixed-effect model and consistency model in a frequentist framework with a graph-theoretical method by the netmeta package in R. We assessed the evidence quality of evidence of outcomes according to the Grading of Recommendations Assessment, Development, and Evaluation (GRADE). Results: In total, 36 studies involving 52,264 patients were included. The network showed that there was no significant difference observed among SGLT2 inhibitors, other active antidiabetic drugs, and placebo in the risk of DKA. There was no significant difference in the DKA risk between different doses of SGLT2 inhibitors. The certainty of the evidence ranged from very low to moderate. The probabilities of rankings and P-score showed that compared to placebo, SGLT2 inhibitors might increase the risk of DKA (P-score = 0.5298). Canagliflozin might have a higher DKA risk than other SGLT2 inhibitors (P-score = 0.7388). Conclusion: Neither SGLT2 inhibitors nor other active antidiabetic drugs were associated with an increased risk of DKA compared to placebo, and the risk of DKA with SGLT2 inhibitors was not found to be dose-dependent. In addition, the use of canagliflozin was less advisable than other SGLT2 inhibitors according to the rankings and P-score. Systematic Review Registration: https://www.crd.york.ac.uk/prospero/, identifier PROSPERO, CRD42021297081.

Effects of glucagon-like peptide-1 receptor agonists and sodium-glucose cotransporter-2 inhibitors on cardiovascular and kidney outcomes in Asian versus White patients with type 2 diabetes mellitus

BACKGROUND

The study aimed to assess the treatment effects of the two medications on cardiovascular and kidney outcomes in Asian compared with White patients with type 2 diabetes mellitus (T2DM).

METHODS

MEDLINE, EMBASE, and CENTRAL were searched up to October 31, 2022. We included the trials that assessed the effects of glucagon-like peptide-1 receptor agonists (GLP-1 RA) or sodium-glucose cotransporter-2 inhibitors (SGLT2i) versus placebo in Asian and White patients with T2DM on major adverse cardiovascular events (MACE) and kidney outcomes. The Bucher method was used to perform an indirect comparison for estimating the differences in treatment effects of GLP-1 RA and SGLT2i between Asian versus White patients. Interaction tests were also performed for treatment-by-race to assess the potential effect modification by race.

RESULTS

We included 22 publications from 13 randomized trials. For MACE, there were no differences in treatment effects of GLP-1 RA (HR = 0.84, 95% CI: 0.68-1.04) or SGLT2i (HR = 0.90, 95% CI: 0.72-1.13) in Asian versus White patients. No differences in treatment effects of SGLT2i on kidney outcomes in Asian versus White patients were found (HR = 1.01, 95% CI: 0.75-1.36). There was no significant effect modification by race on cardiovascular and kidney outcomes.

CONCLUSIONS

There were no significant differences in treatment effects of GLP-1 RA or SGLT2i for MACE between Asian and White patients with T2DM. Likewise, no significant differences in treatment effects of SGLT2i on kidney outcomes were found between Asian and White patients.

Association of the triglyceride-glucose index with subclinical left ventricular dysfunction in type 2 diabetes mellitus patients: A retrospective cross-sectional study

AIMS/INTRODUCTION

The triglyceride-glucose (TyG) index is a simple and reliable indicator of insulin resistance, and is associated with the development and poor outcomes of cardiovascular disease. Subclinical left ventricular dysfunction (SLVD) is frequently detected in approximately one-third of diabetes patients, but it has not been established whether the TyG index correlates with SLVD. We carried out this research to evaluate the relationship between the TyG index and SLVD in type 2 diabetes mellitus patients.

MATERIALS AND METHODS

This was a cross-sectional and observational study of 183 type 2 diabetes mellitus inpatients at Nanjing Drum Tower Hospital, Nanjing, China. The TyG index and homeostasis model assessment 2 estimates for insulin resistance (HOMA2-IR) were calculated from biochemical measurements, and speckle-tracking echocardiography was carried out. According to global longitudinal strain (GLS) by echocardiography, participants were categorized into the SLVD (GLS <18%) group or the non-SLVD (GLS ≥18%) group.

RESULTS

In comparison with non-SLVD participants, SLVD participants had higher insulin resistance, as reflected by elevated TyG and HOMA2-IR indices, as well as a higher body mass index, waist circumference and triglyceride level (P < 0.05 for each). When grouped by TyG index tertiles, an elevated TyG index was correlated with other cardiometabolic risk factors, as well as a decrease in GLS. In the multivariate logistic regression analyses, the TyG index was an independent risk factor for SLVD in type 2 diabetes mellitus patients (odds ratio 2.047, 95% confidence interval 1.07-3.914, P  = 0.03), whereas HOMA2-IR was not.

CONCLUSIONS

The TyG index is independently associated with SLVD in type 2 diabetes mellitus patients and is a more reliable indicator of SLVD than HOMA2-IR.

Benefits and harms of drug treatment for type 2 diabetes: systematic review and network meta-analysis of randomised controlled trials

OBJECTIVE

To compare the benefits and harms of drug treatments for adults with type 2 diabetes, adding non-steroidal mineralocorticoid receptor antagonists (including finerenone) and tirzepatide (a dual glucose dependent insulinotropic polypeptide (GIP)/glucagon-like peptide-1 (GLP-1) receptor agonist) to previously existing treatment options.

DESIGN

Systematic review and network meta-analysis.

DATA SOURCES

Ovid Medline, Embase, and Cochrane Central up to 14 October 2022.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Eligible randomised controlled trials compared drugs of interest in adults with type 2 diabetes. Eligible trials had a follow-up of 24 weeks or longer. Trials systematically comparing combinations of more than one drug treatment class with no drug, subgroup analyses of randomised controlled trials, and non-English language studies were deemed ineligible. Certainty of evidence was assessed following the GRADE (grading of recommendations, assessment, development and evaluation) approach.

RESULTS

The analysis identified 816 trials with 471 038 patients, together evaluating 13 different drug classes; all subsequent estimates refer to the comparison with standard treatments. Sodium glucose cotransporter-2 (SGLT-2) inhibitors (odds ratio 0.88, 95% confidence interval 0.83 to 0.94; high certainty) and GLP-1 receptor agonists (0.88, 0.82 to 0.93; high certainty) reduce all cause death; non-steroidal mineralocorticoid receptor antagonists, so far tested only with finerenone in patients with chronic kidney disease, probably reduce mortality (0.89, 0.79 to 1.00; moderate certainty); other drugs may not. The study confirmed the benefits of SGLT-2 inhibitors and GLP-1 receptor agonists in reducing cardiovascular death, non-fatal myocardial infarction, admission to hospital for heart failure, and end stage kidney disease. Finerenone probably reduces admissions to hospital for heart failure and end stage kidney disease, and possibly cardiovascular death. Only GLP-1 receptor agonists reduce non-fatal stroke; SGLT-2 inhibitors are superior to other drugs in reducing end stage kidney disease. GLP-1 receptor agonists and probably SGLT-2 inhibitors and tirzepatide improve quality of life. Reported harms were largely specific to drug class (eg, genital infections with SGLT-2 inhibitors, severe gastrointestinal adverse events with tirzepatide and GLP-1 receptor agonists, hyperkalaemia leading to admission to hospital with finerenone). Tirzepatide probably results in the largest reduction in body weight (mean difference -8.57 kg; moderate certainty). Basal insulin (mean difference 2.15 kg; moderate certainty) and thiazolidinediones (mean difference 2.81 kg; moderate certainty) probably result in the largest increases in body weight. Absolute benefits of SGLT-2 inhibitors, GLP-1 receptor agonists, and finerenone vary in people with type 2 diabetes, depending on baseline risks for cardiovascular and kidney outcomes (https://matchit.magicevidence.org/230125dist-diabetes).

CONCLUSIONS

This network meta-analysis extends knowledge beyond confirming the substantial benefits with the use of SGLT-2 inhibitors and GLP-1 receptor agonists in reducing adverse cardiovascular and kidney outcomes and death by adding information on finerenone and tirzepatide. These findings highlight the need for continuous assessment of scientific progress to introduce cutting edge updates in clinical practice guidelines for people with type 2 diabetes.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42022325948.

CVOT Summit 2022 Report: new cardiovascular, kidney, and glycemic outcomes

The 8th Cardiovascular Outcome Trial (CVOT) Summit on Cardiovascular, Kidney, and Glycemic Outcomes was held virtually on November 10-12, 2022. Following the tradition of previous summits, this reference congress served as a platform for in-depth discussion and exchange on recently completed outcomes trials as well as key trials important to the cardiovascular (CV) field. This year's focus was on the results of the DELIVER, EMPA-KIDNEY and SURMOUNT-1 trials and their implications for the treatment of heart failure (HF) and chronic kidney disease (CKD) with sodium-glucose cotransporter-2 (SGLT2) inhibitors and obesity with glucose-dependent insulinotropic polypeptide (GIP) and glucagon-like peptide-1 (GLP-1) receptor agonists. A broad audience of primary care physicians, diabetologists, endocrinologists, cardiologists, and nephrologists participated online in discussions on new consensus recommendations and guideline updates on type 2 diabetes (T2D) and CKD management, overcoming clinical inertia, glycemic markers, continuous glucose monitoring (CGM), novel insulin preparations, combination therapy, and reclassification of T2D. The impact of cardiovascular outcomes on the design of non-alcoholic fatty liver disease (NAFLD) and non-alcoholic steatohepatitis (NASH) trials, as well as the impact of real-world evidence (RWE) studies on the confirmation of CVOT outcomes and clinical trial design, were also intensively discussed. The 9th Cardiovascular Outcome Trial Summit will be held virtually on November 23-24, 2023 ( http://www.cvot.org ).

Do Glucagonlike Peptide-1 Receptor Agonist and Sodium-glucose Co-transporter 2 Inhibitor Prescriptions in Germany Reflect Recommendations for Type 2 Diabetes with Cardiovascular Disease of the ADA/EASD Consensus Report?

OBJECTIVES

To analyze whether prescription use of GLP-1RA and SGLT2i in individuals with type 2 diabetes with cardiovascular disease (CVD) has increased after the ADA/EASD consensus guidelines (2018) in a German Real-World setting and which clinical characteristics are associated with prescription use of these drugs.

METHODS

The Disease Analyzer database (IQVIA) comprises a representative panel of 1,373 general practitioners, diabetologists, and cardiologists throughout Germany (01/2015-12/2020: 12.6 million patients). Newly diagnosed type 2 diabetes (n=45,531) was identified by ICD-10 codes (E11). Matching (1:1) on practice specialty, sex, age, and year of diabetes diagnosis was performed for CVD. Logistic regression models were fitted to obtain adjusted odds ratios (OR) for characteristics associated with prescription use (median follow-up: 1.9 years).

RESULTS

Overall, 35% of patients (n=16,006) were treated with glucose-lowering drugs during the first year after type 2 diabetes diagnosis (HbA1c≥7.0%: 80%). GLP-1RA (2.4%) and SGLT2i (8.5%) were rarely prescribed. After the consensus, use of GLP-1RA and SGLT2i increased, however, almost independently of pre-existing CVD (12/2019-11/2020 vs. 12/2017-11/2018: yes, no): GLP-1RA: from 5.7 to 9.2%, 5.2 to 7.6%; SGLT2i: from 13.9 to 20.4%, 12.1 to 16.6%. Among cardiovascular risk factors, the largest OR for GLP-1RA was for obesity (4.5; 95%CI: 3.2-6.3). CVD was moderately related with SGLT2i (1.45; 1.32-1.60) and GLP-1RA (1.35; 1.08-1.69) prescriptions. A weak association was observed between SGLT2i and heart failure (1.18; 95%CI: 1.05-1.32).

CONCLUSION

National prescription use of GLP-1RA and SGLT2i did not come close to the recommendation in subjects with CVD issued by the 2018 ADA/EASD consensus.

Cost-Utility of Liraglutide Plus Standard of Care Versus Standard of Care in People with Type 2 Diabetes and Cardiovascular Risk in Thailand

INTRODUCTION

Liraglutide has demonstrated a significant reduction in the primary major composite cardiovascular (CV) outcome (CV death, non-fatal myocardial infarction, non-fatal stroke). This study aimed to determine the cost-utility of adding liraglutide to the standard of care (SoC) for treating type 2 diabetes (T2D) in Thailand for three cohorts: people with atherosclerotic cardiovascular disease (ASCVD), with no ASCVD, and all people with T2D.

METHODS

A Markov model was developed to capture the long-term costs and outcomes under the perspective of the healthcare system. Costs were based on local data, the transitional probabilities were derived from the LEADER trial, and utilities were derived from published studies. Future costs and outcomes were discounted at 3% annually. A series of sensitivity analyses were performed.

RESULTS

Compared to SoC, adding liraglutide incurred higher costs and gained more quality-adjusted life-years (QALYs), yielding incremental cost-effectiveness ratios (ICERs) of above 1 million Thai baht (THB) for the three cohorts. The most influential parameter was the discount rate. When the annual cost of liraglutide reduced from 87,874 to 30,340 THB, 30,116 THB, and 31,617 THB for all people with T2D, people with ASCVD, and people without ASCVD, respectively, the ICER fell below the local threshold of 160,000 THB/QALY. Compared to the SoC treatment, the liraglutide group acquired more clinical benefit in terms of fewer CVD. Sensitivity analyses revealed that with an increase in the level of willingness-to-pay (WTP) threshold, adding liraglutide had an increased chance of being a cost-effective strategy.

CONCLUSION

Compared to the SoC treatment, adding liraglutide at the current cost is not cost-effective at the local WTP. People with T2D with ASCVD would have the most potential gain from adding liraglutide treatment compared to other populations.

Safety and efficacy of anti-hyperglycemic agents in patients with type 2 diabetes mellitus (T2DM): Protocol for an overview of systematic reviews based on network meta-analysis

Type 2 diabetes mellitus (T2DM) has caused a huge clinical and economic burden worldwide. The management strategy of T2DM has been mentioned in many guidelines. However, controversy still exists in the recommendation of anti-hyperglycemic agents. To this end, this protocol has been written according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols (PRISMA-P). We will make an overview of systematic reviews based-on network meta-analysis firstly that report on safety and efficacy of different category of anti-hyperglycemic agents for T2DM patients. We will identify network meta-analysis by applying a robust and standardized search strategy within Embase, PubMed, Web of Science, and Cochrane Database of Systematic Reviews. Hemoglobin A1c (HbA1c) and fasting plasma glucose (FPG) will be defined as the primary outcomes. We will assess the methodological quality of included reviews by applying the A MeaSurement Tool to Assess Systematic Reviews (AMSTAR-2) tool, and quality of evidence for all outcomes will be judged by using the Grading of Recommendations Assessment, Development and Evaluation (GRADE). This will provide an accessible narrative synthesis to clinicians, patients, policy makers, and developers of clinical guidelines based on published high-quality network meta-analysis. We will submit our results for peer-review publication and presentation at domestic and international conferences. We will also disseminate our results through established clinical networks and consumer networks, using pamphlet where appropriate. Ethics approval is not required for this overview as we will analysis published network meta-analysis only. Trial registration number: INPLASY202070118.

Glycated Haemoglobin A1c Variability Score Elicits Kidney Function Decline in Chinese People Living with Type 2 Diabetes

Our aim was to investigate the association of glycated haemoglobin A1c (HbA1c) variability score (HVS) with estimated glomerular filtration rate (eGFR) slope in Chinese adults living with type 2 diabetes. This cohort study included adults with type 2 diabetes attending outpatient clinics between 2011 and 2019 from a large electronic medical record-based database of diabetes in China (WECODe). We estimated the individual-level visit-to-visit HbA1c variability using HVS, a proportion of changes in HbA1c of ≥0.5% (5.5 mmol/mol). We estimated the odds of people experiencing a rapid eGFR annual decline using a logistic regression and differences across HVS categories in the mean eGFR slope using a mixed-effect model. The analysis involved 2397 individuals and a median follow-up of 4.7 years. Compared with people with HVS ≤ 20%, those with HVS of 60% to 80% had 11% higher odds of experiencing rapid eGFR annual decline, with an extra eGFR decline of 0.93 mL/min/1.73 m2 per year on average; those with HVS > 80% showed 26% higher odds of experiencing a rapid eGFR annual decline, with an extra decline of 1.83 mL/min/1.73 m2 per year on average. Chinese adults with type 2 diabetes and HVS > 60% could experience a more rapid eGFR decline.

Risk of all-cause mortality according to the European Society of Cardiology risk categories in individuals with type 2 diabetes: the Renal Insufficiency And Cardiovascular Events (RIACE) Italian Multicenter Study

AIMS

The 2019 and 2021 European Society of Cardiology (ESC) classifications stratified patients with type 2 diabetes into three categories according to the 10-year risk of death from atherosclerotic cardiovascular disease (ASCVD). The very high-risk category included individuals with established ASCVD, target organ damage (TOD), and/or, in the 2019 classification only, ≥ 3 additional ASCVD risk factors. We assessed risk of all-cause mortality according to the two ESC classifications in the Renal Insufficiency And Cardiovascular Events cohort.

METHODS

Participants (n = 15,773) were stratified based on the presence of ASCVD, TOD, and ASCVD risk factors at baseline (2006-2008). Vital status was retrieved in 2015.

RESULTS

Less than 1% of participants fell in the moderate-risk category. According to the 2019 classification, ~ 1/3 fell in the high-risk and ~ 2/3 in the very high-risk category, whereas the opposite occurred with the 2021 classification. Mortality risk increased across categories according to both classifications. Among very high-risk patients, mortality was much lower in those with ≥ 3 additional ASCVD risk factors and almost equal in those with TOD and ASCVD ± TOD, using the 2019 classification, whereas it was much higher in those with ASCVD + TOD and, to a lesser extent, TOD only than in those with ASCVD only, using the 2021 classification.

CONCLUSIONS

The negligible number of moderate-risk patients suggests that these classifications might overestimate risk of ASCVD death. Downgrading patients with ≥ 3 additional ASCVD risk factors to the high-risk category is consistent with mortality data. Risk of death is very high in the presence of TOD irrespective of established ASCVD.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT00715481.